The association of individual allergen reactivity with respiratory disease in a national sample: data from the second National Health and Nutrition Examination Survey, 1976-80 (NHANES II)

Tolerogenic nanovaccines for the treatment of type I allergic diseases

The high prevalence of type I allergic diseases such as allergic rhinitis, allergic asthma, food allergies, allergic conjunctivitis, and atopic dermatitis has emerged as a significant public health concern globally. Failure of immune tolerance to ordinarily harmless substances or stimulation, and subsequent induction of T helper 2 cells by antigen-presenting cells evokes the allergic immune response, which results in persistent inflammation, tissue damage, and organ function impairment. Current therapeutic approaches for allergic diseases include avoiding allergen exposure, corticosteroids, biologics, etc. However, these strategies only relieve allergic symptoms but hardly prevent the deteriorative progression and may have adverse effects on patients. With the rapid development of nanotechnology and immunology, emerging tolerogenic nanovaccines represent novel approaches with the potential to cure type I allergic diseases rather than merely alleviate symptoms. In this review, we expound the burgeoning field of tolerogenic nanovaccines against type I allergic diseases, highlight various types of antigens employed in constructing allergen extracts, protein/peptide and nucleic acid-based tolerogenic nanovaccines, and discuss their application in allergic rhinitis, allergic asthma, food allergies, allergic conjunctivitis, and atopic dermatitis.

Indoor and Outdoor Fungal Allergens and Impacts on Respiratory Allergic Disease

Humans have a historic and intimate relationship with fungi. Fungi cause decay in the environment and a variety of human disease states including respiratory disease. Immunocompromised persons are particularly susceptible to fungal infection; however, the greater impact of fungi in general is through allergic mechanisms. This impact has been extensively documented in epidemiologic studies. Typically, fungal spore exposure has been examined in the outdoor environment; however, in recent decades, lifestyle changes have resulted in increased concern about fungi in the indoor environment. This review examines evidence for the relationship between fungal exposure and respiratory disease as indicated by documented physician interactions comparing times of high spore exposure with times of low exposure. The taxa Alternaria has been especially associated with respiratory difficulties, but there is extensive cross-reactivity among fungal allergens. We examine recent evidence that damp housing and associated indoor fungal load relate to respiratory disease and some possible mechanisms by which fungal products might cause sensitivity. We also offer some steps allergists might suggest to their patients that may help alleviate fungal exposure.

Impact of Fungal Spores on Asthma Prevalence and Hospitalization

Despite making up a significant proportion of airborne allergens, the relationship between fungal spores and asthma is not fully explored. Only 80 taxa of fungi have so far been observed to exacerbate respiratory presentations, with Cladosporium spp., Aspergillus spp., Penicillium spp., and Alternaria spp. found to comprise the predominant allergenic airborne spores. Fungal spores have been found in indoor environments, such as hospitals and housing due to poor ventilation. Meanwhile, outdoor fungal spores exhibit greater diversity, and higher abundance and have been associated with hospitalizations from acute asthma presentations. In addition, fungal spores may be the underlying, and perhaps the “missing link”, factor influencing the heightened rate of asthma presentations during epidemic thunderstorm asthma events. To improve our knowledge gap on fungal spores, airborne allergen monitoring must be improved to include not only dominant allergenic fungi but also provide real-time data to accurately and quickly warn the general public. Such data will help prevent future asthma exacerbations and thus save lives. In this review, we examine the health risks of prominent allergenic fungal taxa, the factors influencing spore dispersal and distribution, and why improvements should be made to current sampling methods for public health and wellbeing.

Alpha-1 antitrypsin deficiency is significantly associated with atopy in asthmatic patients

BACKGROUND

Although the etiology and disease mechanisms of asthma and alpha-1 antitrypsin deficiency (AATD) are distinct, several reports indicate that asthma is common in AATD patients, however the relationships between asthma and AATD are poorly described in the literature.

OBJECTIVES

The aim of the study was to investigate in a cohort of outpatients affected by mild to moderate asthma the clinical features that may differentiate asthmatic patients with and without mutation on SERPINA1 gene.

METHODS

Seven hundred thirty-five asthmatic outpatients underwent quantitative analysis of the serum level of alpha-1antitrypsin. According to the literature only sixty-seven out of seven hundred thirty-five asthmatic patients were submitted to genetic analysis to identify AATD and non-AATD subjects. Fifty-eight patients were studied. Clinical and functional data, including lung function, atopy and bronchial hyperactivity, were recorded.

RESULTS

The fifty-eight asthmatic patients were divided in AATD patients (n = 22) and non AATD patients (n = 36), according to genotype. The presence of atopy was significantly higher in patients with AATD than in those without AATD (91% vs. 64%; p = 0.031). AATD patients reported allergic manifestations more than non AATD patients (77% vs. 47%; p = 0.030).

CONCLUSION

Our study shows that the presence of atopy in asthmatic patients with AATD is significantly higher than in asthmatic patients without gene mutation. In addition, a higher percentage of AATD patients self-reported allergic manifestations. No significant differences in respiratory symptoms, physical examination, disease severity or inflammation markers were found between AATD patients and non AATD patients.

Respiratory Health Effects of Exposure to Ambient Particulate Matter and Bioaerosols

Researchers have been studying the respiratory health effects of ambient air pollution for more than 70 years. While air pollution as a whole can include gaseous, solid, and liquid constituents, this article focuses only on the solid and liquid fractions, termed particulate matter (PM). Although PM may contain anthropogenic, geogenic, and/or biogenic fractions, in this article, particles that originate from microbial, fungal, animal, or plant sources are distinguished from PM as bioaerosols. Many advances have been made toward understanding which particle and exposure characteristics most influence deposition and clearance processes in the respiratory tract. These characteristics include particle size, shape, charge, and composition as well as the exposure concentration and dose rate. Exposure to particles has been directly associated with the exacerbation and, under certain circumstances, onset of respiratory disease. The circumstances of exposure leading to disease are dependent on stressors such as human activity level and changing particle composition in the environment. Historically, researchers assumed that bioaerosols were too large to be inhaled into the deep lung, and thus, not applicable for study in conjunction with PM2.5 (the 2.5-μm and below size fraction that can reach the deep lung); however, this concept is beginning to be challenged. While there is extensive research on the health effects of PM and bioaerosols independent of each other, only limited work has been performed on their coexposure. Studying these two particle types as dual stressors to the respiratory system may aid in more thoroughly understanding the etiology of respiratory injury and disease. © 2020 American Physiological Society. Compr Physiol 10:1-20, 2020.

Asthma and/or hay fever as predictors of fertility/impaired fecundity in U.S. women: National Survey of Family Growth

This study addresses whether asthma and/or hay fever predict fertility and impaired fecundity. The lifetime number of pregnancies (fertility) and spontaneous pregnancy losses (impaired fecundity) in 10,847 women representative of the U.S. population 15 to 44 years of age with histories of diagnosed asthma and/or hay fever are analyzed in the 1995 National Survey of Family Growth using multivariable Poisson regression with multiple covariates and adjustments for complex sampling. Smokers have significantly increased fertility compared to nonsmokers. Smokers with asthma only have significantly increased fertility compared to other smokers. Higher fertility is associated with impaired fecundity (ectopic pregnancy, miscarriage, stillbirth). Women with asthma (with and without hay fever) have significantly higher pregnancy losses than women without asthma. With increasing number of pregnancies, smokers have increased pregnancy losses compared to nonsmokers. Smokers, especially those with asthma only, have increased fertility and require special attention as to their family planning needs, reproductive health, and smoking cessation. Women with asthma, regardless of number of pregnancies, and smokers with higher numbers of pregnancies have high risk pregnancies that require optimal asthma/medical management prenatally and throughout pregnancy. Whether a proinflammatory asthma endotype underlies both the increased fertility and impaired fecundity associated with age and smoking is discussed.

