A European-Japanese study on peach allergy: IgE to Pru p 7 associates with severity

BACKGROUND

Pru p 3 and Pru p 7 have been implicated as risk factors for severe peach allergy. This study aimed to establish sensitization patterns to five peach components across Europe and in Japan, to explore their relation to pollen and foods and to predict symptom severity.

METHODS

In twelve European (EuroPrevall project) and one Japanese outpatient clinic, a standardized clinical evaluation was conducted in 1231 patients who reported symptoms to peach and/or were sensitized to peach. Specific IgE against Pru p 1, 2, 3, 4 and 7 and against Cup s 7 was measured in 474 of them. Univariable and multivariable Lasso regression was applied to identify combinations of parameters predicting severity.

RESULTS

Sensitization to Pru p 3 dominated in Southern Europe but was also quite common in Northern and Central Europe. Sensitization to Pru p 7 was low and variable in the European centers but very dominant in Japan. Severity could be predicted by a model combining age of onset of peach allergy, probable mugwort, Parietaria pollen and latex allergy, and sensitization to Japanese cedar pollen, Pru p 4 and Pru p 7 which resulted in an AUC of 0.73 (95% CI 0.73-0.74). Pru p 3 tended to be a risk factor in South Europe only.

CONCLUSIONS

Pru p 7 was confirmed as a significant risk factor for severe peach allergy in Europe and Japan. Combining outcomes from clinical and demographic background with serology resulted in a model that could better predict severity than CRD alone.

Component-resolved diagnosis and beyond: Multivariable regression models to predict severity of hazelnut allergy

BACKGROUND

Component-resolved diagnosis (CRD) has revealed significant associations between IgE against individual allergens and severity of hazelnut allergy. Less attention has been given to combining them with clinical factors in predicting severity.

AIM

To analyze associations between severity and sensitization patterns, patient characteristics and clinical history, and to develop models to improve predictive accuracy.

METHODS

Patients reporting hazelnut allergy (n = 423) from 12 European cities were tested for IgE against individual hazelnut allergens. Symptoms (reported and during Double-blind placebo-controlled food challenge [DBPCFC]) were categorized in mild, moderate, and severe. Multiple regression models to predict severity were generated from clinical factors and sensitization patterns (CRD- and extract-based). Odds ratios (ORs) and areas under receiver-operating characteristic (ROC) curves (AUCs) were used to evaluate their predictive value.

RESULTS

Cor a 9 and 14 were positively (OR 10.5 and 10.1, respectively), and Cor a 1 negatively (OR 0.14) associated with severe symptoms during DBPCFC, with AUCs of 0.70-073. Combining Cor a 1 and 9 improved this to 0.76. A model using a combination of atopic dermatitis (risk), pollen allergy (protection), IgE against Cor a 14 (risk) and walnut (risk) increased the AUC to 0.91. At 92% sensitivity, the specificity was 76.3%, and the positive and negative predictive values 62.2% and 95.7%, respectively. For reported symptoms, associations and generated models proved to be almost identical but weaker.

CONCLUSION

A model combining CRD with clinical background and extract-based serology is superior to CRD alone in assessing the risk of severe reactions to hazelnut, particular in ruling out severe reactions.

Further studies on the biological activity of hazelnut allergens

Background

Sensitization to hazelnut allergens vary depending on the geographic origin and age of the patients. The objective of this study was to further investigate the allergenic activity of hazelnut allergens using sera from patients recruited in various European regions and presenting different sensitization patterns to hazelnut proteins.

Methods

Natural Cor a 11 and Cor a 9 were purified from hazelnut whereas Cor a 1 and Cor a 8 were produced as recombinant proteins (rCor a 1.04 and rCor a 8). Sera from hazelnut allergic patients were collected in France (n = 5), Switzerland (n = 2), Greece (n = 11) and Spain (n = 3), within the Europrevall project. Total and allergen-specific IgE were quantified by enzyme allergosorbent test and IgE immunoblot were performed using pooled sera from birch-pollen endemic region or from Greece. Histamine Release (HR) assays were performed with stripped basophils passively sensitized with individual sera and challenged by a hazelnut extract or the different hazelnut allergens.

