Studies on the relationship between the level of specific IgE antibodies and the clinical expression of allergy: I. Definition of levels distinguishing patients with symptomatic from patients with asymptomatic allergy to common aeroallergens

The Burden of Asthma and Allergic Rhinitis: Epidemiology and Health Care Costs

Allergic rhinitis affects up to 78% of people with asthma, and asthma occurs in 38% of people with allergic rhinitis. Asthma has a prevalence of 8.7% among adults and 6.2% among children and accounts for $50 billion in medical costs and $32 billion in indirect and mortality costs in the United States, respectively. Allergic rhinitis occurs in 5% to 15% of people in the United States. Allergic rhinitis also accounts for a significant health care cost burden, predominantly in terms of indirect costs related to reduced quality of life and presenteeism.

Investigation of the diagnostic performance of prick test with two environmental allergens in dogs with atopic dermatitis: A study using intradermal test as the gold standard

BACKGROUND

There are no studies investigating the correlation between prick test (PT) and intradermal test (IDT) with environmental allergens in dogs with atopic dermatitis (AD).

OBJECTIVES

To investigate the correlation between PT and IDT for two environmental allergens, and to calculate the sensitivity, specificity and Youden index of PT, using IDT as the gold standard.

MATERIALS AND METHODS

Twenty-two dogs with AD were selected. PT was performed with glycerinated allergen extracts, along with negative and positive controls, using the Greer Prick System. Reactions were interpreted (positive/negative) subjectively and by using seven objective criteria, by an examiner blinded to the IDT results. IDT reactions to the same allergens were interpreted, subjectively and objectively, by another masked investigator. The agreement between PT and IDT, the sensitivity, specificity and Youden index of PT, using IDT as gold standard, were calculated.

RESULTS

On subjective evaluation, the correlation between PT and IDT was poor and sensitivity of PT was 0%. Of the seven criteria for the objective evaluation of PT, the best diagnostic performance was attained when allergen-induced wheals were considered positive if their longest diameter was ≥8.5 mm. However, even then, the correlation with IDT was moderate, and the sensitivity of PT, albeit based on few positive IDT reactions, was low.

CONCLUSION AND CLINICAL RELEVANCE

At least as performed herein, PT has a poor-to-moderate correlation with IDT, mainly as a consequence of the lack of positive PT reactions. Further studies are needed to improve PT technique, yet, meanwhile, it cannot be recommended as a substitute for IDT.

Efficacy of a house dust mite sublingual immunotherapy tablet as add-on dupilumab in asthma with rhinitis

BACKGROUND

HDM SLIT is one of the disease-modifying treatment for allergic asthma, and has demonstrated efficacy in clinical trials. Dupilumab, blocks IL-4 and IL-13 signaling, key drivers of type 2 inflammation, and is approved for patients with uncontrolled, moderate-to-severe asthma. The aim of this study was to evaluate outcomes after HDM SLIT initiation in asthma with rhinitis not optimally controlled with dupilumab in a real-world setting.

METHODS

At baseline and 48 weeks after treatment, asthma control questionnaire (ACQ)-5, asthma quality of life questionnaire (AQLQ) and rhinoconjunctivitis quality of life questionnaire (RQLQ) were assessed. Spirometry, type 2 inflammatory biomarkers and quantitative computed tomographic parameters of airway remodeling were also collected.

RESULTS

Of 47 patients received HDM SLIT and 41 completed the study. Combined HDM SLIT and dupilumab improved ACQ-5 (p < 0.05), AQLQ (p < 0.05), RQLQ (p < 0.05), and increased lung function and reduced FeNO (p < 0.05) and airway percentage wall area, and wall thickness (each, p < 0.05). The change in ACQ-5 and AQLQ score correlated with both changes in FeNO and FEV₁ percent predicted. Multiple regression analysis showed that the change in FEV₁ percent predicted was independent factor for improvement of AQLQ (r² = 0.510, p = 0.012). Based on ROC analysis for predicting SLIT responders, the baseline area under the curves in serum HDM specific-IgE, total IgE and FEV₁ percent predicted were high (>0.8).

CONCLUSIONS

These results support the benefits of adding HDM SLIT to pharmacotherapy plus dupilumab in uncontrolled asthma with rhinitis.

Concordance of Skin Prick Test, Intradermal Testing, Serum IgE Levels and Symptoms in Patients with Allergic Rhinitis

Background: Diagnosis of allergic rhinitis is achieved by a combination of patient history and different screening tools, followed by specific provocation testing. Screening tools usually involve a skin prick test (SPT), specific serum IgE or a combination of both. Objective: The purpose of this study was to evaluate the correlation of SPT, intradermal testing and specific serum IgE testing in certain allergens and to evaluate sensitization rates, symptom patterns and time of symptoms in a cohort of patients with suspected allergic rhinitis. Methods: Data on 4653 patients with suspected allergic rhinitis were included and divided into five groups: spring bloomers (birch, hazel, etc.), summer bloomers (grasses and rye), autumn bloomers (ribwort and mugwort), mites and mold. Correlation of SPT, intradermal testing and specific IgE test results using Cohen’s kappa and logistic regression were carried out to evaluate the probability of symptoms. Results: Comparison of SPT and specific serum IgE led to kappa coefficients between 0.33 and 0.47, corresponding to a minor to moderate concordance. Comparing the symptoms reported by patients with sensitization diagnosed by SPT, a correlation was only found for spring and summer bloomers with an odds ratio of 1.5 and 2.1, respectively. The most prevalent symptom in the study cohort was rhinitis, followed by others such as asthma, sense of smell and atopic dermatitis. Conclusions: SPT seems to be more sensitive than specific IgE for detection of sensitization. Patients’ symptoms as well as the timing of symptoms, especially for perennial allergies, are not always very pronounced.

First analysis of the Severe Paediatric Asthma Collaborative in Europe registry

New biologics are being continually developed for paediatric asthma, but it is unclear whether there are sufficient numbers of children in Europe with severe asthma and poor control to recruit to trials needed for registration. To address these questions, the European Respiratory Society funded the Severe Paediatric Asthma Collaborative in Europe (SPACE), a severe asthma registry. We report the first analysis of the SPACE registry, which includes data from 10 paediatric respiratory centres across Europe. Data from 80 children with a clinical diagnosis of severe asthma who were receiving both high-dose inhaled corticosteroid and long-acting β2-agonist were entered into the registry between January 2019 and January 2020. Suboptimal control was defined by either asthma control test, or Global Initiative for Asthma criteria, or ≥2 severe exacerbations in the previous 12 months, or a combination. Overall, 62 out of 80 (77%) children had suboptimal asthma control, of whom 29 were not prescribed a biologic. However, in 24 there was an option for starting a licensed biologic. 33 children with suboptimal control were prescribed a biologic (omalizumab (n=24), or mepolizumab (n=7), or dupilumab (n=2)), and for 29 there was an option to switch to a different biologic. We conclude that the SPACE registry provides data that will support the planning of studies of asthma biologics. Not all children on biologics achieve good asthma control, and there is need for new trial designs addressing biologic switching.

Allergen Specificity in Specific IgE Cutoff

This cohort study examines the distribution of specific IgE levels to 5 common aeroallergens in 6-year-old Danish children.