Aeroallergen Exposure and Spread in the Modern Era

Since the initial discovery of aeroallergens in the 20th century, our understanding of their properties including sources and factors influencing their spread continues to expand. Both habits of daily living and the presence of environmental factors such as exposure to animals or pollution can influence susceptibility to atopic disease. Because relevant allergens may vary in individuals and communities, it is necessary to understand the physical properties of environmental aeroallergens that are associated with clinical disease to explain symptoms and to implement successful integrated interventions. The objective of this review was to present an overview of aeroallergens and the environmental factors influencing their current distribution. Using historical studies along with recent advancements, we will give an up-to-date description of the physical characteristics and aerodynamics of aeroallergens in addition to location, quantities, and timing of exposure.

Temporal analysis of determinants for respiratory emergency department visits in a large German hospital

INTRODUCTION

Associations between air pollutants, meteorological conditions and respiratory diseases have been extensively shown. The aim of this study was to investigate associations between daily meteorological data, data on air pollution and emergency department (ED) visits depending on the day of the week, season and year (study period from 2013 to 2015).

METHODS

Highly correlated environmental data entered a categorical principal components analysis (CATPCA). We analysed cross-correlation functions between the time series of the respective daily environmental factors and daily ED visits. Time lags with peak correlations of environmental variables obtained by the CATPCA on ED visits together with day of the week, year, running day (linear, quadratic and cubic), season and interaction terms entered the univariate analysis of variance (UNIANOVA) model.

RESULTS

The analyses demonstrated main effects on ED visits for the day of the week with highest admission rates on Mondays (B=10.69; ƞ2=0.333; p<0.001). A significant time trend could be observed showing increasing numbers of ED visits per each year (p<0.001). The variable 'running day' (linear, quadratic and cubic) indicated a significant non-linear effect over time. The variable season showed significant results with winter, spring and summer recording fewer ED visits compared with the reference season autumn. Environmental variables showed no direct associations with respiratory ED visits.

DISCUSSION

ED visits were significantly associated with temporal variables. Our data did not show direct associations between environmental variables and ED visits.In times of rapid urbanisation, increases in respiratory diseases, temperature and air pollution, our analyses can help focus future studies and enhance strategies to reduce increasing numbers of respiratory diseases and ED visits. Because the potential costs of medical care in hospitals can be high compared with physicians, public health recommendations for reducing the increasing ED visits should be promoted and evaluated.

Innate and adaptive immune responses to fungi in the airway

Fungi are ubiquitous outdoors and indoors. Exposure, sensitization, or both to fungi are strongly associated with development of asthma and allergic airway diseases. Furthermore, global climate change will likely increase the prevalence of fungi and enhance their antigenicity. Major progress has been made during the past several years regarding our understanding of antifungal immunity. Fungi contain cell-wall molecules, such as β-glucan and chitin, and secrete biologically active proteases and glycosidases. Airway epithelial cells and innate immune cells, such as dendritic cells, are equipped with cell-surface molecules that react to these fungal products, resulting in production of cytokines and proinflammatory mediators. As a result, the adaptive arm of antifungal immunity, including TH1-, TH2-, and TH17-type CD4+ T cells, is established, reinforcing protection against fungal infection and causing detrimental immunopathology in certain subjects. We are only in the beginning stages of understanding the complex biology of fungi and detailed mechanisms of how they activate the immune response that can protect against or drive diseases in human subjects. Here we describe our current understanding with an emphasis on airway allergic immune responses. The gaps in our knowledge and desirable future directions are also discussed.

Innate Immunity Induced by the Major Allergen Alt a 1 From the Fungus Alternaria Is Dependent Upon Toll-Like Receptors 2/4 in Human Lung Epithelial Cells

Allergens are molecules that elicit a hypersensitive inflammatory response in sensitized individuals and are derived from a variety of sources. Alt a 1 is the most clinically important secreted allergen of the ubiquitous fungus, Alternaria. It has been shown to be a major allergen causing IgE-mediated allergic response in the vast majority of Alternaria-sensitized individuals. However, no studies have been conducted in regards to the innate immune eliciting activities of this clinically relevant protein. In this study, recombinant Alt a 1 was produced, purified, labeled, and incubated with BEAS-2B, NHBE, and DHBE human lung epithelial cells. Alt a 1 elicited strong induction of IL-8, MCP-1, and Gro-a/b/g. Using gene-specific siRNAs, blocking antibodies, and chemical inhibitors such as LPS-RS, it was determined that Alt a 1-induced immune responses were dependent upon toll-like receptors (TLRs) 2 and 4, and the adaptor proteins MYD88 and TIRAP. Studies utilizing human embryonic kidney cells engineered to express single receptors on the cell surface such as TLRs, further confirmed that Alt a 1-induced innate immunity is dependent upon TLR4 and to a lesser extent TLR2.

Asthma Exacerbations: Pathogenesis, Prevention, and Treatment

Guideline-based management of asthma focuses on disease severity and choosing the appropriate medical therapy to control symptoms and reduce the risk of exacerbations. However, irrespective of asthma severity and often despite optimal medical therapy, patients may experience acute exacerbations of symptoms and a loss of disease control. Asthma exacerbations are most commonly triggered by viral respiratory infections, particularly with human rhinovirus. Given the importance of these events to asthma morbidity and health care costs, we will review common inciting factors for asthma exacerbations and approaches to prevent and treat these events.

The International Study of the Allergic Rhinitis Survey: outcomes from 4 geographical regions

Background

Allergic rhinitis (AR) is a global health problem and is characterised by one or more symptoms, including sneezing, itching, nasal congestion and rhinorrhea.

Objective

We investigated the features of AR and the physician's approach to the management of AR patients in four geographical regions.

Methods

In this cross-sectional study, a questionnaire survey concerning AR was completed by Honorary and Corresponding Members of the Italian Society of Rhinology from different countries among 4 world geographical regions—Asia, Europe, the Americas, and Africa.

Results

The prevalence of AR was reported to be 15%–25%. Children and adolescents, as well as young adults, were the age groups more affected by AR with comorbidities of asthma, sinusitis, conjunctivitis, and nasal polyposis. Nasal symptoms of AR were more intense in the spring (51.92%) and autumn (28.85%). The most common aero-allergens were pollen and mites (67.31%), animal dander and pollutants (23.08%), and fungal allergens (21.15%). Allergen-specific immunotherapy was prescribed for both perennial and seasonal allergens (32.69%) via sublingual swallow (46.15%) and subcutaneous (32.69%) routes. For the AR patients, the most prescribed drugs were intranasal corticosteroids (86.54%) and oral H₁-antihistamines (82.69%).

Conclusion

A network of experts can improve our knowledge concerning AR epidemiology, and together with guidelines, could assist practitioners and otolaryngologists in standardising the diagnosis and treatment of AR.

Immunotherapy: Treating with Fewer Allergens?

Polysensitization, sensitization to more than one allergen, is a common feature of patients with allergic rhinitis, and may be a risk factor for subsequent development of allergic diseases, especially allergic asthma. However, a polysensitized patient does not necessarily have polyallergy, a documented, causal relationship between exposure to 2 or more specific, sensitizing allergens and the subsequent occurrence of relevant clinical symptoms of allergy. Allergen immunotherapy treatment strategy for the polysensitized patient in Europe is to treat the single or 2 most clinically relevant allergen(s), whereas patients in the United States are usually treated for all potential clinically relevant allergens.