Results

As previously described, hazelnut allergic patients from Mediterranean countries are mainly sensitized to the nsLTP Cor a 8 whereas patients from France and Switzerland are sensitized to pollen-related allergens. Interestingly, an intermediate profile was evidenced in patients from Madrid. Hazelnut 7S globulin (Cor a 11) and 11S globulin (Cor a 9) were found to be minor allergens, recognized only by patients from Mediterranean countries. The biologic activity of the 4 tested allergens, analysed by HR assay, further confirmed the sensitization patterns, but also demonstrated the very high elicitation potency of Cor a 8.

Conclusions

This work, extending previously published researches, represents a step towards the better understanding of the complexity of hazelnut allergy and provides new data on the biological activity of hazelnut allergens and extracts.

Electronic supplementary material

The online version of this article (doi:10.1186/s13601-015-0066-7) contains supplementary material, which is available to authorized users.

The EuroPrevall outpatient clinic study on food allergy: background and methodology

BACKGROUND

The EuroPrevall project aimed to develop effective management strategies in food allergy through a suite of interconnected studies and a multidisciplinary integrated approach. To address some of the gaps in food allergy diagnosis, allergen risk management and socio-economic impact and to complement the EuroPrevall population-based surveys, a cross-sectional study in 12 outpatient clinics across Europe was conducted. We describe the study protocol.

METHODS

Patients referred for immediate food adverse reactions underwent a consistent and standardized allergy work-up that comprised collection of medical history; assessment of sensitization to 24 foods, 14 inhalant allergens and 55 allergenic molecules; and confirmation of clinical reactivity and food thresholds by standardized double-blind placebo-controlled food challenges (DBPCFCs) to milk, egg, fish, shrimp, peanut, hazelnut, celeriac, apple and peach.

RESULTS

A standardized methodology for a comprehensive evaluation of food allergy was developed and implemented in 12 outpatient clinics across Europe. A total of 2121 patients (22.6% <14 years) reporting 8257 reactions to foods were studied, and 516 DBPCFCs were performed.

CONCLUSIONS

This is the largest multicentre European case series in food allergy, in which subjects underwent a comprehensive, uniform and standardized evaluation including DBPCFC, by a methodology which is made available for further studies in food allergy. The analysis of this population will provide information on the different phenotypes of food allergy across Europe, will allow to validate novel in vitro diagnostic tests, to establish threshold values for major allergenic foods and to analyse the socio-economic impact of food allergy.

IgE recognition patterns in peanut allergy are age dependent: perspectives of the EuroPrevall study

BACKGROUND

We tested the hypothesis that specific molecular sensitization patterns correlate with the clinical data/manifestation in a European peanut-allergic population characterized under a common protocol.

METHODS

Sixty-eight peanut-allergic subjects and 82 tolerant controls from 11 European countries were included. Allergy to peanut and lowest symptom-eliciting dose was established by double-blind placebo-controlled food challenge in all but anaphylactic subjects. Information of early or late (before or after 14 years of age) onset of peanut allergy was obtained from standardized questionnaires. IgE to peanut allergens rAra h 1-3, 6, 8-9, profilin and CCD was determined using ImmunoCAP.

RESULTS

Seventy-eight percent of peanut allergics were sensitized to peanut extract and 90% to at least one peanut component. rAra h 2 was the sole major allergen for the peanut-allergic population. Geographical differences were observed for rAra h 8 and rAra h 9, which were major allergens for central/western and southern Europeans, respectively. Sensitization to rAra h 1 and 2 was exclusively observed in early-onset peanut allergy. Peanut-tolerant subjects were frequently sensitized to rAra h 8 or 9 but not to storage proteins. Sensitization to Ara h 2 ≥ 1.0 kUA /l conferred a 97% probability for a systemic reaction (P = 0.0002). Logistic regression revealed a significant influence of peanut extract sensitization and region on the occurrence of systemic reactions (P = 0.0185 and P = 0.0436, respectively).

