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Dimou MV, Xepapadaki P, Lakoumentas J, Mageiros L, Aggelidis X, Antonopoulou M, Bakakos P, Βotskariova S, Chliveros K, Chrysoulakis S, Dimas D, Douladiris N, Gaga M, Grigoreas C, Kalogiros L, Katotomichelakis M, Kompoti E, Constantinidis J, Koutsogianni Z, Loukides S, Makris M, Manousakis E, Marangoudakis P, Marmara M, Mikos N, Mitsakou P, Mitsias D, Pagalos A, Papanikolaou V, Paraskevopoulos I, Pitsios C, Psarros F, Rovina N, Samitas K, Stefanaki E, Vallianatou M, Vourdas D, Tsiligianni I, Bousquet J, Papadopoulos NG. Levels of IgE sensitization drive symptom thresholds in allergic rhinitis. Ann Allergy Asthma Immunol 2024; 133:177-185.e10. [PMID: 38679157 DOI: 10.1016/j.anai.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/20/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Allergic rhinitis (AR) is a common respiratory disease encompassing a variety of phenotypes. Patients can be sensitized to 1 or more allergens. There are indications that polysensitization is associated with more severe disease. However, the extent to which the level of sensitization is associated with clinical disease variability, underlying the distinct nature of AR from AR+ conjunctivitis or AR+ asthma, is not known. OBJECTIVE To evaluate phenotypical differences between monosensitized and polysensitized patients with AR and to quantify their symptomatic variability. METHODS A total of 565 patients with a confirmed diagnosis of AR were included in this cross-sectional study. Of those, 155 were monosensitized and 410 were polysensitized. Interactions between sensitization levels and the reporting of different symptoms of AR and co-morbidities, disease duration, and impact were assessed. Furthermore, patients were stratified into monosensitized, oligosensitized, and polysensitized to assess whether the effect of sensitization on the phenotype was ranked. RESULTS Polysensitized patients reported itchy eyes significantly more often (P = .001) and had a higher number of ocular (P = .005), itch-related (P = .036), and total symptoms (P = .007) than monosensitized patients. In addition, polysensitized adults and children more often reported wheeze (P = .015) and throat-clearing (P = .04), respectively. Polysensitization was associated with more burdensome AR based on a visual analog scale (P = .005). Increased sensitization level was reflected in more itchy eyes, a higher number of ocular, itch-related, and total number of symptoms, and disease burden. CONCLUSION With an increasing number of sensitizations, patients with AR experience an increased diversity of symptoms. Multimorbidity-related symptoms increase with sensitization rank, suggesting organ-specific thresholds.
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Affiliation(s)
- Maria V Dimou
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Xepapadaki
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - John Lakoumentas
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonardos Mageiros
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Xenophon Aggelidis
- D. Kalogeromitros Allergy Unit, Second Department of Dermatology and Venereology, University General Hospital, National University of Athens Medical School, Attiko, Athens, Greece
| | | | - Petros Bakakos
- First Department of Respiratory Medicine, Medical School, Sotiria Regional Chest Diseases Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Sophia Βotskariova
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Dionysios Dimas
- General Practitioner, Health Centre of Chalastra, Tessaloniki, Greece
| | - Nikolaos Douladiris
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Mina Gaga
- Αsthma Center, Athens Chest Hospital, Sotiria, Athens, Greece
| | - Christos Grigoreas
- Former President of Hellenic Society of Allergology and Clinical Immunology
| | | | | | - Evangelia Kompoti
- Department of Allergology and Clinical Immunology, Laikon General Hospital, Athens, Greece
| | - Jannis Constantinidis
- First Academic Otorhinolaryngology Department, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Stelios Loukides
- Second Respiratory Department, Attiko University Hospital, University of Athens Medical School, Athens, Greece
| | - Michael Makris
- D. Kalogeromitros Allergy Unit, Second Department of Dermatology and Venereology, University General Hospital, National University of Athens Medical School, Attiko, Athens, Greece
| | - Emmanouil Manousakis
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Pavlos Marangoudakis
- Second Otorhinolaryngology Clinic, Attiko University General Hospital, National University of Athens Medical School, Athens, Greece
| | | | - Nikolaos Mikos
- Department of Allergology and Clinical Immunology, Laikon General Hospital, Athens, Greece
| | | | - Dimitrios Mitsias
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Aris Pagalos
- Private Otorhinolaryngologist, Agios Nikolaos, Crete, Greece
| | | | | | | | | | - Nikoletta Rovina
- First Department of Respiratory Medicine, Medical School, Sotiria Regional Chest Diseases Hospital, National Kapodistrian University of Athens, Athens, Greece
| | | | | | - Mina Vallianatou
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ioanna Tsiligianni
- Department of Social Medicine, University of Crete, Heraklion, Crete, Greece
| | - Jean Bousquet
- Montpellier University Hospital, Montpellier, France; MACVIA-France, Contre les Maladies Chroniques pour un Vieillissement Actif en France, European Innovation Partnership on Active and Healthy Ageing Reference Site, Montpellier, France. INSERM, U1168, Ageing and Chronic Diseases Epidemiological and Public Health Approaches, CHRU Arnaud de Villeneuve, Villejuif, France
| | - Nikolaos G Papadopoulos
- Allergy Department, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece.