Comparison between skin prick test and serum immunoglobulin E by CAP system to inhalant allergens

BACKGROUND

Skin prick tests (SPTs) and measurements of serum specific immunoglobulin E (sIgE) antibodies are the most commonly used diagnostic tools for confirming sensitization. However, disagreement between the tests has been observed.

OBJECTIVE

To compare SPT and the CAP system for diagnosis of sensitization to common inhalant allergens.

METHODS

Subjects included 2,635 patients 10 to 90 years old who underwent analyses by SPT and CAP at the Dong-A University Hospital (Busan, Korea) from June 2011 through May 2016. The 2 test results were compared for 17 inhalant allergens.

RESULTS

Agreement between the SPT and sIgE level was 75.3%. Overall agreement was moderate (κ = 0.59), with strong agreement for house dust mites and birch (κ > 0.7) and weak agreement for Tyrophagus putrescentiae and dog (κ < 0.3). When CAP was compared with SPT as the reference, the sensitivity was 75.8% and the specificity was 75.2%. Mean wheal size by SPT showed a positive correlation with sIgE levels (r = 0.59), which decreased with age.

CONCLUSION

There was a discrepancy between SPT and CAP for diagnosing allergic sensitization among inhalant allergens. The allergic sensitization and correlation between the tests decreased with age. Cautious interpretation of the clinical relevance of allergen sensitization based on SPT and CAP results is required, especially in older patients.

Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision

BACKGROUND

Allergic rhinitis (AR) affects 10% to 40% of the population. It reduces quality of life and school and work performance and is a frequent reason for office visits in general practice. Medical costs are large, but avoidable costs associated with lost work productivity are even larger than those incurred by asthma. New evidence has accumulated since the last revision of the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines in 2010, prompting its update.

OBJECTIVE

We sought to provide a targeted update of the ARIA guidelines.

METHODS

The ARIA guideline panel identified new clinical questions and selected questions requiring an update. We performed systematic reviews of health effects and the evidence about patients' values and preferences and resource requirements (up to June 2016). We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence-to-decision frameworks to develop recommendations.

RESULTS

The 2016 revision of the ARIA guidelines provides both updated and new recommendations about the pharmacologic treatment of AR. Specifically, it addresses the relative merits of using oral H₁-antihistamines, intranasal H₁-antihistamines, intranasal corticosteroids, and leukotriene receptor antagonists either alone or in combination. The ARIA guideline panel provides specific recommendations for the choice of treatment and the rationale for the choice and discusses specific considerations that clinicians and patients might want to review to choose the management most appropriate for an individual patient.

CONCLUSIONS

Appropriate treatment of AR might improve patients' quality of life and school and work productivity. ARIA recommendations support patients, their caregivers, and health care providers in choosing the optimal treatment.

The Influence of Asthma and/or Hay Fever on Pregnancy: Data from the 1995 National Survey of Family Growth

BACKGROUND

Asthma is associated with adverse pregnancy outcomes. At the same time there is a worldwide increase in asthma and hay fever.

OBJECTIVE

This study addresses whether asthma and/or hay fever adversely influence pregnancy outcomes.

METHODS

Data from the 1995 National Survey of Family Growth that include a history of diagnosed asthma, hay fever, and adverse pregnancy outcomes in 10,847 women representative of the US population aged 15 to 44 years were analyzed.

RESULTS

Women with the allergic phenotypes asthma and hay fever and hay fever only had no significant increase in adverse pregnancy outcomes (spontaneous pregnancy loss, preterm birth, infant low birth weight), whereas women with the nonatopic phenotype asthma only (without hay fever) did. The study did not evaluate endotypes.

CONCLUSIONS

This study provides new data that the allergic phenotypes, asthma and hay fever and hay fever only, are compatible with healthy pregnancy, whereas the nonatopic asthma phenotype, asthma only, adversely impacts pregnancy.

Indoor Allergens and Allergic Respiratory Disease

PURPOSE OF REVIEW

The purpose of this review is to evaluate the most recent findings on indoor allergens and their impact on allergic diseases.

RECENT FINDINGS

Indoor allergens are present inside buildings (home, work environment, school), and given the chronic nature of the exposures, indoor allergies tend to be associated with the development of asthma. The most common indoor allergens are derived from dust mites, cockroaches, mammals (including wild rodents and pets), and fungi. The advent of molecular biology and proteomics has led to the identification, cloning, and expression of new indoor allergens, which have facilitated research to elucidate their role in allergic diseases. This review is an update on new allergens and their molecular features, together with the most recent reports on their avoidance for allergy prevention and their use for diagnosis and treatment. Research progress on indoor allergens will result in the development of new diagnostic tools and design of coherent strategies for immunotherapy.

Parental exposures to occupational asthmagens and risk of autism spectrum disorder in a Danish population-based case-control study

BACKGROUND

Environmental exposures and immune conditions during pregnancy could influence development of autism spectrum disorder (ASD) in offspring. However, few studies have examined immune-triggering exposures in relation to ASD. We evaluated the association between parental workplace exposures to risk factors for asthma ("asthmagens") and ASD.

METHODS

We conducted a population-based case-control study in the Danish population using register linkage. Our study population consisted of 11,869 ASD cases and 48,046 controls born from 1993 through 2007. Cases were identified by ICD-10 codes in the Danish Psychiatric Central Register. ASD cases and controls were linked to parental Danish International Standard Classification of Occupations (DISCO-88) job codes. Parental occupational asthmagen exposure was estimated by linking DISCO-88 codes to an asthma-specific job-exposure matrix.

RESULTS

Our maternal analyses included 6706 case mothers and 29,359 control mothers employed during the pregnancy period. We found a weak inverse association between ASD and any maternal occupational asthmagen exposure, adjusting for sociodemographic covariates (adjusted OR: 0.92, 95% CI: 0.86-0.99). In adjusted analyses, including 7647 cases and 31,947 controls with employed fathers, paternal occupational asthmagen exposure was not associated with ASD (adjusted OR: 0.98, 95% CI: 0.92-1.05).

CONCLUSIONS

We found a weak inverse association between maternal occupational asthmagen exposure and ASD, and a null association between paternal occupational exposure and ASD. We suggest that unmeasured confounding negatively biased the estimate, but that this unmeasured confounding is likely not strong enough to bring the effect above the null. Overall, our results were consistent with no positive association between parental asthmagen exposure and ASD in the children.

Indoor Allergens and Allergic Respiratory Disease

PURPOSE OF REVIEW

The purpose of this review is to evaluate the most recent findings on indoor allergens and their impact on allergic diseases.

RECENT FINDINGS

Indoor allergens are present inside buildings (home, work environment, school), and given the chronic nature of the exposures, indoor allergies tend to be associated with the development of asthma. The most common indoor allergens are derived from dust mites, cockroaches, mammals (including wild rodents and pets), and fungi. The advent of molecular biology and proteomics has led to the identification, cloning, and expression of new indoor allergens, which have facilitated research to elucidate their role in allergic diseases. This review is an update on new allergens and their molecular features, together with the most recent reports on their avoidance for allergy prevention and their use for diagnosis and treatment. Research progress on indoor allergens will result in the development of new diagnostic tools and design of coherent strategies for immunotherapy.