IgE Epitope Profiling for Allergy Diagnosis and Therapy - Parallel Analysis of a Multitude of Potential Linear Epitopes Using a High Throughput Screening Platform

Immunoglobulin E (IgE) is pivotal for manifestation and persistence of most immediate-type allergies and some asthma phenotypes. Consequently, IgE represents a crucial target for both, diagnostic purposes as well as therapeutic approaches. In fact, allergen-specific immunotherapy – aiming to re-route an IgE-based inflammatory response into an innocuous immune reaction against the allergen – is the only curative approach for IgE-mediated allergic diseases known so far. However, this requires the cognate allergen to be known. Unfortunately, even in well-characterized allergics or asthmatics, often just a small fraction of total IgE can be assigned to specific target allergens. To overcome this knowledge gap, we have devised an analytical platform for unbiased IgE target epitope detection. The system relies on chemically produced random peptide libraries immobilized on polystyrene beads (“one-bead-one-compound (OBOC) libraries”) capable to present millions of different peptide motifs simultaneously to immunoglobulins from biological samples. Beads binding IgE are highlighted with a fluorophore-labeled anti-IgE antibody allowing fluorescence-based detection and isolation of positives, which then can be characterized by peptide sequencing. Setting-up this platform required an elaborate optimization process including proper choice of background suppressants, secondary antibody and fluorophore label as well as incubation conditions. For optimal performance our procedure involves a sophisticated pre-adsorption step to eliminate beads that react nonspecifically with anti-IgE secondary antibodies. This step turned out to be important for minimizing detection of “false positive” motifs that otherwise would erroneously be classified as IgE epitopes. In validation studies we were able to retrieve artificial test-peptide beads spiked into our library by using IgE directed against those test-peptides at physiological concentrations (≤20 IU/ml of specific IgE), and disease-relevant bead-bound epitopes of the major peanut allergen Ara h 2 by screening with sera from peanut allergics. Thus, we established a platform with which one can find and validate new immunoglobulin targets using patient material which displays a largely unknown immunoglobulin repertoire.

Decreased frequency of allergy in juvenile idiopathic arthritis: Results of a case-control study

OBJECTIVES

To determine the frequency of Th2-mediated allergic diseases (AD) in mainly Th1-driven juvenile idiopathic arthritis (JIA) subtypes.

METHODS

Ninety-nine JIA patients and 128 control subjects were enrolled in a prospective case-control study. All subjects were assessed with standard allergy questionnaire, complete blood cell count, and total serum immunoglobulin (sIg) E. sIgs G, A, M, Juvenile Arthritis Disease Activity Score-27 (JADAS27), and serum acute phase reactants (sAPR) were obtained in JIA. In the presence of allergic symptoms, skin prick (SPT) and pulmonary function tests (PFT) were performed.

RESULTS

Despite similar allergy risk factors, the frequencies of asthma and allergic rhinitis were lower in JIA group (all p ≤ .02). Allergic patients with JIA performed lower FEV₁/FVC ratio, PEF, and FEF25-75 compared to the control group (all p ≤ .04). JADAS27 and sAPR were similar among JIA patients with and without AD. Two JIA patients were found to have hypogammaglobulinemia.

CONCLUSION

The frequencies of AD, asthma, and allergic rhinitis may decrease in Th1-mediated JIA subtypes although the coexistence does not appear to affect the severity of arthritis whereas allergic symptoms may resolve after immunosuppressive treatment. PFTs should be obtained periodically in JIA. JIA patients may have an underlying primary immunodeficiency (ID) or immunosuppressive drugs may cause secondary ID.KEY POINTSCompared to the population, the frequency of Th2-mediated allergic diseases is lower in oligoarthritis and RF-negative polyarthritis that are primarily driven by a Th1 activity.The coexistence of allergic diseases in juvenile idiopathic arthritis does not affect the severity of arthritis.Pulmonary function tests can be thought to be obtained periodically in juvenile idiopathic arthritis.Immunological workup should be considered in atypically or severely presented patients with juvenile idiopathic arthritis before the initiation of immunosuppressive therapy to differentiate primary and secondary immunodeficiency.

Allergen Sensitization and Asthma Outcomes among World Trade Center Rescue and Recovery Workers

A large number of World Trade Center (WTC) rescue and recovery workers are affected by asthma. While physical and mental health comorbidities have been associated with poor asthma control in this population, the potential role of allergen sensitization is unknown. This study examined the association of indoor sensitization and exposure as a risk factor for increased asthma morbidity in WTC workers. We used data from a prospective cohort of 331 WTC workers with asthma. Sensitization to indoor allergens was assessed by measurement of antigen-specific serum immunoglobulin E (IgE) levels. We used validated tools to evaluate the exposure to indoor allergens. Asthma morbidity outcomes included level of control (Asthma Control Questionnaire, ACQ), quality of life (Asthma Quality of Life Questionnaire, AQLQ) and acute resource utilization. The prevalence of sensitization to cat, dog, mouse, dust mite, cockroach, and mold allergens were 33%, 21%, 17%, 40%, 17%, and 17%, respectively. Unadjusted and regression analyses showed no significant relationship between sensitization and increased asthma morbidity (p > 0.05 for all comparisons), except for sensitization to Aspergillus Fumigatus, cat and mouse epithelium, which were associated with decreased morbidity.

Clinical and immunological differences between asymptomatic HDM-sensitized and HDM-allergic rhinitis patients

BACKGROUND

Confirmation of the clinical relevance of sensitisation is important for the diagnosis of allergic rhinitis.

OBJECTIVE

To investigate the usefulness of an in vitro basophil activation test and component-resolved diagnosis in distinguishing between symptomatic allergic rhinitis patients and asymptomatic sensitization to house dust mites (HDMs).

METHODS

Thirty-six subjects with a positive skin prick test (SPT) for HDM were divided into a symptomatic (n = 17) and an asymptomatic (n = 19) group on the basis of their clinical history and a nasal provocation test. A basophil CD63 response to in vitro stimulation with Dermatophagoides pteronyssinus whole allergen extract and the IgE reactivity profiles for Der p 1, 2, 4, 5, 7, 10, 11, 14, 15, 18, 21, 23 were evaluated. Serum IgE and IgG specific to D pteronyssinus whole allergen extract and total IgE were measured.

RESULTS

There were no statistically significant differences in the levels of IgE (IgE levels were higher in symptomatic patients with P = 0.055) and IgG specific to D pteronyssinus and total IgE. Symptomatic patients showed a lower threshold for in vitro basophil activation (3.33 ng/mL vs 33.3 ng/mL), a higher area under the curve (AUC) of basophil activation (171 vs 127) (P = 0.017), a higher response to positive control with anti-FcεRI stimulation (97% vs 79%) (P < 0.001), a recognition of more HDM allergens (4 vs 2) and more frequent sensitization to rDer p 7 (P = 0.016) and rDer p 23 compared to asymptomatic subjects (P = 0.018). There was a positive correlation (r = 0.63; P < 0.001) between the number of recognized allergens and the AUC of basophil activation.

CONCLUSION AND CLINICAL RELEVANCE

In the subjects studied, the differences in the basophil response to D pteronyssinus allergen extract, number of recognized HDM allergens and reactivity to rDer p 7 and rDer p 23 distinguish symptomatic from asymptomatic HDM sensitisation better than SPT or allergen extract-specific IgE. Information regarding the clinical relevance of sensitization is important for the prescription of allergen-specific immunotherapy.

Basophils from allergic rhinitis patients show allergen-specific upregulation of thymic stromal lymphopoietin receptor

BACKGROUND

An allergic rhinitis (AR) diagnosis is based on typical nasal symptoms and allergen sensitization testing. However, it is sometimes difficult to distinguish AR from non-AR, and it is especially difficult to identify the causal allergen for immunotherapy of patients with AR.

OBJECTIVE

To identify differences among patients with AR, subjects with asymptomatic sensitization (AS), and subjects without sensitization (NS) that could facilitate the diagnosis of AR.

METHODS

We used RNA sequencing to examine differential gene expression in unstimulated and allergen-stimulated peripheral basophils from participants with NS, AS, and AR. We selected genes that were upregulated after allergen stimulation and showed differences in expression in patients with AR compared with subjects with AS and NS. Basophil surface expression of 1 gene product was examined by flow cytometry. The usefulness of gene expression in the diagnosis of AR was examined with receiver operating characteristic curves.

RESULTS

Expression of cytokine receptor-like factor 2 and its product, thymic stromal lymphopoietin receptor (TSLPR), was significantly increased in basophils of patients with AR after allergen stimulation. A significantly larger percentage of TSLPR-positive cells was observed after allergen-specific stimulation of basophils from patients with AR compared with subjects with AS. Basophil TSLPR expression was as good as or better than CD203c expression in discriminating between patients with AR and subjects with AS, as judged by receiver operating characteristic curves.