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Lee HY, Lee SM, Kang SY, Kim K, Kim JH, Ryu G, Min JY, Park KH, Park SY, Sung M, Lee Y, Yang EA, Jee HM, Ha EK, Shin YS, Chung EH, Choi SH, Koh YI, Kim ST, Nahm DH, Park JW, Shim JY, An YM, Han DH, Han MY, Lee YW, Choi JH. KAAACI Guidelines for Allergen Immunotherapy. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:725-756. [PMID: 37957792 PMCID: PMC10643862 DOI: 10.4168/aair.2023.15.6.725] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/16/2023] [Accepted: 10/07/2023] [Indexed: 11/15/2023]
Abstract
Allergen immunotherapy (AIT) is a causative treatment for various allergic diseases such as allergic rhinitis, allergic asthma, and bee venom allergy that induces tolerance to offending allergens. The need for uniform practice guidelines in AIT is continuously growing because of the increasing discovery of potential candidates for AIT and evolving interest in new therapeutic approaches. This guideline is an updated version of the Korean Academy of Asthma Allergy and Clinical Immunology recommendations for AIT published in 2010. This updated guideline proposes an expert opinion by allergy, pediatrics, and otorhinolaryngology specialists with an extensive literature review. The guideline deals with basic knowledge and methodological aspects of AIT, including mechanisms, clinical efficacy, patient selection, allergens extract selection, schedule and doses, management of adverse reactions, efficacy measurements, and special consideration in pediatrics. The guidelines for sublingual immunotherapy will be covered in detail in a separate article.
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Affiliation(s)
- Hwa Young Lee
- Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Min Lee
- Division of Pulmonology and Allergy, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Sung-Yoon Kang
- Division of Pulmonology and Allergy, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Kyunghoon Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ju Hee Kim
- Department of Pediatrics, Kyung Hee University Medical Center, Seoul, Korea
| | - Gwanghui Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Young Min
- Department of Otorhinolaryngology-Head & Neck Surgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Kyung Hee Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - So-Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Myongsoon Sung
- Department of Pediatrics, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Youngsoo Lee
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Eun-Ae Yang
- Department of Pediatrics, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hye Mi Jee
- Department of Pediatrics, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam, Korea
| | - Eun Kyo Ha
- Department of Pediatrics, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Eun Hee Chung
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Hee Choi
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Young-Il Koh
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Seon Tae Kim
- Department of Otolaryngology-Head & Neck Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Dong-Ho Nahm
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Jung Won Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Yeon Shim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - Doo Hee Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Man Yong Han
- Department of Pediatrics, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam, Korea
| | - Yong Won Lee
- Division of Allergy & Clinical Immunology, Department of Internal Medicine, Center for Health Policy Research, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, Korea.
| | - Jeong-Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea.