Age, sex and the association between skin test responses and IgE titres with asthma

BACKGROUND

Skin prick tests (SPTs) and allergen-specific serum IgE (sIgE) measurements are the main diagnostic tools for confirming atopic sensitization. Results are usually reported as 'positive' or 'negative', using the same arbitrary cut-offs (SPT>3 mm, sIgE>0.35 kUA /l) across different ages and sexes. We investigated the influence of age and sex on the interpretation of allergy test in the context of childhood asthma.

METHODS

In a population-based birth cohort (n = 1051), we ascertained the information on asthma/wheeze (validated questionnaires) and performed SPTs and sIgE measurement to inhalant allergens (dust mite, cat, dog) at follow-ups between ages three and 11 years. We investigated the association between quantitative sensitization (sum of SPT mean wheal diameters [MWD] and sIgE titres to the three allergens) and current wheeze and asthma across ages and sexes.

RESULTS

We observed a significant association between the SPT MWD and sIgE titres and wheeze/asthma at most ages and for both sexes. However, the strength of this association was age- and sex-dependent. For SPTs, the strength of the association between MWD and asthma increased with increasing age; we observed the opposite pattern for sIgE titre. For any given SPT MWD/sIgE titre, boys were significantly more likely to express clinical symptoms, particularly in early life; this difference between males and females diminished with age and was no longer significant by age 11 years.

CONCLUSIONS

Age and sex should be taken into account when interpreting the results of skin tests and sIgE measurement, and age- and sex-specific normative data are needed for these allergy tests.

Revisiting the Dutch hypothesis

The Dutch hypothesis was first articulated in 1961, when many novel and advanced scientific techniques were not available, such as genomics techniques for pinpointing genes, gene expression, lipid and protein profiles, and the microbiome. In addition, computed tomographic scans and advanced analysis techniques to dissect (small) airways disease and emphysema were not available. At that time, the group of researchers under the visionary guidance of Professor N. G. M. Orie put forward that both genetic and environmental factors can determine whether one would have airway obstructive diseases, such as asthma and chronic obstructive pulmonary disease (COPD). Moreover, they stipulated that the phenotype of obstructive airway disease could be affected by sex and changes with aging. Orie and colleagues' call to carefully phenotype patients with obstructive airways diseases has been adopted by many current researchers in an attempt to determine the heterogeneity of both asthma and COPD to better define these diseases and optimize their treatment. The founders of the Dutch hypothesis were far ahead of their time, and we can learn from their insights. We should fully characterize all patients in our clinical practice and not just state that they have asthma, COPD, or asthma and COPD overlap syndrome. This detailed phenotyping can help in understanding these obstructive airway diseases and provide guidance for disease management.

Airway hyper-responsiveness to mannitol provides a good evaluation of atopy in childhood asthma

AIM

The relationship between airway hyper-responsiveness (AHR) and atopy has been previously investigated, but there are still some issues to be clarified. The aim of this study was to assess the link between AHR and mannitol and atopy in asthmatic children.

METHODS

We evaluated 44 children with asthma, aged 6-16 years of age, using skin prick tests (SPTs), serum total and specific immunoglobulin E (IgE) levels and the mannitol challenge test (MCT).

RESULTS

We found a good correlation between AHR to mannitol and specific IgE against Dermatophagoides pteronissinus (r = -0.66, p < 0.001) and a weak correlation with specific IgE against dog dander (r = -0.33, p = 0.01) and Aspergillus fumigatus (r = -0.23, p = 0.02). Furthermore, we found a weak correlation between AHR to mannitol and serum total IgE (r = -0.30; p = 0.03), the sum of specific IgE to aeroallergens (r = -0.37, p = 0.01) and the number of positive SPTs (r = -0.31, p = 0.02).

CONCLUSION

Measuring AHR with MCT might provide an accurate evaluation of the degree of atopy in children. The patients with a higher degree of atopy were significantly more reactive to mannitol. In clinical practice, these results indicate that children with asthma who are more atopic may require more intensive treatment strategies to reduce AHR.

House dust-mite allergen exposure is associated with serum specific IgE but not with respiratory outcomes

Exposure to house dust has been associated with asthma in adults, and this is commonly interpreted as a direct immunologic response to dust-mite allergens in those who are IgE sensitized to house dust-mite. Mattress house dust-mite concentrations were measured in a population-based sample of 2890 adults aged between 27 and 56 years living in 22 centers in 10 countries. Generalized linear mixed models were employed to explore the association of respiratory symptoms with house dust-mite concentrations, adjusting for individual and household confounders. There was no overall association of respiratory outcomes with measured house dust-mite concentrations, even in those who reported they had symptoms on exposure to dust and those who had physician-diagnosed asthma. However, there was a positive association of high serum specific IgE levels to HDM (>3.5 kUA /l) with mattress house dust-mite concentrations and a negative association of sensitization to cat with increasing house dust-mite concentrations. In conclusion, there was no evidence that respiratory symptoms in adults were associated with exposure to house dust-mite allergen in the mattress, but an association of house mite with strong sensitization was observed.

The Alternaria genomes database: a comprehensive resource for a fungal genus comprised of saprophytes, plant pathogens, and allergenic species

Background

Alternaria is considered one of the most common saprophytic fungal genera on the planet. It is comprised of many species that exhibit a necrotrophic phytopathogenic lifestyle. Several species are clinically associated with allergic respiratory disorders although rarely found to cause invasive infections in humans. Finally, Alternaria spp. are among the most well known producers of diverse fungal secondary metabolites, especially toxins.

Description

We have recently sequenced and annotated the genomes of 25 Alternaria spp. including but not limited to many necrotrophic plant pathogens such as A. brassicicola (a pathogen of Brassicaceous crops like cabbage and canola) and A. solani (a major pathogen of Solanaceous plants like potato and tomato), and several saprophytes that cause allergy in human such as A. alternata isolates. These genomes were annotated and compared. Multiple genetic differences were found in the context of plant and human pathogenicity, notably the pro-inflammatory potential of A. alternata. The Alternaria genomes database was built to provide a public platform to access the whole genome sequences, genome annotations, and comparative genomics data of these species. Genome annotation and comparison were performed using a pipeline that integrated multiple computational and comparative genomics tools. Alternaria genome sequences together with their annotation and comparison data were ported to Ensembl database schemas using a self-developed tool (EnsImport). Collectively, data are currently hosted using a customized installation of the Ensembl genome browser platform.

Conclusion

Recent efforts in fungal genome sequencing have facilitated the studies of the molecular basis of fungal pathogenicity as a whole system. The Alternaria genomes database provides a comprehensive resource of genomics and comparative data of an important saprophytic and plant/human pathogenic fungal genus. The database will be updated regularly with new genomes when they become available. The Alternaria genomes database is freely available for non-profit use at http://alternaria.vbi.vt.edu.

The Alternaria genomes database: a comprehensive resource for a fungal genus comprised of saprophytes, plant pathogens, and allergenic species

BACKGROUND

Alternaria is considered one of the most common saprophytic fungal genera on the planet. It is comprised of many species that exhibit a necrotrophic phytopathogenic lifestyle. Several species are clinically associated with allergic respiratory disorders although rarely found to cause invasive infections in humans. Finally, Alternaria spp. are among the most well known producers of diverse fungal secondary metabolites, especially toxins.