CONCLUSION

Our data suggest that TSLPR expression on basophils was specifically upregulated by allergen stimulation and might be useful for the identification of the causative allergen in patients with AR.

Associations between Atopic Dermatitis and Risk of Gastric Cancer: A Nationwide Population-based Study

Background/Aims

Epidemiologic and clinical data indicate that allergies may be associated with reduced risks for several cancers; however, to date, only a few studies have examined the associations between allergies and gastric cancer. This study aimed to examine the associations between allergies and gastric cancer using a large population-based dataset.

Methods

This cross-sectional study obtained data from the Korea National Health and Nutrition Examination Survey between 2010 and 2014, involving a total of 24,089 participants. The associations between allergies and gastric cancer were analyzed using univariable and multivariable logistic regression analyses with complex sampling, while adjusting for confounding factors that included age, sex, body mass index, smoking status, alcohol intake, and level of education.

Results

Multivariable logistic regression analyses that were adjusted for the potential confounders determined that a history of allergic diseases tended to be associated with reduced risk of gastric cancer; however, this relationship was not statistically significant (any allergy: odds ratio [OR], 0.62; 95% confidence interval [CI], 0.34-1.12; atopic dermatitis: OR, 0.34; 95% CI, 0.50-1.72; allergic rhinitis: OR, 0.71; 95% CI, 0.34-1.46; asthma: OR, 0.44; 95% CI, 0.15-1.29). Multivariable analysis showed that a history of atopic dermatitis was associated with reduced risk of gastric cancer in men (OR, 0.16; 95% CI, 0.03-0.75).

Conclusions

This findings of this study suggest that individuals with allergies tend to have a reduced risk of gastric cancer, without a statistically significant association. Furthermore, atopic dermatitis was associated with reduced risk of gastric cancer, particularly in men.

Multisensory integration, body representation and hyperactivity of the immune system

Multisensory stimuli are integrated over a delimited window of temporal asynchronies. This window is highly variable across individuals, but the origins of this variability are still not clear. We hypothesized that immune system functioning could partially account for this variability. In two experiments, we investigated the relationship between key aspects of multisensory integration in allergic participants and healthy controls. First, we tested the temporal constraint of multisensory integration, as measured by the temporal binding window. Second, we tested multisensory body representation, as indexed by the Rubber Hand Illusion (RHI). Results showed that allergic participants have a narrower temporal binding window and are less susceptible to the RHI than healthy controls. Overall, we provide evidence linking multisensory integration processes and the activity of the immune system. The present findings are discussed within the context of the effect of immune molecules on the brain mechanisms enabling multisensory integration and multisensory body representation.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Pathogenicity of memory Th2 cells is linked to stage of allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) consists of three developmental stages that are based on the presence/absence of antigen-specific IgE and symptoms. The pathogenic Th2 (Tpath2) cells constitute a population of Th2 cells with additional potentially pathogenic characteristics. We examined the relationship between Tpath2 cells and the stages of allergic rhinitis by focusing on ST2, which is an IL-33 receptor.

METHODS

Patients with Japanese cedar pollen-induced AR (JCP-AR) and healthy volunteers were divided into "nonsensitized," "asymptomatic sensitized (AS)," and "JCP-AR" groups. We analyzed the ST2 expression and the Th2 function of cultured CD4⁺ T cells. Next, we observed the progress of patients in the AS stage around the time of seasonal pollen dispersal, with the characteristics of Th2 cells.

RESULTS

The ST2 expression of T cells was only upregulated in the AR group. The production of IL-4 and IL-13 was found in CD4⁺ T cells obtained from AS by stimulation with JCP, but reactivity to IL-33 was not observed. Although IL-33 did not induce the elevation of IL-4 production in the JCP-AR group, IL-33 substantially increased the production of IL-5 and IL-13 in comparison with antigen stimulation alone. In newly afflicted patients, the increased expression of ST2 and elevated reactivity to IL-33 was observed, even before the pollen dispersal season.

CONCLUSIONS

Our study demonstrated that the pathogenicity of memory Th2 cells is linked to sensitization and the stage of allergic rhinitis. Therefore, Tpath2 cells may provide useful insights into the mechanism of the onset and progression of allergic rhinitis.

Windows of opportunity for tolerance induction for allergy by studying the evolution of allergic sensitization in birth cohorts

Allergic sensitization is a risk factor for developing IgE-mediated allergic diseases, which are a major cause of chronic illness world-wide. The introduction of allergen molecules to the field of allergy diagnostics has allowed dissecting the IgE response on a molecular level to pinpoint the specific disease-causing allergens. Studying birth cohorts is an essential tool for understanding the development and life course of allergy, enabling the possibility to design preventive strategies. Here we review the evolution of sensitization using data from some of the large European birth cohort studies. Differences and similarities between sensitization to food and various sources of inhalant allergens are discussed and allergen molecules of importance in early childhood predicting disease in adolescence are highlighted. Finally, we discuss windows of opportunity where intervention could be considered and address possible preventive strategies.

Occupational Respiratory Allergic Diseases in Healthcare Workers

Healthcare workers (HCWs) are exposed to a range of high and low molecular weight agents that are allergic sensitizers or irritants including cleaners and disinfectants, natural rubber latex, and various medications. Studies have shown that exposed HCWs are at risk for work-related rhinitis and asthma (WRA). Work-related rhinitis may precede development of WRA and should be considered as an early marker of WRA. Avoidance of causative exposures through control strategies such as elimination, substitution, engineering controls, and process modification is the preferred primary prevention strategy for preventing development of work-related allergic diseases. There is limited evidence for the effectiveness of respirators in preventing occupational asthma. If sensitizer-induced WRA is diagnosed, it is important to avoid further exposure to the causative agent, preferably by more rigorous application of exposure control strategies to the workplace. This review focuses on allergic occupational respiratory diseases in HCWs.

Dry eye disease and allergic conditions: A Korean nationwide population-based study

BACKGROUND

Dry eye disease (DED) is a multifactorial disease of the tears and ocular surface. No epidemiologic reports have yet been published about the relationship between DED and allergic rhinitis or sensitization to allergens.

OBJECTIVE

To investigate the association between DED and allergic conditions in the general adult Korean population.

METHODS

This population-based cross-sectional study included 17,542 individuals (ages ≥ 19 years) who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) from 2010 to 2012. Data for total serum immunoglobulin E (IgE) and allergen-specific IgE levels were available for 1857 subjects. Data were analyzed by using logistic regression to determine the association of DED with allergy or allergic conditions, including allergic rhinitis, atopic dermatitis, asthma, increased total serum IgE, and sensitization to house-dust mite (Dermatophagoides farinae), dog, and cockroach allergens.

RESULTS

The prevalence of DED, allergic rhinitis, atopic dermatitis, and asthma was 10.4, 13.1, 2.2, and 3.3%, respectively. The prevalence of the increased total serum IgE level and sensitization to D. farinae, dog, and cockroach allergens was 34.6, 15.7, 1.0, and 2.8%, respectively. After adjusting for general characteristics, DED was significantly associated with allergic rhinitis (odds ratio 1.58 [95% confidence interval, 1.38-1.81]) and D. farinae sensitization (odds ratio 1.80 [95% confidence interval, 1.17-2.79]).

CONCLUSION

This study demonstrated a close association between DED and both allergic rhinitis and D. farinae sensitization in Korean adults. Further studies are warranted to establish temporal relationships between DED and allergic rhinitis.

