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Dreborg S, Walter G, Kim H. International recommendations on epinephrine auto-injector doses often differ from standard weight-based guidance: a review and clinical proposals. Allergy Asthma Clin Immunol 2022; 18:102. [PMID: 36471385 PMCID: PMC9724388 DOI: 10.1186/s13223-022-00736-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 10/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In anaphylaxis, the dosing of injectable epinephrine in medical settings has been arbitrarily recommended to be 0.01 mg/kg of body weight. For ethical reasons, there have been no dose-response studies or double-blind studies performed on patients with active anaphylaxis. Intramuscular delivery of epinephrine has been the standard. Auto-injectors for use in the treatment of anaphylaxis are available in four strengths (0.1, 0.15, 0.3, and 0.5 mg). However, in many countries, only the 0.15 and 0.3 mg strengths are available. Consequently, many adult, heavy patients are prescribed the 0.3 mg dose, which may result in only one-fifth to one-third of the recommended weight-based dose being administered in heavy patients experiencing anaphylaxis. Underdosing may have therefore contributed to mortality in anaphylaxis. OBJECTIVE To review the doses of epinephrine recommended for the treatment of anaphylaxis in the community, and assess whether recommendations should be made to increase dosing for heavy adult patients in hopes of avoiding future deaths from anaphylaxis. METHODS We reviewed multiple national and international recommendations for the dosing of epinephrine. We also reviewed the literature on adverse drug reactions from epinephrine, lethal doses of epinephrine, and epinephrine dose-finding studies. RESULTS The majority of national and regional professional societies and authorities recommend epinephrine delivered by auto-injectors at doses far lower than the generally accepted therapeutic dose of 0.01 mg/kg body weight. Furthermore, we found that the recommendations vary even within regions themselves. CONCLUSIONS We suggest prescribing more appropriate doses of epinephrine auto-injectors based on weight-based recommendations. There may be some exceptions, such as for patients with heart disease. We hypothesize that these recommendations will lead to improved outcomes of anaphylaxis.
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Affiliation(s)
- Sten Dreborg
- grid.8993.b0000 0004 1936 9457Department of Child and Adolescent Allergology, Women’s and Children’s Health, University of Uppsala, Uppsala, Sweden
| | - Graham Walter
- grid.39381.300000 0004 1936 8884Department of Medicine, Western University, London, ON Canada ,grid.39381.300000 0004 1936 8884Division of Clinical Immunology and Allergy, Western University, London, ON Canada
| | - Harold Kim
- grid.39381.300000 0004 1936 8884Department of Medicine, Western University, London, ON Canada ,grid.39381.300000 0004 1936 8884Division of Clinical Immunology and Allergy, Western University, London, ON Canada ,grid.25073.330000 0004 1936 8227Department of Medicine, McMaster University, Hamilton, ON Canada
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Abstract
Background For a century, epinephrine has been the drug of choice for acute treatment of systemic allergic reactions/anaphylaxis. For 40 years, autoinjectors have been used for the treatment of anaphylaxis. Over the last 20 years, intramuscular epinephrine injected into the thigh has been recommended for optimal effect. Objective To review the literature on pharmacokinetics of epinephrine autoinjectors. Results Six studies assessing epinephrine autoinjector pharmacokinetics were identified. The studies, all on healthy volunteers, were completed by Simons, Edwards, Duvauchelle, Worm and Turner over the span of 2 decades. Simons et al. published two small studies that suggested that intramuscular injection was superior to subcutaneous injection. These findings were partially supported by Duvauchelle. Duvauchelle showed a proportional increase in Cmax and AUC0-20 when increasing the dose from 0.3 to 0.5 mg epinephrine intramuscularly. Turner confirmed these findings. Simons, Edwards and Duvauchelle documented the impact of epinephrine on heart rate and blood pressure. Turner confirmed a dose-dependent increase in heart rate, cardiac output and stroke volume. Based on limited data, confirmed intramuscular injections appeared to lead to faster Cmax. Two discernable Cmax’s were identified in most of the studies. We identified similarities and discrepancies in a number of variables in the aforementioned studies. Conclusions Intramuscular injection with higher doses of epinephrine appears to lead to a higher Cmax. There is a dose dependent increase in plasma concentration and AUC0-20. Most investigators found two Cmax’s with Tmax 5–10 min and 30–50 min, respectively. There is a need for conclusive trials to evaluate the differences between intramuscular and subcutaneous injections with the epinephrine delivery site confirmed with ultrasound.