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3
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Armero G, Penela-Sánchez D, Belmonte J, Gómez-Barroso D, Larrauri A, Henares D, Vallejo V, Jordan I, Muñoz-Almagro C, Brotons P, Launes C. Concentrations of nitrogen compounds are related to severe rhinovirus infection in infants. A time-series analysis from the reference area of a pediatric university hospital in Barcelona. Pediatr Pulmonol 2022; 57:2180-2188. [PMID: 35652447 PMCID: PMC9543680 DOI: 10.1002/ppul.26021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/17/2022] [Accepted: 05/29/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND There is scarce information focused on the effect of weather conditions and air pollution on specific acute viral respiratory infections, such as rhinovirus (RV), with a wide clinical spectrum of severity. OBJECTIVE The aim of this study was to analyze the association between episodes of severe respiratory tract infection by RV and air pollutant concentrations (NOx and SO2 ) in the reference area of a pediatric university hospital. METHODS An analysis of temporal series of daily values of NOx and SO2 , weather variables, circulating pollen and mold spores, and daily number of admissions in the pediatric intensive care unit (PICU) with severe respiratory RV infection (RVi) in children between 6 months and 18 years was performed. Lagged variables for 0-5 days were considered. The study spanned from 2010 to 2018. Patients with comorbidities were excluded. RESULTS One hundred and fifty patients were admitted to the PICU. Median age was 19 months old (interquartile range [IQR]: 11-47). No relationship between RV-PICU admissions and temperature, relative humidity, cumulative rainfall, or wind speed was found. Several logistic regression models with one pollutant and two pollutants were constructed but the best model was that which included average daily NOx concentrations. Average daily NOx concentrations were related with the presence of PICU admissions 3 days later (odds ratio per IQR-unit increase: 1.64, 95% confidence interval: 1.20-2.25)). CONCLUSIONS This study has shown a positive correlation between NOx concentrations at Lag 3 and children's PICU admissions with severe RV respiratory infection. Air pollutant data should be taken into consideration when we try to understand the severity of RVis.
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Affiliation(s)
- Georgina Armero
- Pediatrics Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Pediatrics Intensive Care Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Jordina Belmonte
- Botanic Unit of Animal Biology, Vegetal Biology and Ecology Department, Science and Ambiental Technology Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Diana Gómez-Barroso
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Amparo Larrauri
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Desiree Henares
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Grupo de investigación en enfermedades infecciosas pediátricas, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Violeta Vallejo
- Pediatrics Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Iolanda Jordan
- Pediatrics Intensive Care Unit, Hospital Sant Joan de Déu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Grupo de investigación en enfermedades infecciosas pediátricas, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Carmen Muñoz-Almagro
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Grupo de investigación en enfermedades infecciosas pediátricas, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Molecular Microbiology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Department of Medicine, School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Pedro Brotons
- Grupo de investigación en enfermedades infecciosas pediátricas, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Department of Medicine, School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Cristian Launes
- Pediatrics Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Grupo de investigación en enfermedades infecciosas pediátricas, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
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Food Sensitization Impact on Asthma Attacks in Children According to Age Group. ALLERGIES 2022. [DOI: 10.3390/allergies2020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: The progression of allergy disorders is termed “atopic march.” Having one allergic disorder increases the likelihood of acquiring others. Asthma and food allergies often coexist. There are no thresholds for specific IgE (sIgE) associated with the presence of clinical symptoms. Each allergen shows a particular trend with age. Objective: Our study and analysis aim to identify food sensitization in children with asthma and evaluate its impact on asthma attacks and clinical control. Material and methods: As a part of a bigger study, 56 children (mean age 11.07 years (5.3–17.5), 38 boys, and 18 girls) with bronchial asthma were tested for total IgE and sIgE against food and inhalator allergens. All children performed baseline and post-BD spirometry and were assessed for asthma control. Results: In the studied population of children, sIgE against several food allergens was positive in the same patient. A significant correlation was found between the positive sIgE for milk and soy (p < 0.0001), for milk and egg yolk (p = 0.01), compared to milk and peanuts (p = 0.004), compared to egg yolk and fish (p < 0.0001), compared to egg yolk and casein (p < 0.001), and soy (p < 0.0001). The children who are positive for sIgE antibodies in cats, dogs, Cladosporium, Aspergillus, wormwood from aeroallergens and soy from food allergens have a higher risk of hospitalization for exacerbation of bronchial asthma. (p < 0.05). In the studied population, sensitization to food allergens among asthmatics does not contribute to the number of asthma attacks. Conclusions: Food sensitivity is associated with eczema, while mite sensitization is strongly associated with rhinitis and asthma. Food sensitization is not a risk factor for asthma exacerbation in children older than five years old.