Probiotics (Lactobacillus gasseri KS-13, Bifidobacterium bifidum G9-1, and Bifidobacterium longum MM-2) improve rhinoconjunctivitis-specific quality of life in individuals with seasonal allergies: a double-blind, placebo-controlled, randomized trial

Background: Rhinoconjunctivitis-specific quality of life is often reduced during seasonal allergies. The Mini Rhinoconjunctivitis Quality of Life Questionnaire (MRQLQ) is a validated tool used to measure quality of life in people experiencing allergies (0 = not troubled to 6 = extremely troubled). Probiotics may improve quality of life during allergy season by increasing the percentage of regulatory T cells (Tregs) and inducing tolerance.Objective: The objective of this study was to determine whether consuming Lactobacillus gasseri KS-13, Bifidobacterium bifidum G9-1, and B. longum MM-2 compared with placebo would result in beneficial effects on MRQLQ scores throughout allergy season in individuals who typically experience seasonal allergies. Secondary outcomes included changes in immune markers as part of a potential mechanism for changes in MRQLQ scores.Design: In this double-blind, placebo-controlled, parallel, randomized clinical trial, 173 participants (mean ± SEM: age 27 ± 1 y) who self-identified as having seasonal allergies received either a probiotic (2 capsules/d, 1.5 billion colony-forming units/capsule) or placebo during spring allergy season for 8 wk. MRQLQ scores were collected weekly throughout the study. Fasting blood samples were taken from a subgroup (placebo, n = 37; probiotic, n = 35) at baseline and week 6 (predicted peak of pollen) to determine serum immunoglobulin (Ig) E concentrations and Treg percentages.Results: The probiotic group reported an improvement in the MRQLQ global score from baseline to pollen peak (-0.68 ± 0.13) when compared with the placebo group (-0.19 ± 0.14; P = 0.0092). Both serum total IgE and the percentage of Tregs increased from baseline to week 6, but changes were not different between groups.Conclusions: This combination probiotic improved rhinoconjunctivitis-specific quality of life during allergy season for healthy individuals with self-reported seasonal allergies; however, the associated mechanism is still unclear. This trial was registered at clinicaltrials.gov as NCT02349711.

House dust mite sublingual tablet is effective and safe in patients with allergic rhinitis

BACKGROUND

House dust mite (HDM) is the major indoor allergen for allergic diseases such as allergic rhinitis (AR) and asthma. Although sublingual immunotherapy is a curative treatment for HDM-induced AR, data from large-scale studies are limited. We evaluated the efficacy and safety of HDM tablets in adolescent and adult patients (aged 12-64 years) with HDM-induced AR with or without intermittent asthma.

METHODS

In a double-blind trial in Japan, 968 subjects were randomized 1 : 1 : 1 to 300 index of reactivity (IR), 500 IR, or placebo groups. The primary endpoint was the Average Adjusted Symptom Score (AASS) in the last eight weeks of the 52-week treatment. Secondary endpoints included individual nasal and ocular symptom scores, rescue medication use, and the Japanese Rhinoconjunctivitis Quality of Life Questionnaire (JRQLQ) scores.

RESULTS

The AASS in the last eight weeks of treatment significantly improved in both the 300 IR and the 500 IR groups compared to that in the placebo group (P < 0.001). In the 300 IR group, the onset of action occurred at week 8-10. All four nasal symptoms significantly improved in both active treatment groups; rescue medication use and JRQLQ outcome improved in the 300 IR group. Most adverse events (AEs) were mild, and 16 serious AEs (SAEs) were reported; however, none of them were drug-related.

CONCLUSIONS

One-year treatment with 300 IR and 500 IR HDM tablets was effective without major safety concerns. The recommended therapeutic dose for AR is 300 IR.

Developing and testing of a screening tool to predict people without IgE-mediated allergy: a quantitative analysis of the predictive value of a screening tool

BACKGROUND

Consultations in primary care for allergies are common. It can be difficult to differentiate between IgE-mediated (atopic) symptoms - which respond to allergen-specific interventions - and those that are non-atopic, without performing objective tests that are largely unavailable in UK general practice.

AIM

To develop and test a screening tool that can accurately discriminate between atopic and non-atopic individuals.

DESIGN AND SETTING

A validation study that took place in 2012 in adult volunteers aged >16 years in Scotland.

METHOD

A questionnaire screening tool was developed using questions from a large cohort study and through consultation with experts. Participants answered the questions and had skin prick tests for four aeroallergens (house dust mite, cat, dog, and mixed grasses). Participants were classified as atopic if any average wheal diameter was ≥3 mm bigger than the negative control. Sensitivity, specificity, and positive and negative predictive values of individual and combinations of questions were calculated.

RESULTS

In all, 143 participants completed the questionnaire and underwent skin prick testing. Of these, 81 (56.6%) were atopic. Negative predictive values for the individual questions ranged from 48.2% (55 not atopic out of 114 negative answers) to 72.0% (18/25). An optimum combination of four questions was identified, in which a negative answer to all four questions was reported by 24 participants, 21 (87.5%) of whom were not atopic.

CONCLUSION

The authors have identified a set of questions that correctly predict negative skin prick tests to common aeroallergens 88% of the time. These may be useful to exclude patients who do not warrant further investigation and who can reliably be advised that allergen avoidance is neither necessary nor helpful.

Gene-Environment Interactions-What Can These Tell Us about the Relationship between Asthma and Allergy?

Asthma is a common condition, which is associated with atopy and allergic conditions including hay fever, eczema, and food allergies. Asthma and atopy are both complex conditions where genetic and environmental factors are implicated in causation. Interactions between genetic and environmental factors, likely via epigenetic mechanisms, are widely thought to be important in determining the risk for developing asthma and atopy. The nature of the relationship between asthma and atopy is unclear and the answer to the question "does atopy cause asthma?" remains unknown. This review explores the relationship between asthma and atopy from a gene-environment interaction perspective and tackles the question "are similar gene-environment interactions present for asthma and atopy?" The main finding is that gene-environment interactions are described for asthma and atopy in children but these interactions are seldom sought for both asthma and atopy in the same population. In the few instances where a gene-environment interaction is related to both asthma and atopy, there is no consistent evidence that similar interactions are common to asthma and atopy. Many plausible gene-environment interactions for asthma and atopy are yet to be explored. Overall, from the gene-environment interaction perspective, there is absence of evidence to better understand the complex relationship between asthma and atopy.

Usefulness of House Dust Mite Nasal Provocation Test in Asthma

Purpose

We previously reported that the skin prick test was sensitive and the serum specific immunoglobulin E test was specific for predicting positive airway responses to house dust mites (HDMs) in patients with asthma. Because the nose and bronchus are one airway, the nasal provocation test would be more specific for predicting the bronchial responses to HDM than the skin test.

Methods

The allergy skin prick test and nasal and bronchial provocation tests using HDM (Dermatophagoides farinae) were performed in 41 young men (age, 19–28 years) who wanted military certification for asthma. The nasal responses to HDM was scored according to the severity of rhinorrhea, sneezing, and nose itching.

Results

The prevalence of a positive skin prick test to HDM did not significantly differ between patients with (n=24) and without (n=17) an early airway reaction (EAR; 79.2% vs 70.6%, P=0.534). However, the prevalence of a positive nasal test was significantly higher in the airway responders than in the others (37.5% vs 0%, P=0.005). The concordance of a positive response to the nasal test (κ=0.332, P=0.004) but not to the skin prick test (κ=0.091, P=0.529) was significant with an EAR. The diagnostic sensitivity of the nasal test (37.5%) was lower than that of the skin prick test (79.2%), but the specificity was higher (100% vs 29.4%).

Conclusions

The skin prick test is more sensitive, whereas the nasal test is more specific and accurate, for predicting an EAR to HDM in patients with asthma.

Distinct Contributory Factors Determine Basophil-Allergen Sensitivity in Grass Pollen Rhinitis and in Anaphylactic Wasp Venom Allergy

BACKGROUND

We sought to determine whether basophil-allergen sensitivity could be transferred to donor basophils by passive IgE sensitisation in allergic rhinitis and anaphylactic Hymenoptera venom hypersensitivity.

METHODS

We studied 15 wasp venom-, 19 grass pollen- and 2 house dust mite-allergic patients, 2 healthy donors, and 8 wasp venom-allergic donors. In all subjects, we first evaluated the initial basophil response to wasp venom, grass pollen, or house dust mite allergen. Donor basophils were then stripped, sensitised with the different patients' serum IgE, and challenged with the corresponding allergen. The CD63 response of donor basophils was then compared with initial basophil responses.