DESCRIPTION

We have recently sequenced and annotated the genomes of 25 Alternaria spp. including but not limited to many necrotrophic plant pathogens such as A. brassicicola (a pathogen of Brassicaceous crops like cabbage and canola) and A. solani (a major pathogen of Solanaceous plants like potato and tomato), and several saprophytes that cause allergy in human such as A. alternata isolates. These genomes were annotated and compared. Multiple genetic differences were found in the context of plant and human pathogenicity, notably the pro-inflammatory potential of A. alternata. The Alternaria genomes database was built to provide a public platform to access the whole genome sequences, genome annotations, and comparative genomics data of these species. Genome annotation and comparison were performed using a pipeline that integrated multiple computational and comparative genomics tools. Alternaria genome sequences together with their annotation and comparison data were ported to Ensembl database schemas using a self-developed tool (EnsImport). Collectively, data are currently hosted using a customized installation of the Ensembl genome browser platform.

CONCLUSION

Recent efforts in fungal genome sequencing have facilitated the studies of the molecular basis of fungal pathogenicity as a whole system. The Alternaria genomes database provides a comprehensive resource of genomics and comparative data of an important saprophytic and plant/human pathogenic fungal genus. The database will be updated regularly with new genomes when they become available. The Alternaria genomes database is freely available for non-profit use at http://alternaria.vbi.vt.edu .

Allergen skin prick testing in early childhood: reproducibility and prediction of allergic symptoms into early adulthood

OBJECTIVE

To assess the predictive value of skin prick testing in early childhood on subsequent allergic symptoms up to adult age.

STUDY DESIGN

A cohort of 200 unselected healthy newborns was prospectively followed from birth to 20 years of age. Of them, 163 (82%) were reassessed at age 5 years, 150 (76%) at age 11 years, and 164 (83%) at age 20 years with a skin prick test that included 11 common allergens. On the basis of clinical examination and structured interview, the occurrence of atopic dermatitis, allergic rhinoconjunctivitis, recurrent wheezing, and symptoms of food hypersensitivity were recorded at each of the follow-up visits.

RESULTS

The reproducibility of skin prick test positivity at age 5 years was 100% at ages 11 and 20 years, ie, none of the skin prick-positive subjects turned negative during the follow-up. Gaining of new sensitizations to aeroallergens was common. Skin prick test positivity at age 5 years predicted allergic symptoms at ages 11 (sensitivity 28%, specificity 94%) and 20 years (sensitivity 23%, specificity 91%) but not atopic dermatitis.

CONCLUSIONS

Skin prick test positivity at age 5 years strongly predicts later skin prick test positivity and is associated with respiratory symptoms, ie, allergic rhinoconjunctivitis and recurrent wheezing, at ages 11 and 20 years. However, skin prick test negativity at age 5 years does not exclude sensitization and allergic symptoms at a later age.

Frequency of IgE-dependent hypersensitivity to moulds in patients with chronic rhinosinusitis with polyps

INTRODUCTION

The complicated etiology of chronic sinusitis with polyps and frequent allergy to mould is established.

AIM

We aimed to investigate the frequency of the IgE-dependent hypersensitivity in this group of patients and prove the need of surgery in allergic chronic rhinosinusitis patients.

MATERIAL AND METHODS

Forty-two patients (19 females, 23 males) aged 34-73 years (55 ±12.6 years), with chronic sinusitis with polyps were included into the study. Functional endoscopic sinus surgery, laryngological examination, sinus computed tomography scans, and smear from maxillary sinus for microbiological examination were done in all patients. Skin prick tests with common perennial and seasonal inhalant allergens, tIgE and sIgE against moulds were required.

RESULTS

Thirty-two of 42 patients (71.4%) were allergic to at least one inhalant allergen. A mean concentration of total IgE was 241.2 ±186.3 kU/l (35.0-708.0 kU/l) and was lower in patients with fungal culture found in sinus mucin than in patients without fungal presence 75.1 ±54.6 kU/l vs. 284.3 ±204.1 kU/l. We found no difference in the number of positive skin prick tests in a group with and without fungal culture. None of patients with fungal culture found in sinuses presented a detectable level of mold sIgE. All patients with fungal vegetation in sinuses required at least two polypectomy procedures.

CONCLUSIONS

The total IgE concentration was significantly lower in patients with fungal presence in sinuses. Nasal polyps occurred more frequently in patients with fungal presence in sinuses.

Inhaled environmental allergens and toxicants as determinants of the asthma phenotype

The driving environmental factors behind the development of the asthma phenotype remain incompletely studied and understood. Here, we present an overview of inhaled allergic/atopic and mainly nonallergic/nonatopic or toxicant shapers of the asthma phenotype, which are present in both the indoor and outdoor environment around us. The inhaled allergic/atopic factors include fungus, mold, animal dander, cockroach, dust mites, and pollen; these allergic triggers and shapers of the asthma phenotype are considered in the context of their ability to drive the immunologic IgE response and potentially induce interactions between the innate and adaptive immune responses, with special emphasis on the NADPH-dependent reactive oxygen-species-associated mechanism of pollen-associated allergy induction. The inhaled nonallergic/nonatopic, toxicant factors include gaseous and volatile agents, such as sulfur dioxide, ozone, acrolein, and butadiene, as well as particulate agents, such as rubber tire breakdown particles, and diesel exhaust particles. These toxicants are reviewed in terms of their relevant chemical characteristics and hazard potential, ability to induce airway dysfunction, and potential for driving the asthma phenotype. Special emphasis is placed on their interactive nature with other triggers and drivers, with regard to driving the asthma phenotype. Overall, both allergic and nonallergic environmental factors can interact to acutely exacerbate the asthma phenotype; some may also promote its development over prolonged periods of untreated exposure, or possibly indirectly through effects on the genome. Further therapeutic considerations should be given to these environmental factors when determining the best course of personalized medicine for individuals with asthma.

Fungal allergy in asthma-state of the art and research needs

Sensitization to fungi and long term or uncontrolled fungal infection are associated with poor control of asthma, the likelihood of more severe disease and complications such as bronchiectasis and chronic pulmonary aspergillosis. Modelling suggests that >6.5 million people have severe asthma with fungal sensitizations (SAFS), up to 50% of adult asthmatics attending secondary care have fungal sensitization, and an estimated 4.8 million adults have allergic bronchopulmonary aspergillosis (ABPA). There is much uncertainty about which fungi and fungal allergens are relevant to asthma, the natural history of sensitisation to fungi, if there is an exposure response relationship for fungal allergy, and the pathogenesis and frequency of exacerbations and complications. Genetic associations have been described but only weakly linked to phenotypes. The evidence base for most management strategies in ABPA, SAFS and related conditions is weak. Yet straightforward clinical practice guidelines for management are required. The role of environmental monitoring and optimal means of controlling disease to prevent disability and complications are not yet clear. In this paper we set out the key evidence supporting the role of fungal exposure, sensitisation and infection in asthmatics, what is understood about pathogenesis and natural history and identify the numerous areas for research studies.

Prevalence of allergic sensitization in the United States: results from the National Health and Nutrition Examination Survey (NHANES) 2005-2006

BACKGROUND

Allergic sensitization is an important risk factor for the development of atopic disease. The National Health and Nutrition Examination Survey (NHANES) 2005-2006 provides the most comprehensive information on IgE-mediated sensitization in the general US population.

OBJECTIVE

We investigated clustering, sociodemographic, and regional patterns of allergic sensitization and examined risk factors associated with IgE-mediated sensitization.

METHODS

Data for this cross-sectional analysis were obtained from NHANES 2005-2006. Participants aged 1 year or older (n = 9440) were tested for serum specific IgEs (sIgEs) to inhalant and food allergens; participants 6 years or older were tested for 19 sIgEs, and children aged 1 to 5 years were tested for 9 sIgEs. Serum samples were analyzed by using the ImmunoCAP System. Information on demographics and participants' characteristics was collected by means of questionnaire.