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Di Cicco M, Del Tufo E, Fasola S, Gracci S, Marchi MG, Fibbi L, Cilluffo G, Ferrante G, Peroni DG, La Grutta S. The Effect of Outdoor Aeroallergens on Asthma Hospitalizations in Children in North-Western Tuscany, Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063586. [PMID: 35329272 PMCID: PMC8949088 DOI: 10.3390/ijerph19063586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/04/2022] [Accepted: 03/15/2022] [Indexed: 02/01/2023]
Abstract
Few data are currently available on the effects of aeroallergens in triggering respiratory symptoms in children. To evaluate the potential effects of daily outdoor aeroallergens loads on childhood admissions, in this case-crossover study, we analyzed data from 85 children hospitalized at the University Hospital of Pisa, Italy, for asthma or asthma-like symptoms without respiratory infection, between 2010 and 2019. Data were linked to outdoor allergens, temperature, nitrogen dioxide, and relative humidity observed during the same period. A 10-grains/m3 increase in the total aeroallergen concentration was associated with an increased risk of admission at lag 0 (OR = 1.054, 95% CI: 1.011–1.098), with a smaller effect at lag 1 (OR = 1.037, 95% CI: 1.008–1.067) and lag 2 (OR = 1.021, 95% CI: 1.003–1.039). Trends to larger effects were observed in children with sensitization to one or more aeroallergens (OR = 1.085, 95% CI: 1.004–1.173 at lag 0), in males (OR = 1.069, 95% CI: 1.009–1.132 at lag 0) and in older children (OR = 1.065, 95% CI: 1.007–1.127 at lag 0). Our study shows an association between increased outdoor allergens loads and asthma or asthma-like symptoms in children up to at least two days prior to hospitalization, suggesting that tracking aeroallergen counts may be useful to improve the management of respiratory allergic diseases.
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Affiliation(s)
- Maria Di Cicco
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma n. 55, 56126 Pisa, Italy; (E.D.T.); (S.G.); (D.G.P.)
- Allergology Section, Pediatrics Unit, Pisa University Hospital, Via Roma n. 67, 56126 Pisa, Italy
- Correspondence: ; Tel.: +39-050-992-797
| | - Ester Del Tufo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma n. 55, 56126 Pisa, Italy; (E.D.T.); (S.G.); (D.G.P.)
- Allergology Section, Pediatrics Unit, Pisa University Hospital, Via Roma n. 67, 56126 Pisa, Italy
| | - Salvatore Fasola
- Institute of Translational Pharmacology, IFT, National Research Council, 90146 Palermo, Italy; (S.F.); (S.L.G.)
| | - Serena Gracci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma n. 55, 56126 Pisa, Italy; (E.D.T.); (S.G.); (D.G.P.)
- Allergology Section, Pediatrics Unit, Pisa University Hospital, Via Roma n. 67, 56126 Pisa, Italy
| | - Maria Giovanna Marchi
- Regional Agency for Environmental Protection of Tuscany (ARPAT), 50144 Florence, Italy;
| | - Luca Fibbi
- Laboratory for Meteorology and Environmental Modelling (LaMMA Consortium), 50019 Sesto Fiorentino, Italy;
- Institute of Bioeconomy, IBE, National Research Council, 50019 Sesto Fiorentino, Italy
| | - Giovanna Cilluffo
- Department of Earth and Marine Sciences, University of Palermo, 90123 Palermo, Italy;
| | - Giuliana Ferrante
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Pediatric Division, University of Verona, 37126 Verona, Italy;
| | - Diego G. Peroni
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma n. 55, 56126 Pisa, Italy; (E.D.T.); (S.G.); (D.G.P.)
- Allergology Section, Pediatrics Unit, Pisa University Hospital, Via Roma n. 67, 56126 Pisa, Italy
| | - Stefania La Grutta
- Institute of Translational Pharmacology, IFT, National Research Council, 90146 Palermo, Italy; (S.F.); (S.L.G.)