RESULTS

In wasp venom-allergic subjects, the IgE transfer did not reflect the initial basophil-allergen sensitivity, because the venom IgE of subjects with high or low basophil sensitivity induced comparable responsiveness in healthy donor basophils. Furthermore, vice versa, when we sensitised the donor basophils of wasp venom-allergic individuals with different wasp venom or house dust mite IgE, we demonstrated that their response was predictable by their initial basophil allergen sensitivity. In the rhinitis allergy model, the IgE transfer correlated with the patients' initial basophil responsiveness because the grass pollen IgE of the subjects with high basophil allergen sensitivity induced significantly higher responsiveness of donor basophils than the IgE of subjects with initially low basophil allergen sensitivity.

CONCLUSIONS

Our results suggest that basophil allergen sensitivity evaluated by flow-cytometric CD63 analysis depends on two distinct contribution factors. In anaphylactic Hymenoptera allergy, the major factor was intrinsic cellular sensitivity, whereas in pollen allergy, the major factor was allergen-specific IgE on the cell surface.

High alcohol consumption causes high IgE levels but not high risk of allergic disease

BACKGROUND

High alcohol consumption is associated with high IgE levels in observational studies; however, whether high alcohol consumption leads to high IgE levels and allergic disease is unclear.

OBJECTIVE

We tested the hypothesis that high alcohol consumption is associated with high IgE levels and allergic disease both observationally and genetically using a Mendelian randomization design free of reverse causation and largely free of confounding.

METHODS

Among 111,408 subjects aged 20 to 100 years from the general population, 50,019 had plasma IgE measurements, and 102,270 were genotyped for the alcohol-metabolizing enzymes alcohol dehydrogenase 1B (ADH-1B; rs1229984) and alcohol dehydrogenase 1c (ADH-1C; rs698). Observationally, we investigated associations between IgE levels and allergic disease (allergic asthma, rhinitis, and eczema) and between alcohol consumption and IgE levels and allergic disease. Genetically, we explored potential causal relationships between alcohol consumption and IgE levels and allergic disease.

RESULTS

The multivariable adjusted odds ratio for IgE levels greater than versus less than 150 kU/L and compared with subjects without allergic disease was 2.3 (95% CI, 2.2-2.5) for 1 allergic disease, 3.9 (95% CI, 3.5-4.4) for 2 allergic diseases, and 7.5 (95% CI, 6.2-9.0) for 3 allergic diseases. High alcohol consumption was associated with high IgE levels but not with high risk of allergic disease. The odds ratio for high versus low IgE levels per 1 alcoholic drink per week higher consumption was 1.12 (95% CI, 1.02-1.23) genetically and 1.01 (95% CI, 1.01-1.02) observationally; for allergic disease, the corresponding odds ratios were 0.96 (95% CI, 0.92-1.00) genetically and 1.00 (95% CI, 1.00-1.00) observationally.

CONCLUSION

High alcohol consumption is associated observationally and genetically with high IgE levels but not with high risk of allergic disease.

Debates in allergy medicine: Specific immunotherapy in children with atopic dermatitis, the "con" view

Atopic dermatitis (AD) is a common chronic skin condition in children that has a proven association with other atopic conditions and allergies. These associations, like the general pathophysiology of AD, are complex and not fully understood. While there is evidence for the efficacy of specific immunotherapy (SIT) in pediatric asthma and allergic rhinitis (AR), there is a lack of strong data to support its use in AD. IgE has been shown to be elevated in many patients with AD, but it is an unreliable biomarker due to variability and great fluctuation over time, poor positive predictive value for clinically relevant allergy, and poor correlation with disease state. In spite of this, almost all studies of SIT use either positive skin prick testing (SPT) or serum specific IgE levels to guide therapy. Allergen avoidance, with some exceptions, is generally not effective at controlling AD in children. The few studies that have investigated the efficacy of SIT in children with AD have produced conflicting results, and a lack of reproducibility with a standard treatment protocol. Limited studies have shown clinical improvement in mild to moderate AD cases, but no effect on more severe patients. Uncontrolled studies are difficult to interpret, due to the natural history of remission or “outgrowing” of AD over time in many patients without specific interventions. Drawbacks to SIT include the length of treatment, poor compliance, cost, and potential side effect profile. The potential for misdirection of time and energy away from skin directed therapy could negatively impact on AD outcomes.

Pollinosis and all-cause mortality among middle-aged and elderly Japanese: a population-based cohort study

BACKGROUND

Having an allergic disease may have health implications beyond those more commonly associated with allergy given that previous epidemiological studies have suggested that both atopy and allergy are linked to mortality. More viable immune functioning among the elderly, as indicated by the presence of an allergic disease, might therefore be associated with differences in all-cause mortality.

OBJECTIVE

Using data from a Japanese cohort, this study examined whether having pollinosis (a form of allergic rhinitis) in a follow-up survey could predict all-cause and cause-specific mortality.

METHODS

Data came from the Komo-Ise cohort, which at its 1993 baseline recruited residents aged 40-69 years from two areas in Gunma prefecture, Japan. The current study used information on pollinosis that was obtained from the follow-up survey in 2000. Mortality and migration data were obtained throughout the follow-up period up to December 2008. Proportional hazard models were used to examine the relation between pollinosis and mortality.

RESULTS

At the 2000 follow-up survey, 12% (1088 of 8796) of respondents reported that they had pollinosis symptoms in the past 12 months. During the 76 186 person-years of follow-up, 748 died from all causes. Among these, there were 37 external, 208 cardiovascular, 74 respiratory, and 329 neoplasm deaths. After adjusting for potential confounders, pollinosis was associated with significantly lower all-cause [hazard ratio 0.57 (95% confidence interval = 0.38-0.87)] and neoplasms mortality [hazard ratio 0.48 (95% confidence interval = 0.26-0.92)].

CONCLUSIONS AND CLINICAL RELEVANCE

Having an allergic disease (pollinosis) at an older age may be indicative of more viable immune functioning and be protective against certain causes of death. Further research is needed to determine the possible mechanisms underlying the association between pollinosis and mortality.

Are allergic multimorbidities and IgE polysensitization associated with the persistence or re-occurrence of foetal type 2 signalling? The MeDALL hypothesis

Allergic diseases [asthma, rhinitis and atopic dermatitis (AD)] are complex. They are associated with allergen-specific IgE and nonallergic mechanisms that may coexist in the same patient. In addition, these diseases tend to cluster and patients present concomitant or consecutive diseases (multimorbidity). IgE sensitization should be considered as a quantitative trait. Important clinical and immunological differences exist between mono- and polysensitized subjects. Multimorbidities of allergic diseases share common causal mechanisms that are only partly IgE-mediated. Persistence of allergic diseases over time is associated with multimorbidity and/or IgE polysensitization. The importance of the family history of allergy may decrease with age. This review puts forward the hypothesis that allergic multimorbidities and IgE polysensitization are associated and related to the persistence or re-occurrence of foetal type 2 signalling. Asthma, rhinitis and AD are manifestations of a common systemic immune imbalance (mesodermal origin) with specific patterns of remodelling (ectodermal or endodermal origin). This study proposes a new classification of IgE-mediated allergic diseases that allows the definition of novel phenotypes to (i) better understand genetic and epigenetic mechanisms, (ii) better stratify allergic preschool children for prognosis and (iii) propose novel strategies of treatment and prevention.

Assessment of allergen-induced respiratory hyperresponsiveness before the prescription of a specific immunotherapy

BACKGROUND

Asymptomatic sensitization is a frequent condition that must be considered before the indication of allergic-specific immunotherapy.

OBJECTIVE

The aim of this study was to appreciate and correlate the local and spirometric changes elicited by the allergen-specific nasal provocation test (NPT) to define practical and feasible guidelines for the allergist/immunologist to demonstrate specific respiratory hyperresponsiveness before the indication of allergic-specific immunotherapy.