CONCLUSION

Sensitization to Ara h 1, 2 and 3 is usually acquired in childhood. IgE to Ara h 2 ≥ 1.0 kUA /l is significantly associated with the development of systemic reactions to peanut.

Development of a standardized low-dose double-blind placebo-controlled challenge vehicle for the EuroPrevall project

BACKGROUND

  Double-blind placebo-controlled food challenge (DBPCFC) is the gold standard for diagnosing food allergy. Standardized materials and protocols are essential for comparing DBPCFC results for multicentre studies such as EuroPrevall. This required the development and piloting of a standardized vehicle and low-dose protocol for confirming food allergy and determination of minimum eliciting doses (MEDs).

METHODS

  A low-dose DBPCFC protocol was developed, with eight titrated protein doses from 3 μg to 1 g. This was delivered using a simple, microbiologically stable food base incorporating allergenic food ingredients manufactured at three sites and centrally distributed to clinical centres. Allergen blinding was assessed by a professional sensory testing panel using a triangle test. Homogeneity and allergen content were confirmed by ELISA and clinical efficacy was assessed in a pilot study, using celeriac and hazelnut as exemplars.

RESULTS

  Celeriac and hazelnut ingredients were sufficiently blinded in the dessert. The dessert meals were successfully piloted with hazelnut in allergy clinics in Spain, the Netherlands and Italy and with celeriac and hazelnut in Zurich. The challenges elicited a range of subjective and objective reactions ranging in severity from mild itching of the oral mucosa to bronchospasm.

CONCLUSIONS

  A standardized challenge vehicle proven to sufficiently blind processed, powdered hazelnut and celeriac ingredients and that can be reproducibly manufactured has been developed. This pilot study shows that the vehicle is promising for the confirmation of food allergy and determination of MEDs in adults and children with body weight >28.8 kg (approximately 7-11 years old).

HDAC2 mediates therapeutic resistance of pancreatic cancer cells via the BH3-only protein NOXA

BACKGROUND

Although histone deacetylase inhibitors (HDACi) are promising cancer therapeutics regulating proliferation, differentiation and apoptosis, molecular pathways engaged by specific HDAC isoenzymes in cancer are ill defined.

RESULTS

In this study we demonstrate that HDAC2 is highly expressed in pancreatic ductal adenocarcinoma (PDAC), especially in undifferentiated tumours. We show that HDAC2, but not HDAC1, confers resistance towards the topoisomerase II inhibitor etoposide in PDAC cells. Correspondingly, the class I selective HDACi valproic acid (VPA) synergises with etoposide to induce apoptosis of PDAC cells. Transcriptome profiling of HDAC2-depleted PDAC cells revealed upregulation of the BH3-only protein NOXA. We show that the epigenetically silenced NOXA gene locus is opened after HDAC2 depletion and that NOXA upregulation is sufficient to sensitise PDAC cells towards etoposide-induced apoptosis.

CONCLUSIONS

In summary, our data characterise a novel molecular mechanism that links the epigenetic regulator HDAC2 to the regulation of the pro-apoptotic BH3-only protein NOXA in PDAC. Targeting HDAC2 will therefore be a promising strategy to overcome therapeutic resistance of PDAC against chemotherapeutics that induce DNA damage.

