Stress, mindfulness, and the allergic patient

Mast Cell Activation Syndrome and Gut Dysfunction: Diagnosis and Management

PURPOSE OF REVIEW

Mast cell activation syndrome (MCAS) is a clinical disorder that may explain irritable bowel syndrome (IBS) type symptoms as well as other allergic symptoms experienced by an individual. The diagnosis and treatment of MCAS with specific focus on gastrointestinal (GI) manifestations is reviewed.

RECENT FINDINGS

Although biomarkers for MCAS remain elusive, testing for baseline serum tryptase will distinguish the type of mast cell disorder and urine tests for mast cell mediator metabolites may support the diagnosis. Endoscopy and Colonoscopy with biopsies is not used to diagnose MCAS but is important to rule out other conditions that may cause symptoms. There is increased awareness of the association between MCAS and autonomic dysfunction, small fiber neuropathy, and connective tissue disorders which all impact GI symptoms. MCAS is a disorder often of unknown etiology (idiopathic) and characterized by intermittent allergy type symptoms that affect multiple organ systems after exposure to a trigger. GI symptoms including abdominal cramping and loose stool are prominent and mimic those of IBS. Diagnostic testing is performed to assess for elevations in mast cell mediators during symptoms and to rule out other conditions. A comprehensive treatment plan includes medications that target mast cells, treatments for associated conditions including autonomic dysfunction, and management of comorbid psychiatric illness and nutritional deficits.

Work-related stress and atopic dermatitis: Results from the study on occupational allergy risks

Chronic stress at work is ubiquitous in modern societies. However, its influence on atopic dermatitis (AD) has hardly been investigated. This study aimed to elucidate the association between work-related stress and AD via a longitudinal study. The analysis comprised data from three phases (2002-2003, 2007-2009, 2017-2018) of the prospective Study on Occupational Allergy Risks (SOLAR), including 1,240 young adults aged 16 to 18 years at baseline (61% female) who were originally recruited for the International Study of Asthma and Allergies in Childhood Phase II in 1995-1996. AD was assessed at all three phases based on self-reports of a physician's diagnosis and symptoms. Work-related stress was measured at all three periods using the work discontent and work overload scales from the Trier Inventory for the Assessment of Chronic Stress with adaptions to school and university. Generalized estimating equations were used to analyze the association between stress and AD, treating work discontent and work overload first as continuous and then as categorical exposure variables. We observed 50 AD cases (4%) at SOLAR I, 48 (4%) at SOLAR II, and 42 (3%) at SOLAR III. A one-point increase in the work discontent score was associated with an odds ratio (OR) for AD of 1.05 (95% confidence interval [CI], 1.00-1.10). The respective increase in the work overload score led to an OR of 1.03 (95% CI, 0.99-1.06). In the categorical analysis, there was no clear indication of elevated odds of AD in the highest vs. lowest exposure group (4th vs. 1st quartile: OR, 1.53; 95% CI, 0.92-2.53 for work discontent; OR, 1.38, 95% CI, 0.83-2.27 for work overload). Altogether, we observed limited to no evidence for an association between work-related stress and AD. Our study's ability to detect stronger evidence may have been compromised by shortcomings such as nondifferential misclassification of the outcome or insufficient statistical precision due to small numbers of AD cases. Another explanation could be that AD predominantly becomes evident in childhood, not in adulthood.

Respiratory psychophysiology and COVID-19: A research agenda

After multiple waves of the COVID-19 pandemic, it has become clear that the impact of SARS-CoV-2 will carry on for years to come. Acutely infected patients show a broad range of disease severity, depending on virus variant, vaccination status, age and the presence of underlying medical and physical conditions, including obesity. Additionally, a large number of patients who have been infected with the virus present with post-COVID syndrome. In September 2020, the International Society for the Advancement of Respiratory Psychophysiology organized a virtual interest meeting on 'Respiratory research in the age of COVID-19', which aimed to discuss how research in respiratory psychophysiology could contribute to a better understanding of psychophysiological interactions in COVID-19. In the resulting current paper, we propose an interdisciplinary research agenda discussing selected research questions on acute and long-term neurobiological, physiological and psychological outcomes and mechanisms related to respiration and the airways in COVID-19, as well as research questions on comorbidity and potential treatment options, such as physical rehabilitation.