RESULTS

Of the study population aged 6 years and older, 44.6% had detectable sIgEs, whereas 36.2% of children aged 1 to 5 years were sensitized to 1 or more allergens. Allergen-specific IgEs clustered into 7 groups that might have largely reflected biological cross-reactivity. Although sensitization to individual allergens and allergen types showed regional variation, the overall prevalence of sensitization did not differ across census regions, except in early childhood. In multivariate modeling young age, male sex, non-Hispanic black race/ethnicity, geographic location (census region), and reported pet avoidance measures were most consistently associated with IgE-mediated sensitization.

CONCLUSIONS

The overall prevalence of allergic sensitization does not vary across US census regions, except in early life, although allergen-specific sensitization differs based on sociodemographic and regional factors. Biological cross-reactivity might be an important but not the sole contributor to the clustering of allergen-specific IgEs.

The relationship of aeroallergen sensitization phenotypes to asthma control in primarily Hispanic asthmatic children

OBJECTIVE

The purpose of this study was to determine whether aeroallergen sensitization phenotypes could predict maintenance of well-controlled asthma.

METHODS

Asthmatic children age 2-18 years who enrolled in the CHOC Children's Breathmobile™ program from April 2002 to December 2011 were included in this retrospective analysis if they had been skin tested to a panel of indoor and outdoor aeroallergens and had returned for follow-up care within 6 months of their baseline visit. The study observation period encompassed all year one visits. Asthma severity and control were defined by NHLBI EPR-3 Guidelines criteria.

RESULTS

In the 1627 primarily Hispanic children evaluated, those with persistent asthma were more likely than those with intermittent disease to be sensitized to each aeroallergen tested and to have more total sensitizations. Children with intermittent, but not persistent, asthma at baseline who were sensitized to pollen2 (trees or weeds) were less likely to maintain well-controlled asthma at follow-up visits. Whereas, sensitization to dander (cat, dog or feather) showed a protective effect to maintenance of well-controlled asthma in patients with persistent, but not intermittent, baseline disease severity.

CONCLUSIONS

Our data suggest that both indoor and outdoor aeroallergens should be assessed regardless of baseline asthma severity, including those with intermittent asthma.

Seasonal variation in skin sensitivity to aeroallergens

Purpose

We previously demonstrated seasonal variation in sensitization to aeroallergens in a small group of patients with exercise-induced asthma. This study was performed to confirm the relationship in a much larger population.

Methods

The charts of 1,891 patients who received allergy skin prick tests were reviewed retrospectively. The test results from subjects aged ≤60 years were compared between the groups classified according to the season when the patients received the tests (spring: March-May, summer: June-August, fall: September-November, winter: December-February). The data from 25 respiratory allergy patients who received the tests two or more times and showed a positive response at least once were analyzed longitudinally.

Results

The most prevalent among 29 tested aeroallergens were house dust mites (HDMs) Dermatophagoides pteronyssinus and D. farinae. The skin sensitization rates to D. pteronyssinus (23.2% vs. 32.1%, P=0.004) and D. farinae (22.2% vs. 30.2%, P=0.009) were significantly lower in the summer and higher in the fall (38.3% vs. 26.6% and 35.6% vs. 25.3%; P=0.001 respectively) than those in other seasons in patients with a respiratory allergy (n=1,102). The sensitization rates to weed pollens in the fall (13.9% vs. 8.3%, P=0.006) and to Aspergillus fumigatus in the winter (2.9% vs. 0.7%, P=0.005) were significantly higher. In patients with non-respiratory allergy such as urticaria/anaphylaxis (n=340), the D. farinae sensitization rate was significantly lower in the summer also but higher in the spring. The trend of the HDM sensitization rate being lower in the summer and higher in the fall was observed in the longitudinal study.

Conclusions

Skin sensitivity to aeroallergens such as HDMs, pollens, and molds demonstrates seasonal variation in respiratory allergy patients. Non-respiratory allergy patients also showed seasonal variation in sensitivity to aeroallergens, which might be related to the "priming" effect of allergens.

Analysis of global gene expression changes in human bronchial epithelial cells exposed to spores of the allergenic fungus, Alternaria alternata

Exposure and sensitivity to ubiquitous airborne fungi such as Alternaria alternata have long been implicated in the development, onset, and exacerbation of chronic allergic airway disorders. This present study is the first to investigate global changes in host gene expression during the interaction of cultured human bronchial epithelial cells and live Alternaria spores. In in vitro experiments human bronchial epithelial cells (BEAS-2B) were exposed to spores or media alone for 24 h. RNA was collected from three biological replicates per treatment and was used to assess changes in gene expression patterns using Affymetrix Human Genome U133 Plus 2.0 Arrays. In cells treated with Alternaria spores compared to controls, 613 probe sets representing 460 individual genes were found differentially expressed (p ≤ 0.05). In this set of 460 statistically significant, differentially expressed genes, 397 genes were found to be up-regulated and 63 were down-regulated. Of these 397 up-regulated genes, 156 genes were found to be up-regulated ≥2 fold. Interestingly, none of the 63 down-regulated genes were found differentially expressed at ≤−2 fold. Differentially expressed genes were identified following statistical analysis and subsequently used for pathway and network evaluation. Interestingly, many cytokine and chemokine immune response genes were up-regulated with a particular emphasis on interferon-inducible genes. Genes involved in cell death, retinoic acid signaling, and TLR3 response pathways were also significantly up-regulated. Many of the differentially up-regulated genes have been shown in other systems to be associated with innate immunity, inflammation and/or allergic airway diseases. This study now provides substantial information for further investigating specific genes and innate immune system pathways activated by Alternaria in the context of allergic airway diseases.

Survey on immunotherapy practice patterns: dose, dose adjustments, and duration

BACKGROUND

Practical issues dealing with the administration of allergen immunotherapy (AIT) by European and US allergists are not well known. Several concerns are only partially covered by guidelines.

OBJECTIVE

To survey AIT practice patterns among worldwide members of the American Academy of Allergy, Asthma and Immunology (AAAAI).

METHODS

A web-based survey was conducted among AAAAI members on dosing, dose adjustment after missed doses, and duration of AIT.

RESULTS

A total of 1,201 replies (24.7% response rate of which 10% of responses were from non-US and non-Canada members). A total of 57% to 65% of the US-Canadian dosing falls within the recommended Practice Parameter ranges (9.4%-19% too low). Dose adjustment after missed doses is based on time elapsed since the last administered dose by 77% of US-Canadian and 58% of non-US-Canadian allergists. Doses are reduced when a patient comes in more than 14 days for 5 weeks after the last administration and initial dosing restarted after more than 30 days for 12 weeks since last administration during the build-up or maintenance stage. After missing 1 to 3 doses, the dosing schedules were mostly followed (build-up phase: repeat last dose, reduce by 1 dose, reduce by 2doses; maintenance phase: reduce by 1 dose, reduce by 2 doses, reduce by 3 doses). AIT is prescribed for a median of 3 years by non-US-Canadian allergists but for a median of 5 years by 75% of US-Canadian allergists. Main reasons for continuing beyond 5 years were "after stopping, symptoms reappeared" or "patient afraid to relapse."

CONCLUSION

Many patients receive less than recommended doses. Two areas in which to plan further research are establishment of an optimal dose-adjustment plan for missed applications and exploration of the maximum appropriate duration of immunotherapy.

Diagnosis and treatment of allergic rhinitis in children: results of the PETRA study

BACKGROUND

Good control of allergic rhinitis (AR) in children is desirable because it is associated with diseases such as asthma. The aim of this analysis of the PETRA study was to characterise its diagnosis and treatment in Spanish children.