METHODS

A total of 172 subjects (children and adults) with a diagnosis of allergic rhinitis were submitted to flow-volume spirometry immediately before and after the NPT performed with Dermatophagoides antigens. The differences between the pre- and postspirometric estimated values of peak expiratory flow rate (PEFdif%), forced expiratory volume in 1 second (FEV1dif%), and forced vital capacity (FVCdif%) were correlated with the results of the nasal provocation test symptom score (NPT-SS).

RESULTS

There were 119 subjects (69%) with NPT-SS > 2. Among these patients who were reactive, the mean NPT-SS was 6.3. The Spearman's correlation between PEFdif% and NPT-SS was r = -0.44 (p = 0.01); the Spearman's correlation between FEV1dif% and NPT-SS was r = -0.22 (p = 0.01), and the Spearman's correlation between FVCdif% and NPT-SS was r = -0.21 (p = 0.04).

CONCLUSION

The combined utilization of the allergen-specific NPT-SS with the spirometry (or PEF meter) is a safe methodology to evaluate allergen-specific nasal and bronchial hyperresponsiveness (which sometimes acts as a bronchial provocation test) in patients with allergic rhinitis and asthma due to hypersensitivity who are candidates for allergen-specific immunotherapy.

Relation of lung function and current inhalant allergen-specific immunoglobulin E concentrations in adolescents (GINIplus cohort)

BACKGROUND

The prevalence of allergen sensitization reaches up to 46.6% in 14- to 17-year-old German adolescents. Polysensitization is strongly associated with a higher risk of allergic rhinitis or asthma. Whether or how sensitization also is related to lung function remains uncertain.

OBJECTIVE

To assess whether sensitization to common inhalant allergens is associated with lung function in adolescents after stratification by allergic respiratory disease.

METHODS

In total, 1,719 15-year-old participants of the German Infant Study on the Influence of Nutrition Intervention plus Air Pollution and Genetics on Allergy Development (GINIplus) birth cohort provided valid spirometric indices, including forced expiratory volume in 1 second, forced vital capacity (FVC), forced expiratory flow rate at 25% to 75% of the FVC, and specific immunoglobulin E (IgE) screening test to 8 inhalant allergens (ImmunoCAP). Complete information on allergic rhinitis and asthma status was available for 1,128 subjects. Associations between lung function parameters and sensitization, classified into 4 groups (no sensitization to polysensitization) were analyzed using adjusted linear regression models.

RESULTS

Among participants, 21.1% (n = 347) had allergic rhinitis, 10.1% (n = 119) had asthma, and 46.4% (n = 798) had a positive screening test to inhalant allergens. Prevalences were consistently higher in boys. The percentage of subjects with rhinitis or asthma increased from 5.8% in non-sensitized subjects (n = 620) to 69.4% in polysensitized subjects (n = 144). Sensitization was not associated with any spirometric parameter considered in subjects with allergic rhinitis, asthma, or neither disease.

CONCLUSION

Although allergen-specific IgE concentrations can contribute to the identification of subjects at higher risk for allergic rhinitis and asthma, sensitization to inhalant allergens is not related to impaired spirometric lung parameters within the different allergic respiratory disease subgroups.

The role of dendritic cells and monocytes in the maintenance and loss of respiratory tolerance

Promoting tolerance to inhaled antigens is an active area of study with the potential to benefit the millions of Americans currently suffering from respiratory allergies and asthma. Interestingly, not all individuals with atopy are symptomatic, arguing that sensitization alone does not lead to an allergic clinical phenotype. Respiratory dendritic cells (rDCs), classically associated with inducing inflammatory responses, can actively promote tolerance. Tolerance can be broken when inflammatory stimuli, including viral infections and other environmental exposures, inhibit rDC-mediated tolerance by allowing innocuous antigen to be presented to initiate type-2 immunity. Importantly, rDCs are composed of multiple subsets, each with a unique response to an inhaled antigen that can lead to either tolerance or inflammation. In this review, we will discuss how rDC subsets actively maintain tolerance or, alternatively, break tolerance in response to environmental cues.

Sublingual immunotherapy: World Allergy Organization position paper 2013 update

We have prepared this document, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2013 Update", according to the evidence-based criteria, revising and updating chapters of the originally published paper, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2009", available at http://www.waojournal.org. Namely, these comprise: "Mechanisms of sublingual immunotherapy;" "Clinical efficacy of sublingual immunotherapy" - reporting all the data of all controlled trials published after 2009; "Safety of sublingual immunotherapy" - with the recently published Grading System for adverse reactions; "Impact of sublingual immunotherapy on the natural history of respiratory allergy" - with the relevant evidences published since 2009; "Efficacy of SLIT in children" - with detailed analysis of all the studies; "Definition of SLIT patient selection" - reporting the criteria for eligibility to sublingual immunotherapy; "The future of immunotherapy in the community care setting"; "Methodology of clinical trials according to the current scientific and regulatory standards"; and "Guideline development: from evidence-based medicine to patients' views" - including the evolution of the methods to make clinical recommendations.Additionally, we have added new chapters to cover a few emerging crucial topics: "Practical aspects of schedules and dosages and counseling for adherence" - which is crucial in clinical practice for all treatments; "Perspectives and new approaches" - including recombinant allergens, adjuvants, modified allergens, and the concept of validity of the single products. Furthermore, "Raising public awareness about sublingual immunotherapy", as a need for our patients, and strategies to increase awareness of allergen immunotherapy (AIT) among patients, the medical community, all healthcare stakeholders, and public opinion, are also reported in detail.

Association between allergies and risk of pancreatic cancer

BACKGROUND

Less than 10% of pancreatic cancer cases survive 5 years, yet its etiology is not well understood. Studies suggest allergies are associated with reduced pancreatic cancer risk. Our study collected additional information on allergies (including skin prick test results and differentiation of allergic/nonallergic asthma), and is the first to assess possible confounding by allergy medications.

METHODS

A population-based case-control study was designed to comprehensively assess the association between allergy and pancreatic cancer risk. Pancreas cancer cases were diagnosed during 2011 to 2012, and identified through the Ontario Cancer Registry (345 cases). Population-based controls were identified using random digit dialing and age/sex frequency matched to cases (1,285 controls). Questionnaires collected lifetime allergy history (type of allergy, age at onset, skin prick testing results), allergy medications, and established pancreas cancer risk factors. Logistic regression was used to estimate odd ratios and test potential confounders, including allergy medications.

RESULTS

Hay fever was associated with a significant reduction in pancreatic cancer risk [AOR = 0.68; 95% confidence intervals (CI), 0.52-0.89], and reduction was greatest for those whose skin prick test was positive for hay fever allergens. No particular patterns were observed as regards age at onset and duration of allergy. Positive dust/mold allergy skin prick test and animal allergies were associated with a statistically significant reduced pancreatic cancer risk; AOR = 0.49; 95% CI, 0.31-0.78 and AOR = 0.68; 95% CI, 0.46-0.99, respectively. Asthma was not associated with pancreatic cancer risk.

CONCLUSIONS/IMPACT

These findings support the growing body of evidence that suggests certain allergies are associated with reduced pancreatic cancer risk.

Assessment of Total/Specific IgE Levels Against 7 Inhalant Allergens in Children Aged 3 to 6 Years in Seoul, Korea

PURPOSE

Childhood allergies are a serious problem, as they may lead to lifetime chronic disease. Determination of total and specific IgE levels is known to be a diagnostic tool for allergic sensitization; however, IgE levels are affected by various factors, such as age, sex, ethnicity, and geographic area. Thus, we evaluated the distribution of total and specific serum IgE levels against seven inhalant allergens in preschool children and examined their association with allergic diseases in Seoul, Korea.

METHODS

Total/specific serum IgE determination and skin prick tests for seven common allergens were performed on 509 children aged 3 to 6 years from 16 child care centers in Seoul, Korea. Demographic characteristics were surveyed from parents using a modified International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. A diagnosis of atopic dermatitis was made by physicians.