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Fungal allergic sensitisation in young rural Zimbabwean children: Gut mycobiome and seroreactivity characteristics. CURRENT RESEARCH IN MICROBIAL SCIENCES 2022; 2:100082. [PMID: 35028627 PMCID: PMC8714770 DOI: 10.1016/j.crmicr.2021.100082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 11/20/2022] Open
Abstract
Background The prevalence of allergic diseases has increased over the last few decades, with sensitisation to fungal allergens and gut microbiome dysbiosis implicated in this trend. The fungal community in the gut (mycobiome) has yet to be characterised and related to fungal allergic sensitisation. Thus, we characterised the gut mycobiome and related it to fungal sensitisation and seroreactivity among Zimbabwean children. We further determined the effect of host age, sex, Schistosoma haematobium infection and mycobiome composition on fungal sensitisation and seroreactivity. Methods Using shotgun metagenomic sequencing, we characterised the gut microbiome of stool samples of 116 preschool aged children (PSAC) (≤5 years old, 57(49.1%) male and 59 (50.9%) female). Sensitisation to common fungi in Zimbabwe was assessed using skin prick tests (SPTs). Allergen-specific IgM, IgA, IgG, IgE and IgG4 antibodies were quantified by ELISA. We analysed the relationship between fungal genera and SPT reactivity by ANOVA; fungal genera and IgE antibody reactivity by linear regression; variation in mycobiome abundance with host and environmental factors by PERMANOVA; SPT reactivity and host and environmental factors by logistic regression; seroreactivity and host and environmental factors by ANOVA. Results The mycobiome formed <1% of the sequenced gut microbiome and 228 fungal genera were identified. The most abundant genera detected were Protomyces, Taphrina, and Aspergillus. S.haematobium infection had a significant effect on fungal genera. Prevalence of SPT sensitisation to ≥1 fungal species was 96%, and individuals were frequently sensitised to Saccharomyces cerevisiae. Antibodies were detected in 100% of the population. There was no relationship between mycobiome abundance and IgE titres or IgE/IgG4 ratios for each fungal species; no significant differences between SPT reactivity and abundance of fungal species except for S. cerevisiae; and fungal seroreactivity did not significantly differ with age. There were some sex (m>f for, Epicoccum nigrum and Penicillium chrysogenum) and SPT reactivity -related differences in seroreactivity. Conclusion This is the first comprehensive characterisation of gut mycobiome and fungal allergic sensitisation of rural children in Zimbabwe. Although reported allergic disease is low there is a high percentage of sensitisation. Further studies with larger populations are required to understand the role of the mycobiome in allergic diseases.
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Jung JH, Kim GE, Park M, Kim SY, Kim MJ, Lee YJ, Kim YH, Kim KW, Sohn MH. Changes in allergen sensitization in children with allergic diseases in the 1980 to 2019. ALLERGY ASTHMA & RESPIRATORY DISEASE 2021. [DOI: 10.4168/aard.2021.9.4.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jae Hwa Jung
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Ga Eun Kim
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Mireu Park
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Ju Lee
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Hee Kim
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Hyun Sohn
- Department of Pediatrics, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
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8
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Kim YJ, Lee MY, Yang AR, Sol IS, Kwak JH, Jung HL, Shim JW, Kim DS, Shim JY. Trends of Sensitization to Inhalant Allergens in Korean Children Over the Last 10 Years. Yonsei Med J 2020; 61:797-804. [PMID: 32882764 PMCID: PMC7471077 DOI: 10.3349/ymj.2020.61.9.797] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Climate and lifestyle changes increase an individual's susceptibility to various allergens and also the incidence of allergic diseases. We aimed to examine the changes in sensitization rate for aeroallergens over a 10-year period in Korean children. MATERIALS AND METHODS We retrospectively reviewed the medical records of 4493 children who visited the allergy clinic at a tertiary hospital in Korea for allergic rhinitis or asthma from January 2009 to December 2018. The serum specific immunoglobulin E (IgE) levels were measured to confirm the sensitization against Dermatophagoides farinae (D. farinae), Alternaria, weed and tree pollen mixtures, as well as cat and dog dander through ImmunoCAP test. RESULTS D. farinae was the most common sensitizing aeroallergen (45.9%) during the 10-year span. The sensitization rate for tree pollen mixture (p for trend <0.001), weed pollen mixtures (p for trend <0.001), dog dander (p for trend=0.025), and cat dander (p for trend=0.003) showed ascending trends during the 10-year study period. Furthermore, the sensitization rate for multiple allergens (≥2) in 2018 increased significantly compared to that in 2009 (p for trend=0.013). Compared with children without sensitization to D. farinae, those with sensitization to D. farinae showed higher sensitization rates to other aeroallergens (p for interaction <0.001). CONCLUSION Children's sensitization rate to cat and dog dander and weed and tree pollen mixtures significantly increased during the 10-year period in Korea. Children with sensitization to D. farinae are likely to be sensitized to other aeroallergens as well.