METHODS

Data were analysed for paediatric patients (age 5-17 years, inclusive) included in the PETRA study, which included consecutive patients with allergic rhinitis attending respiratory specialists throughout Spain. Demographic information, disease characteristics (duration, severity according to the Allergic Rhinitis and its Impact on Asthma [ARIA] classification), diagnostic procedures, treatments and physicians' attitudes to treatment were recorded.

RESULTS

Of the original sample of 1043 patients, 260 children were included (mean age, 11.7 years; 56.2% boys; 61.9% allergic to house dust mites (HDM) and 38.1% allergic to grass pollen). By ARIA classification, 180/260 (69.4%) had persistent AR and 176/280 (63%) had moderate disease. Asthma was reported in 89/161 (55%) with HDM allergy and 44/99 (45%) with grass pollen allergy. Symptomatic treatment was prescribed in 98.5%, although disease control had been no better than poor in 57.3%. Allergen specific immunotherapy was administered to 56.9%, and was used more often for HDM AR. When asked why specific immunotherapy was not prescribed, two-thirds of the investigators preferred a wait-and-see approach, prescribing immunotherapy if symptoms worsened or asthma developed.

CONCLUSIONS

Paediatric patients treated by specialists for allergic rhinitis have moderate or severe disease. Symptomatic treatment was extensively prescribed but often did not achieve good disease control. Many specialists preferred a wait-and-see approach before prescribing immunotherapy.

Seasonal factors influencing exercise-induced asthma

Purpose

Exercise-induced bronchoconstriction (EIB) in patients with asthma occurs more frequently in winter than in summer. The concentration of house dust mite (HDM) allergens in beds also shows seasonal variation. This study examined the relationship between seasonal differences in the prevalence of EIB and sensitization to HDMs in patients with asthma.

Methods

The medical records of 74 young adult male patients with asthma-like symptoms who underwent bronchial challenge with methacholine, 4.5% saline and exercise, and allergen skin prick tests, were reviewed. The subjects were divided into summer (n=27), spring/fall (n=26) and winter (n=21) groups according to the season during which they underwent testing.

Results

The positive responses to exercise differed according to season (48.1% in summer, 73.1% in spring/fall, and 90.5% in winter; P<0.01). In addition, the prevalence of positive responses to HDM (70.4%, 88.5%, and 95.2%, respectively; P<0.05) and pollen skin tests (37.0%, 19.2%, and 0%, respectively; P<0.01) also showed significant seasonal differences. Severe responses to 4.5% saline showed a similar trend, although it was not statistically significant (44.4%, 50.0%, and 71.4%, respectively; P=0.07). Skin test reactivity to HDMs was significantly related to maximal fall in forced expiratory volume in one second (FEV1) following exercise (r=0.302, P<0.01) and the index of airway hyperresponsiveness (AHR) to 4.5% saline (r=-0.232, P<0.05), but not methacholine (r=-0.125, P>0.05).

Conclusions

Positive skin test reactions to HDMs and EIB occurred in winter, spring/fall, and summer in decreasing order of frequency. Seasonal variation in the prevalence of EIB may be related to seasonal variation in sensitization to HDMs, accompanied by differences in indirect, but not direct, AHR.

Alternaria-induced release of IL-18 from damaged airway epithelial cells: an NF-κB dependent mechanism of Th2 differentiation?

Background

A series of epidemiologic studies have identified the fungus Alternaria as a major risk factor for asthma. The airway epithelium plays a critical role in the pathogenesis of allergic asthma. These reports suggest that activated airway epithelial cells can produce cytokines such as IL-25, TSLP and IL-33 that induce Th2 phenotype. However the epithelium-derived products that mediate the pro-asthma effects of Alternaria are not well characterized. We hypothesized that exposure of the airway epithelium to Alternaria releasing cytokines that can induce Th2 differentiation.

Methodology/Principal Finding

We used ELISA to measure human and mouse cytokines. Alternaria extract (ALT-E) induced rapid release of IL-18, but not IL-4, IL-9, IL-13, IL-25, IL-33, or TSLP from cultured normal human bronchial epithelial cells; and in the BAL fluids of naïve mice after challenge with ALT-E. Both microscopic and FACS indicated that this release was associated with necrosis of epithelial cells. ALT-E induced much greater IL-18 release compared to 19 major outdoor allergens. Culture of naïve CD4 cells with rmIL-18 induced Th2 differentiation in the absence of IL-4 and STAT6, and this effect was abrogated by disrupting NF- κB p50 or with a NEMO binding peptide inhibitor.

Conclusion/Significance

Rapid and specific release of IL-18 from Alternaria-exposed damaged airway epithelial cells can directly initiate Th2 differentiation of naïve CD4⁺ T-cells via a unique NF-κB dependent pathway.

The burden of allergic rhinitis and asthma

Asthma and allergic rhinitis are common health problems that cause major illness and disability worldwide. The prevalence of allergic rhinitis is estimated to range from 10% to 20% in the USA and Europe. Multiple factors contribute to the wide range of reported prevalence rates. These include type of prevalence rate reported (current or cumulative), study selection criteria, age of participants, differences in survey methods, varied geographic locations and socioeconomic status, any of which are significant enough to confound direct comparison between studies. There is no standard set of diagnostic criteria for allergic rhinitis. In most studies, the criteria for diagnosis are based on the subject's reporting, solely by questionnaire and rarely confirmed by skin testing. In addition, most studies focus on hay fever, leaving perennial allergic rhinitis underestimated. Sinus imaging is generally not performed and, therefore, rhinosinusitis not differentiated. Some investigators report 'current' prevalence while others report 'cumulative' or 'lifetime' prevalence. Epidemiologic studies have consistently shown that asthma and rhinitis often coexist in the same patients. The prevalence of asthma is <2% in subjects without rhinitis while it varies from 10% to 40% in patients with rhinitis. Furthermore, the majority of patients with asthma experience rhinitis, which is a factor in the risk for asthma. Despite recognition that allergic rhinitis and asthma are global health problems, there are insufficient epidemiologic data and more data are needed with regard to their etiologic risk factors and natural history. This aim of this review is to enable the reader to discuss prevalence, risk factors and prognosis of allergic rhinitis and asthma.

Quantification of atopy, lung function and airway hypersensitivity in adults

BACKGROUND

Studies in children have shown that concentration of specific serum IgE (sIgE) and size of skin tests to inhalant allergens better predict wheezing and reduced lung function than the information on presence or absence of atopy. However, very few studies in adults have investigated the relationship of quantitative atopy with lung function and airway hyperresponsiveness (AHR).

OBJECTIVE

To determine the association between lung function and AHR and quantitative atopy in a large sample of adults from the UK.

METHODS

FEV1 and FVC (% predicted) were measured using spirometry and airway responsiveness by methacholine challenge (5-breath dosimeter protocol) in 983 subjects (random sample of 800 parents of children enrolled in a population-based birth cohort enriched with 183 patients with physician-diagnosed asthma). Atopic status was assessed by skin prick tests (SPT) and measurement of sIgE (common inhalant allergens). We also measured indoor allergen exposure in subjects' homes.