RESULTS

The geometric mean of total IgE was 80.48±3.80 kU/L in preschool children. IgE levels were higher in boys (boys, 102.34±3.52 kU/L; girls, 62.37±3.93 kU/L; P<0.001) and atopic subjects (atopic, 158.00±3.35 kU/L; non-atopic, 52.75±3.44 kU/L; P<0.001). An increased prevalence of atopy was associated with a high monthly household income (P=0.004) and higher maternal education level (above university-level education; P=0.009), as well as increased total IgE levels (P=0.036). Physician-diagnosed atopic dermatitis was associated with sensitization to inhalant allergens.

CONCLUSIONS

Total IgE levels were very high as compared with those in previous reports from other countries. The most common sensitized allergen was Dermatophagoides farinae, and the positive response rate peaked at age 3 years and was maintained thereafter, particularly in boys. Specific IgE levels for seven inhalant allergens varied with age in preschool children. Although further investigations are needed with a broad range of ages and various allergens, the distribution of the total and specific serum IgE levels in preschool children might help to serve as a reference value to diagnose atopy.

Characteristics of allergic sensitization among asthmatic adults older than 55 years: results from the National Health and Nutrition Examination Survey, 2005-2006

BACKGROUND

Approximately 60% to 80% of children and young adults with asthma are sensitized to at least one allergen. In contrast, previous studies from specific subpopulations of older patients with asthma suggest that allergic sensitization is significantly lower in this age group. The prevalence and patterns of IgE-mediated sensitization have not been compared among a broad population of younger and older patients with asthma.

OBJECTIVE

To determine the prevalence and patterns of IgE-mediated sensitization among a broad population of younger and older patients with asthma.

METHODS

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2005-2006 to compare IgE-mediated sensitization rates between younger (20-40 years) and older (≥55 years) patients with current asthma. Atopy was defined as a detectable serum IgE to at least 1 allergen in a panel of 19 allergens. The associations among sensitization, current asthma, and asthma control measures (health care use and symptoms) were examined by logistic regression.

RESULTS

In a group of 2,573 patients, either 20 to 40 years of age or 55 years or older, 108 (6.7%) and 43 (4.5%) patients with current asthma were identified, respectively. Allergic sensitization rates among the adults with asthma differed only moderately and not statistically significantly between the age groups; 75.4% of the younger and 65.2% of the older asthmatic patients were sensitized to at least 1 allergen. The association between sensitization and markers of asthma control did not appear to differ among the age groups.

CONCLUSION

Allergic sensitization in older patients with asthma may be more common than previously reported.

Immunological parameters associated with the development of allergic rhinitis: a preliminary prospective study

BACKGROUND

Many subjects are sensitized to Japanese cedar pollen but do not develop allergic rhinitis (AR). The aim of this study was to examine the immunologic parameters related to the development of AR in sensitized subjects.

METHODS

The subjects were 33 adults who were sensitized to Japanese cedar pollen, but had not developed as of 2007. Cedar pollen-specific IgE (sIgE) and total IgE (tIgE) in serum, cedar pollen antigen (Cry j 1) Cry j-specific memory Th2 cell clone size, and the Cry j-specific induced regulatory T cell (iTreg) level were examined before and after the season in 2008.

RESULTS

Eight of the 33 subjects developed cedar pollinosis. The sIgE titers before the season in these eight subjects did not differ from those in the subjects who did not develop pollinosis, but the titers after the season were significantly higher in the group that developed pollinosis. The sIgE/tIgE ratio increased in almost all subjects, but the ratio was significantly higher before the season in the subjects who developed pollinosis. Cry j-specific Th2 cells were detected in all subjects, but the clone size only increased in those that developed pollinosis. The Cry j-specific iTreg population did not differ between the two groups.

CONCLUSION

A high sIgE/tIgE ratio before the season may be predictive of development of pollinosis, and an increase in the allergen-specific Th2 clone size during the pollen season could be a biomarker for pollinosis. The role of allergen-specific iTreg cells in the development of pollinosis could not be clarified in this preliminary study.

Basophil activation test compared to skin prick test and fluorescence enzyme immunoassay for aeroallergen-specific Immunoglobulin-E

Background

Skin prick test (SPT) and fluorescence enzyme immunoassay (FEIA) are widely used for the diagnosis of Immunoglobulin-E (IgE)-mediated allergic disease. Basophil activation test (BAT) could obviate disadvantages of SPT and FEIA. However, it is not known whether BAT gives similar results as SPT or FEIA for aeroallergens.

Objectives

In this study, we compared the results of SPT, BAT and FEIA for different aeroallergens.

Methods

We performed BAT, SPT and FEIA in 41 atopic subjects (symptomatic and with positive SPT for at least 1 of 9 common aeroallergens) and 31 non-atopic subjects (asymptomatic and with negative SPT).

Results

Correlations between SPT and BAT, SPT and FEIA, and BAT and FEIA results were statistically significant but imperfect. Using SPT as the "gold standard", BAT and FEIA were similar in sensitivity. However, BAT had lower specificity than FEIA. False positive (BAT^posSPT^neg) results were frequent in those atopic subjects who were allergic by SPT to a different allergen and rare in non-atopic subjects. The false positivity in atopic subjects was due in part to high levels of serum Total-IgE (T-IgE) levels in atopic individuals that lead to basophil activation upon staining with fluorochrome-labeled anti-IgE.

Conclusion

As an alternative to SPT in persons allergic to aeroallergens, BAT in its present form is useful for distinguishing atopic from non-atopic persons. However, BAT in its present form is less specific than FEIA when determining the allergen which a patient is allergic to. This is due to IgE staining-induced activation of atopic person's basophils and/or nonspecific hyperreactivity of atopic person's basophils.

Current and future applications of the anti-IgE antibody omalizumab

IgE antibodies are a pivotal factor in pathophysiology of allergic diseases, and the possibility of reducing their level by anti-IgE has long been envisioned. Following several attempts, an effective biologic agent was obtained with the recombinant humanized mono-clonal antibody (rhuMAb)-E25, known as omalizumab. A number of controlled clinical trials demonstrated its efficacy and safety in the treatment of severe allergic asthma uncontrolled by standard drug treatment with maximal recommended doses, and treatment with omalizumab is currently included in international guidelines on asthma management. Other studies reported a clear effectiveness also in allergic rhinitis, but the cost of the anti-IgE treatment suggests its use in patients with rhinitis concomitant with asthma. Other indications to be further investigated are skin disorders such as atopic dermatitis and IgE-mediated urticaria, as well as adverse reactions to foods, with a particularly important role in preventing food-induced anaphylaxis. Finally, there are data indicating the usefulness of omalizumab when used in combination with allergen specific immunotherapy, in terms of reducing the adverse reactions to treatment and increasing the clinical efficacy.

Correlation of routine examinations for the diagnosis of house dust mite allergic rhinitis

OBJECTIVE

To evaluate the correlation between the routine diagnostic tests for house dust mite (HDM) sensitization in Chinese allergic rhinitis (AR) patients, including the skin prick test (SPT), serum HDM-specific immunoglobulin E (sIgE) and nasal smear eosinophilia.

METHODS

The ImmunoCAP assay was employed to detect serum total IgE and sIgE. The SPT and nasal smear eosinophil counts were performed using standard procedures.

RESULTS

Of 82 subjects with HDM-related symptoms and positive SPT results, 55 individuals showed an sIgE level equal to or greater than CAP class 1 for both Dermatophagoides pteronyssinus (Der p) and D. farinae (Der f), and 62 individuals demonstrated positive eosinophils in nasal smears. sIgE of Der p and Der f presented a linear correlation, and the level of serum HDM-sIgE was also positively correlated with total IgE. An increasing sIgE level was correlated with higher SPT grades in both Der p and Der f. Meanwhile, the correlation coefficient exhibited an increase in value with aging, and the 31- to 40-year age group demonstrated the highest value for both Der p and Der f.

CONCLUSION

The positive correlation between SPT and sIgE reaction to HDM varied according to the age of patients with AR.