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Affiliation(s)
- Yea Ji Kim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Yeon Lee
- Division of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - A Ram Yang
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Suk Sol
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hee Kwak
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Lim Jung
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Won Shim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Deok Soo Kim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Yeon Shim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
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9
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Lee SW, Yon DK, James CC, Lee S, Koh HY, Sheen YH, Oh JW, Han MY, Sugihara G. Short-term effects of multiple outdoor environmental factors on risk of asthma exacerbations: Age-stratified time-series analysis. J Allergy Clin Immunol 2019; 144:1542-1550.e1. [PMID: 31536730 DOI: 10.1016/j.jaci.2019.08.037] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although the different age groups had differences in sensitivity of asthma exacerbations (AEs) to environmental factors, no comprehensive study has examined the age-stratified effects of environmental factors on AEs. OBJECTIVE We sought to examine the short-term effects in age-stratified groups (infants, preschool children, school-aged children, adults, and the elderly) of outdoor environmental factors (air pollutants, weather conditions, aeroallergens, and respiratory viral epidemics) on AEs. METHODS We performed an age-stratified analysis of the short-term effects of 4 groups of outdoor environmental factors on AEs in Seoul Metropolitan City (Korea) from 2008 and 2012. The statistical analysis used a Poisson generalized linear regression model, with a distributed lag nonlinear model for identification of lagged and nonlinear effects and convergent cross-mapping for identification of causal associations. RESULTS Analysis of the total population (n = 10,233,519) indicated there were 28,824 AE events requiring admission to an emergency department during the study period. Diurnal temperature range had significant effects in pediatric (infants, preschool children, and school-aged children) and elderly (relative risk [RR], 1.056-1.078 and 1.016, respectively) subjects. Tree and weed pollen, human rhinovirus, and influenza virus had significant effects in school-aged children (RR, 1.014, 1.040, 1.042, and 1.038, respectively). Tree pollen and influenza virus had significant effects in adults (RR, 1.026 and 1.044, respectively). Outdoor air pollutants (particulate matter of ≤10 μm in diameter, nitrogen dioxide, ozone, carbon monoxide, and sulfur dioxide) had significant short-term effects in all age groups (except for carbon monoxide and sulfur dioxide in infants). CONCLUSION These findings provide a need for the development of tailored strategies to prevent AE events in different age groups.
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Affiliation(s)
- Seung Won Lee
- Graduate School of Medicine, CHA University, Seongnam, Korea; Department of Data Science, Sejong University College of Software Convergence, Seoul, Korea
| | - Dong Keon Yon
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea; Medical Corps, Republic of Korea Army, Seongnam, Korea
| | - Chase C James
- Scripps Institution of Oceanography, University of California San Diego, San Diego, Calif
| | - Shinhae Lee
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyun Yong Koh
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Youn Ho Sheen
- Department of Pediatrics, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Korea
| | - Jae-Won Oh
- Department of Pediatrics, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Man Yong Han
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea.
| | - George Sugihara
- Scripps Institution of Oceanography, University of California San Diego, San Diego, Calif
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10
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Critical role of interleukin-23 in development of asthma promoted by cigarette smoke. J Mol Med (Berl) 2019; 97:937-949. [PMID: 31020341 DOI: 10.1007/s00109-019-01768-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/12/2019] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Abstract
It has been recently reported that cigarette smoke exposure during allergen sensitization facilitates the development of allergic asthma; however, the underlying mechanisms remain elusive. We evaluated the role of interleukin (IL-23) in a cigarette smoke extract (CSE)-induced Dermatophagoides pteronyssinus (Dp)-allergic asthma mouse model. BALB/c mice were exposed to CSE during allergen sensitization period. Anti-IL-23p19 or IL-23R antibody was administered during the sensitization period. And we evaluated several immunological responses. The expression of IL-23 and IL-23 receptor (IL-23R) was examined in lung tissue. IL-23 and IL-23R expression was increased in the airway epithelium of Dp/CSE co-administered mice. CSE administration during the sensitization promoted Dp-allergic sensitization and the development of asthma phenotypes. Additionally, the proportion of innate lymphoid type 2 cells (ILC2) was also increased by CSE and Dp co-instillation. Anti-IL-23 or IL-23R antibody treatment during allergen sensitization significantly diminished phenotypes of allergic asthma and the ILC2 population. The levels of IL-33 and thymic stromal lymphopoietin (TSLP) were also significantly reduced by anti-IL-23 or IL-23R antibody treatment. IL-23 may thus play a significant role in cigarette smoke-induced allergic sensitization and asthma development. Clinically, the increase in allergen sensitization due to cigarette exposure causes onset of asthma, and IL-23 may be important in this mechanism. KEY MESSAGES: IL-23 and IL-23R expression was increased in the lung epithelium of Dp and CSE co-exposed mice during sensitization period. The population of ILC2s was increased in Dp and CSE co-exposed mice during sensitization period. Anti-IL23 or IL-23R antibody treatment with co-administration of CSE and HDM during sensitization period significantly suppresses ILC2. In vitro, IL-23 blockade in Dp and CSE-stimulated epithelial cells suppressed IL-13 expression in ILC2.