Allergy education and training for physicians

The increasing prevalence of allergic diseases has placed a significant burden on global healthcare and society as whole. This has necessitated a rapid development of "allergy" as a specialist area. However, as allergy is so common and, for most, relatively easy to diagnose and control, all clinicians need to have basic knowledge and competence  to manage  mild disease and recognize when referral is required. The allergology specialty has not yet been recognized in many countries and even where allergy is fully recognized as a specialty, the approach to training in allergy differs significantly. In the light of recent developments in allergy diagnosis and management, there is an urgent need to harmonize core competences for physicians, as well as the standardization of core principles for medical education and post-graduate training in allergy. All physicians and allied health professionals must appreciate the multidisciplinary team (MDT) approach to allergy, which is key to achieving the highest standards in holistic care. Due to worldwide variation in resources and personnel, some MDT roles will need to be absorbed by the treating physician or other healthcare professionals. We draw particular attention to the role of psychological input for all allergy patients, dietetic input in the case of food allergy and patient education to support all patients in the supported self-management of their condition on a daily basis. A strong appreciation of these multidisciplinary aspects will help physicians provide quality patient-centered care. We consider that harmonization of allergy components within undergraduate curricula is crucial to ensure all physicians develop the appropriate allergy-related knowledge and skills, particularly in light of inconsistencies seen in the primary care management of allergy. This review from the World Allergy Organization (WAO) Education and Training Committee also outlines allergy-related competences required of physicians working with allergic patients and provides recommendations to promote harmonization of allergy training and practice worldwide.

Association of stress and functional gastrointestinal disorders in high school graduates

BACKGROUND

Psychosocial factors are seemed as important causes of functional gastrointestinal disorders (FGIDs). However, the role of stress in FGIDs in high school students under the pressure of college entrance examination is largely unknown. The aim of this study is to investigate the association between the stress and FGIDs in high school graduates.

METHODS

A cross-sectional survey was conducted in randomly selected high school fresh graduates. Questionnaires concerned health condition, living habits, gastrointestinal symptoms and life stress were given out and be finished voluntarily. Participants were diagnosed as FGIDs based on the Rome IV criteria.

RESULTS

Stress level of FGIDs population was higher than control group and stress was independent predicted factor of high risk of FGIDs. The stressor "changes" was significantly correlated with functional gastroduodenal disorders (OR1.118(1.011-1.238)). Stressor "frustration" was significantly correlated with functional bowel disorders (OR1.038(1.006-1.071)). "Physiological reaction" was correlated with functional bowel disease and functional gastroduodenal disorders + functional bowel disorders (OR1.027(1.007-1.046) and OR1.055(1.000-1.113)). Students with more than one gastrointestinal symptom exhibited higher stress level. Moreover, there was mediation effect of stress in the association between gender, sleep quality, allergies and FGIDs.

LIMITATIONS

This was a cross-section study and the sample included in the study were only from Wuhan, China.

CONCLUSIONS

Our findings illustrated the predicted and mediated role of stress in FGIDs in high school fresh graduates. Different stressors and reactions to stressors contributed to different FGIDs. Intervening measures aimed at stress coping strategies were warranted for students in daily school life.

Association of stress management skills and stressful life events with allergy risk: a case-control study in southern China

BACKGROUND

Psychosocial stress and stressful life events are known to aggravate allergic diseases. Less is known about the impact of stress management skills on allergies. Here we sought to determine whether stress management skills are associated with the allergies and to assess the combined effects of stress management skills and stressful events on allergy risk.

METHODS

A survey on risk factors for self-reported allergic diseases was carried out among 28,144 southern Chinese people; 14 stressful life events and 8 stress management skills were retrospectively recorded in a case-control setting with multivariate logistic regression analysis. Multiplicative and additive interactions between stressful events and stress management skills were evaluated.

RESULTS

Stressful events significantly increased allergy risk. The odds ratio (OR) for allergies was 1.65 (95% confidence interval CI, 1.41-1.93) for those reporting one or two stressful events and 3.10 (95% CI, 2.55-3.79) for those reporting more than three stressful events compared to participants without stressful events. Stress management skills were adversely associated with allergic risk for people experiencing stressful events (OR, 0.71; 95% CI, 0.53-0.97) when adjusted demographically, particularly "concentrate on pleasant thoughts at bedtime" (OR, 0.67; 95% CI, 0.51-0.89), "pace myself to prevent tiredness" (OR, 0.67; 95% CI, 0.54-0.83), "get enough sleep" (OR, 0.48; 95% CI, 0.32-0.72) and "take some time for relaxation each day" (OR, 0.55; 95% CI, 0.37-0.80). But in people without stressful events, no association was observed. There was a significant linear trend for allergy risk from good stress management skills with no stressful events to poor stress management skills with stressful events (P < 0.001), with significant interaction in additive models (P = 0.006).

CONCLUSIONS

There are independent and antagonistic combined associations of stressful life events and stress management skills with allergy risk. The data supports the use of stress management skills in managing allergic disease among people with stressful life events.