[Decision making in borderline situations--anesthesiological aspects]

Over the last few decades, major biomedical developments have been taken place so that dying and death are nowadays more a matter of deliberate decision--a change that has profound ethical and legal implications. This progress has influenced medical decision-making generally and intensively, especially that of the surgeon and the anaesthesiologist. The representatives of these professions are often confronted with problems of life-sustaining therapy at the beginning and the end of life and of resuscitative measures. The surgeon and the anaesthesiologist have to accept the necessity of close partnership while maintaining a clear dividing-line between their responsibilities, but at the same time jointly doing their utmost for the good of the patient. Above all the physician has to give due consideration to the patient's will, but there are many and sometimes great variations in the individual situations of conscious or permanently unconscious patients. The highest courts in Germany have laid down that the principles of medical ethics must supplement the law.

Permanent monocular blindness and ocular migraine

Images

[Pain and the experience of pain]

Pain research has been considerably expanded in the past few decades. Pain sensation must be differentiated from pain perception. The psychological experience of pain varies individually and depends on each patient's conditioning. Although there is an abundance of analgesics and sedatives, the patients' attitude towards pain and suffering, his or her motivation, past experiences, social environment and susceptibility towards suggestive guidance are of great importance.

[Respiratory depression after diazepam-fentanyl anaesthesia (author's transl)]

105 patients were given diazepam-fentanyl anaesthesia and the respiratory values were studied spirometrically before the operation, after intramuscular premedication and postoperatively (i.e. after additional doses of diazepam during induction). The occurrence of respiratory depression which has been reported by some authors was confirmed. Blood gas analyses performed in 79 patients during the recovery period showed a significant improvement after the patients had been made to breathe deeply for five minutes. The results confirm the observations made in more than 12000 patients who had this type of anaesthesia that they must be kept under surveillance during the first 30-40 minutes in the recovery ward, but can then be returned to the ward.

Renal malposition associated with omphalocele

Nine patients with omphalocele had abnormally positioned kidneys; in 8, the kidneys were more cephalad than normal, immediately subdiaphragmatic in position. In one patient the kidneys were more caudal than normal. This renal malposition should be recognized in order to avoid unnecessary imaging procedures in patients with omphalocele.

[Experiences in the treatment of children with pseudocroup (author's transl)]

In most of the own 93 cases the paediatrician could manage the syndrome conservatively. In 14 children of them the question of an active procedure was discussed in cooperation of paediatricians, laryngologists and anaesthesiologists. In most of the cases this was necessary in the first 2 to 3 hours after admission. Recommendations for the active procedure are given in detail, generally spoken a balanced manner with confined prolonged orotracheal intubation.

[Long-term intubation (author's transl)]

Establishment of a clear airway has become increasingly frequent and is of high importance, especially in patients with severe injuries, head injuries or intoxications. Though the endotracheal intubation-technique has been improved and soft intubation-tubes are now available, tracheostomy is not rendered unnecessary. However, its indications have changed and have become restricted. This trend was proved by the own experiences in 841 patients. The presuppositions for nasal long-term intubation are described in details.

[Anaesthesia for diagnostic and therapeutic endoscopy procedures (author's transl)]

The experienced anaesthetist in endoscopic anaesthesia in otolaryngology appreciates the need for adequate alveolar ventilation and that the risks are considerable. Certain principles, which have been found useful are presented. From five anaesthetic techniques for laryngeal microsurgery the injector method is described in detail. This method has proved very advantageous especially for surgical procedures on the posterior laryngeal commissure and for the treatment in special instances of tracheal stenosis. The technique mentioned were used without serious complications in about 1000 endoscopies in the last five years.

[Must therapy be continued at all costs (author's transl)]

In acknowledging the remarkable progress of medicine, the possible consequential harmful effects should not be overlooked. Judgement should be based on the total welfare of the patient and not on the ease with which technical procedures can be executed. The prolongation of life per se by any means is not the only principal of conduct, especially when it results in extension of the patient's misery. In some situations it may be necessary to renounce any form of treatment from the beginning or to abandon any already in progress. This apparent harshness however does not imply that the terminally ill must be abandoned in his suffering.