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11
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Tang HH, Teo SM, Belgrave DC, Evans MD, Jackson DJ, Brozynska M, Kusel MM, Johnston SL, Gern JE, Lemanske RF, Simpson A, Custovic A, Sly PD, Holt PG, Holt KE, Inouye M. Trajectories of childhood immune development and respiratory health relevant to asthma and allergy. eLife 2018; 7:35856. [PMID: 30320550 PMCID: PMC6221547 DOI: 10.7554/elife.35856] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 10/05/2018] [Indexed: 12/28/2022] Open
Abstract
Events in early life contribute to subsequent risk of asthma; however, the causes and trajectories of childhood wheeze are heterogeneous and do not always result in asthma. Similarly, not all atopic individuals develop wheeze, and vice versa. The reasons for these differences are unclear. Using unsupervised model-based cluster analysis, we identified latent clusters within a prospective birth cohort with deep immunological and respiratory phenotyping. We characterised each cluster in terms of immunological profile and disease risk, and replicated our results in external cohorts from the UK and USA. We discovered three distinct trajectories, one of which is a high-risk ‘atopic’ cluster with increased propensity for allergic diseases throughout childhood. Atopy contributes varyingly to later wheeze depending on cluster membership. Our findings demonstrate the utility of unsupervised analysis in elucidating heterogeneity in asthma pathogenesis and provide a foundation for improving management and prevention of childhood asthma. Asthma causes wheezy and troubled breathing, and can be life-threatening. Scientists and doctors understand that asthma begins in early childhood. Chest infections, exposure to bacteria, viruses, and allergies may cause or trigger asthma. One person with asthma may not have the same origins as another. But it is not yet clear how various triggers may interact to trigger or exacerbate asthma. To disentangle how these factors contribute to asthma, experts have tried to group people with asthma into subgroups. Unfortunately, the groups often vary from expert to expert. Now, some scientists are using computers to sort patients with asthma. The scientists let the computers decide the best criteria for sorting patients. This way the machines may identify patterns that are not obvious to humans. Using this computer-based approach, Tang et al. sorted Australian children with asthma into 3 groups based on their early life allergies and respiratory health. One group has high-risk asthma with frequent chest infections and strong allergic responses. The other two groups are low-risk, but they respond differently to allergy and infection. Common tests used by doctors to diagnose patients with allergy or asthma may not work the same with all three groups. The bacteria found in the nose influence the risk of asthma, even in patients who are well, and the way this occurs varies by group. Similar groups were also found among children with asthma in the United States and the United Kingdom. Learning more about subgroups of patients with asthma may help other scientists and doctors design better ways to diagnose, treat, or prevent asthma. Working together with scientists around the world to determine how to best describe subgroups of people according to asthma type and risk is a critical step in the process. Tang et al. hope other scientist will test whether these three groups are also found in people from other parts of the world.