RESULTS

Spirometry was completed by 792 subjects and 626 underwent methacholine challenge, with 100 (16.0%) having AHR (dose-response slope>25). Using sIgE as a continuous variable in a multiple linear regression analysis, we found that increasing levels of sIgE to mite, cat and dog were significantly associated with lower FEV1 (mite p = 0.001, cat p = 0.0001, dog p = 2.95 × 10-8). Similar findings were observed when using the size of wheal on skin testing as a continuous variable, with significantly poorer lung function with increasing skin test size (mite p = 8.23 × 10-8, cat p = 3.93 × 10-10, dog p = 3.03 × 10-15, grass p = 2.95 × 10-9). The association between quantitative atopy with lung function and AHR remained unchanged when we repeated the analyses amongst subjects defined as sensitised using standard definitions (sIgE>0.35 kUa/l, SPT-3 mm>negative control).

CONCLUSIONS

In the studied population, lung function decreased and AHR increased with increasing sIgE levels or SPT wheal diameter to inhalant allergens, suggesting that atopy may not be a dichotomous outcome influencing lung function and AHR.

Correlation between Asian dust storms and worsening asthma in Western Japan

BACKGROUND

Severe wind storms during spring in East Asia, called Asian dust storms (ADS), have been assessed in the past for their effect on health in Asian countries. Our objective was to study the ADS association with asthma symptoms in adult patients in Japan.

METHODS

We designed a telephone survey to assess ADS influence on upper and lower respiratory, ocular and cutaneous symptoms in 98 patients with adult asthma from April to May 2007. Peak expiratory flow (PEF) was also measured from February to May.

RESULTS

Worsening lower respiratory symptoms were noted by 22 of 98 patients during ADS in April, when Japanese cedar pollen levels also increased. During ADS in May, however, Japanese cedar and cypress pollen levels were not elevated, 11 patients had worsening of lower respiratory symptoms. None required emergency treatment for the exacerbation. Lower respiratory symptoms worsening most were cough and sputum; this was more common in patients with allergic rhinitis or atopy than in those without (P < 0.05). Min%Max differed significantly at 88.7 ± 6.6% during dust dispersion period, defined as the ADS day plus the next 6 days, versus 92.0 ± 5.3% during the 7-day period before a dust storm.

CONCLUSIONS

We found that ADS aggravated lower respiratory symptoms in adult patients with asthma, but this influence was mild.

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.

Clinical evolution of patients with respiratory allergic disease due to sensitisation to Alternaria alternata being treated with subcutaneous immunotherapy

INTRODUCTION

Sensitisation to Alternaria is a cause of respiratory disease in Spain, particularly in childhood, but it is also a significant marker of the severity of this disease. Therefore, the use of an aetiological treatment (allergen specific immunotherapy) is essential, and both subjective and objective clinical parameters should be used to follow up this treatment.

OBJECTIVE

This open-label, uncontrolled, observational, prospective study was designed in order to study the evolution of these patients on allergen specific immunotherapy therapy in daily clinical practice and to assess the use of different monitoring tools.

MATERIAL AND METHODS

A total of 99 patients were included. They were monosensitised to this perennial allergen and treated with subcutaneous allergen specific immunotherapy. After one year of follow-up, these patients were assessed for the presence of symptoms, use of medication, clinical incidents, quality of life and asthma control.

RESULTS

After one year of treatment a significant fall was observed in the use of concomitant medication (β2-agonists: p=0.0278, inhaled corticosteroids: p=0.0007, anti-leukotrienes: p=0.0495), nasal symptoms (p=0.0081), quality of life (PAQLQ, p<0.0001) and asthma control (ACQ, p<0.0001). Twenty-one patients had to attend emergency department due to exacerbation of their allergic disease, and only one of them had to be admitted to hospital.

CONCLUSION

respiratory allergic disease due to Alternaria alternata is a disease which is hard to control, and in our daily practice, the use of specific subcutaneous immunotherapy can be of significant benefit in our paediatric patients.

Associations between atmospheric concentrations of spores and emergency department visits for asthma among children living in Montreal

The authors carried out a time-series study to determine whether short-term increases in the concentrations of spores were associated with emergency department visits from asthma among children 0 to 9 years of age in Montreal, 1994-2004. Concentrations of spores were obtained from one sampling monitor. The authors used parametric Poisson models to model the association between daily admissions to emergency rooms for asthma and ambient exposures to a variety of spores, adjusting for secular trends, changes in weather, and chemical pollutants. For first admissions and exposures to Basidiomycetes, the authors found positive associations at all lags but the concurrent day. For Deuteromycetes and Cladosporium, risks were positive starting at lag 3 days and diminished at lag 6 days. There was little evidence of associations for readmissions, except for Basidiomycetes. The results indicate that Basidiomycetes and Cladosporium spores may be implicated in the exacerbation of asthma among children, most notably in the case of first-time visits to emergency departments, and that the effects appear to be delayed by several days.

Evaluation of optical rhinometry for nasal provocation testing in allergic and nonallergic subjects

OBJECTIVE: Optical rhinometry is a new method that quantifies light extinction in optical density to assess nasal blood volume as a measure of nasal patency. The purpose of this study is to evaluate optical rhinometry as an objective evaluation of nasal patency using nasal provocation testing with histamine and oxymetazoline.

STUDY DESIGN: Prospective pilot.

SETTING: Academic tertiary rhinologic practice.

SUBJECTS AND METHODS: Convenience sample of five adult subjects with allergic rhinitis and five adult normal subjects who underwent challenge with histamine and oxymetazoline. Patients underwent challenge with increasing concentrations of histamine to determine the amount of histamine needed to cause a positive optical rhinometry reading. The same subjects then underwent histamine challenge with this amount followed by oxymetazoline. Nasal patency was assessed subjectively after each challenge with the visual analog scale.

RESULTS: The median histamine amount needed to cause a positive response was statistically lower in allergic rhinitis as compared with nonallergic subjects at 150 μg and 300 μg, respectively ( P = 0.04). When comparing the optical rhinometry with subjective nasal congestion after histamine and oxymetazoline challenges, there was a statistically significant correlation with r = 0.79 ( P = 0.00003).

CONCLUSION: This initial study demonstrates a correlation between subjective symptoms of nasal patency and objective measurements with the optical rhinometer. Less histamine amount necessary to incite nasal congestion in allergic rhinitis suggests that these patients may be primed to the effects of histamine. These preliminary data suggest that optical rhinometry is able to assess changes in nasal patency during challenges with histamine and oxymetazoline.

© 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Culturable mold in indoor air and its association with moisture-related problems and asthma and allergy among Swedish children

In a nested case-control study with 198 children with asthmatic and allergic symptoms (cases) and 202 healthy controls in Värmland, Sweden, we have investigated the relationship between mold spore exposure (mean colony-forming unit) indoor and (i) different indexes of moldy odor indoor (observed by professional inspectors and reported by parents), (ii) visible signs of dampness in the homes of the children (observed and reported), and (iii) doctor-diagnosed asthma/allergy in children. No association was found between the spore concentration indoor and moldy odor and signs of visible dampness in the homes. When a semi-quantitative method in distinguishing between moldy houses or non-moldy houses was used, there were no significant differences between the observed indexes of moldy odor or visible signs of dampness (both observed and reported). No association could be found between the spore concentration in indoor air and asthma/allergy in the children.

PRACTICAL IMPLICATIONS

Mold spore exposure indoor have been suggested as a possible explanation for airway problems such as asthma and allergy among people living in buildings with moisture-related problems. However, this investigation could not find any associations between the spore concentrations in indoor air and signs of dampness and moldy odor reported by parents or observed by professional inspectors. Neither was there any association between the indoor spore concentration and asthma/allergy among children. With these results, there is no reason for one-time air sampling of mold colony-forming unit (CFU) in indoor air of homes to identify risk factors for asthma/allergy in children living in Scandinavian countries.