Advances and novel developments in environmental influences on the development of atopic diseases

Although genetic factors play a role in the etiology of atopic disease, the rapid increases in the prevalence of these diseases over the last few decades suggest that environmental, rather than genetic factors are the driving force behind the increasing prevalence. In modern societies, there is increased time spent indoors, use of antibiotics, and consumption of processed foods and decreased contact with farm animals and pets, which limit exposure to environmental allergens, infectious parasitic worms, and microbes. The lack of exposure to these factors is thought to prevent proper education and training of the immune system. Increased industrialization and urbanization have brought about increases in organic and inorganic pollutants. In addition, Caesarian birth, birth order, increased use of soaps and detergents, tobacco smoke exposure and psychosomatic factors are other factors that have been associated with increased rate of allergic diseases. Here, we review current knowledge on the environmental factors that have been shown to affect the development of allergic diseases and the recent developments in the field.

The impact of psychological stress on mast cells

OBJECTIVE

Atopic diseases worsen with psychological stress, but how stress contributes to their pathogenesis is still not clear. We review the evidence supporting the premise that stress contributes to allergic and inflammatory processes through stimulation of mast cells (MCs) by neuroimmune stimuli.

DATA SOURCES

PubMed was searched between 1950 and 2019 using the following terms: allergies, atopic diseases, corticotropin-releasing hormone, inflammation, hypothalamic-pituitary-adrenal axis, mast cells, mastocytosis, neuropeptides, psychological stress, neurotensin, and substance P.

STUDY SELECTIONS

Only articles published in English were selected based on their relevance to stress and MCs, especially those that discussed potential mechanisms of action.

RESULTS

Psychological stress worsens many diseases, especially asthma, atopic dermatitis, and mastocytosis. This effect is mediated through MCs stimulated by neuropeptides, especially corticotropin-releasing hormone, neurotensin, and substance P, a process augmented by interleukin-33.

CONCLUSION

Understanding how stress stimulates MCs to release proinflammatory mediators is important in advancing treatments for diseases that worsen with stress.

Effect of Stress on Neuroimmune Processes

PURPOSE

Psychological stress worsens many diseases, especially those with inflammatory components, such as atopic dermatitis (AD) and autism spectrum disorder (ASD), conditions that are significantly correlated in large epidemiologic studies. However, how stress contributes to these conditions is still poorly understood. This narrative review of the relevant literature advances the premise that stress affects inflammatory processes in AD and ASD via stimulation of mast cells (MCs).

METHODS

MEDLINE was searched between 1980 and 2019 using the terms allergies, atopic dermatitis, autism spectrum disorder, brain, corticotropin-releasing hormone, inflammation, hypothalamic-pituitary-adrenal axis, mast cells, neuropeptides, stress, neurotensin, and substance P.

FINDINGS

Exposure to psychological stress is associated with onset and/or exacerbation of AD and ASD. This association could be attributable to activation of MCs, which are ubiquitous in the body, including the brain, and could contribute to inflammation.

IMPLICATIONS

Understanding and addressing the connection between stress and MCs is important in clarifying the pathogenesis and developing effective treatments for diseases that worsen with stress and involve inflammation, such as AD and ASD.

Reprogramming of the Immune System by Stress and Faulty Hormonal Imprinting

PURPOSE

Hormonal imprinting is taking place perinatally at the first encounter between the developing hormone receptors and their target hormones. However, in this crucial period when the developmental window for physiological imprinting is open, other molecules, such as synthetic hormones and endocrine disruptors can bind to the receptors, leading to faulty imprinting with life-long consequences, especially to the immune system. This review presents the factors of stress and faulty hormonal imprinting that lead to reprogramming of the immune system.

METHODS

Relevant publications from Pubmed since 1990 were reviewed and synthesized.

FINDINGS

The developing immune system is rather sensitive to hormonal effects. Faulty hormonal imprinting is able to reprogram the original developmental program present in a given cell, with lifelong consequences, manifested in alteration of hormone binding by receptors, susceptibility to certain (non-infectious) diseases, and triggering of other diseases. As stress mobilizes the hypothalamic-pituitary-adrenal axis if it occurred during gestation or perinatally, it could lead to faulty hormonal imprinting in the immune system, manifested later as allergic and autoimmune diseases or weakness of normal immune defenses. Hormonal imprinting is an epigenetic process and is carried to the offspring without alteration of DNA base sequences. This means that any form of early-life stress alone or in association with hormonal imprinting could be associated with the developmental origin of health and disease (DOHaD). As puberty is also a period of reprogramming, stress or faulty imprinting can change the original (developmental) program, also with life-long consequences.

IMPLICATIONS

Considering the continuous differentiation of immune cells (from blast-cells) during the whole life, there is a possibility of late-imprinting or stress-activated reprogramming in the immune system at any periods of life, with later pathogenetic consequences.