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Affiliation(s)
- Howard Hf Tang
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Victoria, Australia.,School of BioSciences, The University of Melbourne, Victoria, Australia
| | - Shu Mei Teo
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Victoria, Australia.,Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | | | - Michael D Evans
- Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,University of Wisconsin School of Medicine and Public Health, Madison, United States
| | - Daniel J Jackson
- University of Wisconsin School of Medicine and Public Health, Madison, United States
| | - Marta Brozynska
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Victoria, Australia.,Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Merci Mh Kusel
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Sebastian L Johnston
- Airway Disease Infection Section, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James E Gern
- University of Wisconsin School of Medicine and Public Health, Madison, United States
| | - Robert F Lemanske
- University of Wisconsin School of Medicine and Public Health, Madison, United States
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, United Kingdom
| | - Adnan Custovic
- Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Peter D Sly
- Telethon Kids Institute, University of Western Australia, Perth, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Patrick G Holt
- Telethon Kids Institute, University of Western Australia, Perth, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Kathryn E Holt
- Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Victoria, Australia.,The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Inouye
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Victoria, Australia.,Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,The Alan Turing Institute, London, United Kingdom
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12
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Leffler J, Stumbles PA, Strickland DH. Immunological Processes Driving IgE Sensitisation and Disease Development in Males and Females. Int J Mol Sci 2018; 19:E1554. [PMID: 29882879 PMCID: PMC6032271 DOI: 10.3390/ijms19061554] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 05/21/2018] [Accepted: 05/21/2018] [Indexed: 01/15/2023] Open
Abstract
IgE sensitisation has increased significantly over the last decades and is a crucial factor in the development of allergic diseases. IgE antibodies are produced by B cells through the process of antigen presentation by dendritic cells, subsequent differentiation of CD4⁺ Th2 cells, and class switching in B cells. However, many of the factors regulating these processes remain unclear. These processes affect males and females differently, resulting in a significantly higher prevalence of IgE sensitisation in males compared to females from an early age. Before the onset of puberty, this increased prevalence of IgE sensitisation is also associated with a higher prevalence of clinical symptoms in males; however, after puberty, females experience a surge in the incidence of allergic symptoms. This is particularly apparent in allergic asthma, but also in other allergic diseases such as food and contact allergies. This has been partly attributed to the pro- versus anti-allergic effects of female versus male sex hormones; however, it remains unclear how the expression of sex hormones translates IgE sensitisation into clinical symptoms. In this review, we describe the recent epidemiological findings on IgE sensitisation in male and females and discuss recent mechanistic studies casting further light on how the expression of sex hormones may influence the innate and adaptive immune system at mucosal surfaces and how sex hormones may be involved in translating IgE sensitisation into clinical manifestations.
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Affiliation(s)
- Jonatan Leffler
- Telethon Kids Institute, The University of Western Australia, 100 Roberts Rd, Subiaco, WA 6008, Australia.
| | - Philip A Stumbles
- Telethon Kids Institute, The University of Western Australia, 100 Roberts Rd, Subiaco, WA 6008, Australia.
- School of Paediatrics and Child Health, The University of Western Australia, Subiaco, WA 6008, Australia.
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, WA 6150, Australia.
| | - Deborah H Strickland
- Telethon Kids Institute, The University of Western Australia, 100 Roberts Rd, Subiaco, WA 6008, Australia.
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13
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Wooldridge AL, McMillan M, Marshall HS, Gatford KL. Relationship between birth weight or fetal growth rate and postnatal allergy: a systematic review protocol. ACTA ACUST UNITED AC 2018; 14:11-20. [PMID: 27941506 DOI: 10.11124/jbisrir-2016-003177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this systematic review is to synthesize the best available evidence on the relationship between size at birth or fetal growth and postnatal allergy. Specifically, this review aims to assess evidence regarding relationships between absolute birth weight at term, birth weight corrected for gestational age, expressed as relative to population or customized growth data, or fetal growth measures and physician-diagnosed or parent- and self-reported postnatal clinical allergic disease (eczema/atopic dermatitis, hay fever/rhinitis, allergic asthma or anaphylaxis).The specific review question is: what is the association between the absolute birth weight at full-term or birth weight relative to population or customized data and corrected for gestational age or direct measures of fetal growth, and physician-diagnosed or parent- and self-reported clinical allergic disease (eczema/atopic dermatitis, hay fever/rhinitis, allergic asthma or anaphylaxis)?
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Affiliation(s)
- Amy L Wooldridge
- 1Robinson Research Institute and School of Medicine, The University of Adelaide, Adelaide, Australia 2Vaccinology and Immunology Research Trials Unit (VIRTU), Women's and Children's Hospital, North Adelaide, Australia
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14
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Lee YJ, Yang HJ, Yoon JS, Han MY, Kim CK, Kim JT. Proper allergen selection for serum specific IgE test in children. ALLERGY ASTHMA & RESPIRATORY DISEASE 2018. [DOI: 10.4168/aard.2018.6.5.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yong Ju Lee
- Department of Pedaitrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Hyeon-Jong Yang
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Jong-Seo Yoon
- Department of Pediatrics, College of Medicine, The Catholic University, Seoul, Korea
| | - Man-Yong Han
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Bundang, Korea
| | - Chang Keun Kim
- Department of Pediatircs, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Jin Tack Kim
- Department of Pediatrics, College of Medicine, The Catholic University, Seoul, Korea
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