Allergy-related outcomes in relation to serum IgE: results from the National Health and Nutrition Examination Survey 2005-2006

BACKGROUND

The National Health and Nutrition Examination Survey (NHANES) 2005-2006 was the first population-based study to investigate levels of serum total and allergen-specific IgE in the general US population.

OBJECTIVE

We estimated the prevalence of allergy-related outcomes and examined relationships between serum IgE levels and these outcomes in a representative sample of the US population.

METHODS

Data for this cross-sectional analysis were obtained from NHANES 2005-2006. Study subjects aged 6 years and older (n = 8086) had blood taken for measurement of total IgE and 19 specific IgE levels against common aeroallergens, including Alternaria alternata, Aspergillus fumigatus, Bermuda grass, birch, oak, ragweed, Russian thistle, rye grass, cat dander, cockroach, dog dander, dust mite (Dermatophagoides farinae and Dermatophagoides pteronyssinus), mouse and rat urine proteins, and selected foods (egg white, cow's milk, peanut, and shrimp). Serum samples were analyzed for total and allergen-specific IgE by using the Pharmacia CAP System. Information on allergy-related outcomes and demographics was collected by questionnaire.

RESULTS

In NHANES 2005-2006, 6.6% reported current hay fever, and 23.5% had current allergies. Allergy-related outcomes increased with increasing total IgE levels (adjusted odds ratios for a 10-fold increase in total IgE level of 1.86 [95% CI, 1.44-2.41] for hay fever and 1.64 [95% CI, 1.41-1.91] for allergies). Increased levels of plant-, pet-, and mold-specific IgE contributed independently to allergy-related symptoms. The greatest increase in odds was observed for hay fever and plant-specific IgE (adjusted odds ratio, 4.75; 95% CI, 3.83-5.88).

CONCLUSION

In the US population self-reported allergy symptoms are most consistently associated with increased levels of plant-, pet-, and mold-specific IgE.

Immunoglobulin E in health and disease

The discovery of immunoglobulin E (IgE) was a breakthrough in the field of Allergy and Immunology. Our understanding of mechanisms of allergic reactions and the role of IgE in these disorders has paralleled to the discovery of treatment modalities for patients with allergy. Apart from allergic diseases, IgE is involved in pathogenesis of other disorders. Much controversy exists about the control of total IgE (tIgE) levels and allergen-specific IgE (sIgE) profiles in allergic individuals. This review aims at giving a comprehensive overview of IgE molecule and discussing the issues related to its importance in clinical setting.

Analysis of allergen specific IgE cut points to cat and dog in the Childhood Allergy Study

BACKGROUND

The application of a single allergen specific IgE (sIgE) cut point, such as 0.35 kU/L, to determine sensitization for all allergens may be suboptimal.

OBJECTIVES

To analyze self-reported symptoms suggestive of dog and cat allergy in relation to the test performance characteristics of low level, but reliably detectable, sIgE and to compare these cut points to the traditional 0.35-kU/L cut point.

METHODS

Interviews and blood samples were collected among 564 young adult participants of a general risk birth cohort. Data collected from the participants' parents were analyzed as validation populations. A history of symptoms consistent with allergy on exposure to pets was obtained by standardized questionnaire. Allergen sIgE levels for dog and cat were evaluated with Pharmacia CAP. Receiver operating characteristic curves were constructed and the performance characteristics of the traditional sIgE cut point of 0.35 kU/L were compared with cut points as low as 0.1 kU/L.

RESULTS

Using the Youden J criteria, based on the highest sum of sensitivity and specificity for a diagnostic test, cut points of 0.12 kU/L for cat and 0.2 kU/L for dog were identified as performing optimally among the participant population. In 2 validation populations, consisting of the participants' mothers and fathers, the performance of these alternative cut points were superior or similar to the traditional 0.35-kU/L sIgE level.

CONCLUSIONS

Accurately measured sIgE at levels approaching the lower limit of detection of current assays may be useful in confirming sensitization. Optimal clinical application of these tests will continue to require careful integration of the result and the strength of the patient's history.

Differences and similarities between allergic and nonallergic rhinitis in a large sample of adult patients with rhinitis symptoms

BACKGROUND

Allergic rhinitis (AR) and nonallergic rhinitis (NAR) may present with different clinical and laboratory characteristics.

METHODS

A total of 1,511 consecutive patients, aged 18-81 years, diagnosed with rhinitis, 56% females and 44% males, underwent complete allergic evaluation including skin prick test, blood eosinophil counts, nasal eosinophil counts, peak nasal inspiratory flow (PNIF) measurement and evaluation of nasal symptoms using a visual analog scale (VAS).

RESULTS

A total of 1,107 patients (73%)had AR, whereas 404 (27%) had NAR. Patients with NAR were older and predominantly female. A higher nasal eosinophils count was associated with AR and a lack of clinical response to antihistamines. AR patients had more sneezing and nasal pruritus, whereas NAR was characterized mainly by nasal obstruction and rhinorrhea. AR patients had more severe symptoms and recurrent conjunctivitis, whereas NAR patients had slightly more frequent episodes of recurring headaches as well as olfactory dysfunction. PNIF, blood eosinophil counts and VAS of nasal symptoms were higher in patients with AR. In a final logistic regression model, 10 variables were statistically different between AR and NAR: age [OR 0.97 (95% CI 0.96-0.98)], sneezing [OR 4.09 (95% CI 2.78-6.00)], nasal pruritus [OR 3.84 (95% CI 2.60-5.67)], mild symptoms [OR 0.21 (95% CI 0.09-0.49)], intermittent/severe nasal symptoms [OR 3.66 (95% CI 2.06-6.50)], VAS [OR 1.06 (95% CI 1.04-1.08)], clinical response to antihistamines [OR 22.59 (95% CI 13.79-37.00)], conjunctivitis [OR 4.49 (95% CI 2.86-7.05)], PNIF [OR 1.01 (95% CI 1.00-1.01)] and nasal eosinophil counts [OR 1.14 (95% CI 1.10-1.18)]. Receiver operating characteristic analysis showed high predictive accuracy for a model including these variables independently of the diagnosis of AR/NAR (cutoff <0.74).

CONCLUSIONS

We showed that the several clinical and laboratory parameters reported above may help to reinforce or exclude the diagnosis of AR obtained with skin prick test.

European and Mexican vs US diagnostic extracts of Bermuda grass and cat in skin testing

BACKGROUND

Laboratory testing of various diagnostic extracts has shown lower potencies for several European and Mexican extracts relative to the US Food and Drug Administration (FDA) reference (10,000 BAU/mL). Quantitative skin prick testing (QSPT) with Dermatophagoides pteronyssinus extracts have previously shown a similar picture.

OBJECTIVE

To compare European and Mexican Bermuda grass (BG) and cat diagnostic extracts against an FDA-validated extract using QSPT.

METHODS

Six diagnostic BG and cat extracts (1 reference FDA extract, 3 European extracts, 1 imported nonstandardized extract from the United States, and 1 Mexican extract) were tested with quadruplicate QSPT, as a concentrate and as 2 serial 2-fold dilutions, in cat and BG allergic individuals.

RESULTS

BG showed good dose response in wheal size for the concentrate (1:2-1:4 dilutions; steep part of the curve). Cat showed poorer dose response. The Wilcoxon test for linked random samples was used to investigate whether the distribution of the reference differed from each of the test extracts to a statistically significant degree (2-sided asymptotic significance, α = .05). All BG and 2 cat extracts were statistically less potent than the 10,000 BAU/mL US reference. European BG extracts were 7,700, 4,100, and 1,600 BAU/mL, and cat extracts were 12,500, 4,400, and 5,100 BAU/mL.

CONCLUSIONS

The potency of some diagnostic extracts of BG and cat used in Europe, Mexico, and the United States differs, with the US extracts being generally more potent. On the basis of provocation tests, optimal diagnostic concentrations should be determined. Similar comparisons using other manufacturers and therapeutic extracts might be interesting.