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Affiliation(s)
- Sten Dreborg
- Department of Child and Adolescent Allergology, Women's and Children's Health, University of Uppsala, 751 85, Uppsala, Sweden.
| | - Harold Kim
- Department of Medicine, Western University, London, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
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Klimek L, Hoffmann HJ, Kalpaklioglu AF, Demoly P, Agache I, Popov TA, Muraro A, Schmid‐Grendelmeier P, Bonini S, Bonertz A, Mahler V, Vieths S, Pfaar O, Zuberbier T, Jutel M, Schmidt‐Weber C, Hellings PW, Dreborg S, Bonini M, Brough HA, Bousquet J, Hoffmann‐Sommergruber K, Palomares O, Ollert M, Shamji MH, Cardona V. In-vivo diagnostic test allergens in Europe: A call to action and proposal for recovery plan-An EAACI position paper. Allergy 2020; 75:2161-2169. [PMID: 32306414 DOI: 10.1111/all.14329] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 12/30/2022]
Abstract
Diagnostic allergens are defined as medicinal products in the EU. Marketing authorization by national authorities is necessary; however, diagnostic allergens are not homogeneously regulated in different EU member states. Allergen manufacturers argue with increasing costs forcing them to continuously reduce the diagnostic allergen portfolios offered to allergists. In contrast, EAACI and national European Allergy Societies see the need for the availability of a wide range of high-quality diagnostic allergens for in vivo diagnosis of IgE-mediated allergies not only covering predominant but also less frequent allergen sources. In a recent EAACI task force survey, the current practice of allergy diagnosis was shown to rely on skin tests as first option in almost 2/3 of all types of allergic diseases and in 90% regarding respiratory allergies. With the need to ensure the availability of high-quality diagnostic allergens in the EU, an action plan has been set up by EAACI to analyse the current regulatory demands in EU member states and to define possible solutions stated in this document: (a) simplification of authorization for diagnostic allergens; (b) specific regulation of special types of diagnostic allergens; (c) new models beyond the current model of homologous groups; (d) simplification of pharmacovigilance reporting; (e) reduction of regulation fees for diagnostic allergens; (f) reimbursement for diagnostic allergens. Joining forces of allergists, manufacturers and authorities are of high importance to ensure remaining relevant allergens in the EU markets to facilitate a sustainable and comprehensive service for the diagnosis and treatment of allergic diseases.
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Affiliation(s)
- Ludger Klimek
- Center for Rhinology and Allergology Wiesbaden Germany
| | - Hans J. Hoffmann
- Department of Clinical Medicine Aarhus University Aarhus C Denmark
| | - Ayse F. Kalpaklioglu
- Department of Pulmonary and Allergic Diseases Kirikkale University Faculty of Medicine Kirikkale Turkey
| | - Pascal Demoly
- Department of Respiratory Medicine University Hospital of Montpellier Montpellier France
- UMR‐S 1136 IPLESP Equipe EPAR Sorbonne Université Paris France
| | - Ioana Agache
- Faculty of Medicine Department of Allergy and Clinical Immunology Transylvania University Brasov Brasov Romania
| | | | - Antonella Muraro
- Past President, European Academy of Allergy & Clinical Immunology (EAACI), Centre for Paediatrics and Child Health Head Food Allergy Referral Centre Veneto Region Department of Women and Child Health Padua General University Hospital Padua Italy
| | | | - Sergio Bonini
- Institute of Translational Pharmacology Italian National Research Council Rome Italy
| | | | | | | | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital MarburgPhilipps‐Universität Marburg Marburg Germany
| | - Torsten Zuberbier
- Department of Dermatology and Allergy Allergie‐Centrum‐CharitéCharité ‐ Universitätsmedizin Berlin Berlin Germany
| | - Marek Jutel
- President, European Academy of Allergy & Clinical Immunology (EAACI) Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- ALL‐MED” Medical Research Institute Wroclaw Poland
| | - Carsten Schmidt‐Weber
- Center of Allergy and Environment (ZAUM) Technical University and Helmholtz Center Munich Munich Germany
| | - Peter W. Hellings
- Euforea Brussels Belgium
- Laboratory of Clinical Immunology Department of Microbiology and Immunology KU Leuven Leuven Belgium
| | - Sten Dreborg
- Professor emeritus, Child and Adolescent Allergology Department of Women's and Children's Health Academic Hospital Uppsala University Uppsala Sweden
| | - Matteo Bonini
- Department of Cardiovascular and Thoracic Sciences Fondazione Policlinico Universitario A. Gemelli ‐ IRCCSUniversità Cattolica del Sacro Cuore Rome Italy
- National Heart and Lung Institute Imperial College London London UK
| | - Helen A. Brough
- Chair for Paediatric Section European Academy of Allergy & Clinical Immunology (EAACI) Head of Service Children's Allergy Service Evelina Children's HospitalGuy's and St. Thomas' Hospital NHS Foundation Trust London UK
- Paediatric Allergy Group Department of Women and Children's Health King's College LondonSt. Thomas' Hospital London UK
- Paediatric Allergy Group Peter Gorer Dept of Immunobiology School of Immunology & Microbial Sciences King's College LondonGuys' Hospital London UK
| | - Jean Bousquet
- MACVIA‐France Contre les Maladies Chroniques pour un VieillissementActifen France European Innovation Partnership on Active and Healthy Ageing Reference Site Montpellier France
- Université Montpellier Montpellier France
- Berlin Institute of Health, Comprehensive Allergy Center, Department of Dermatology and Allergy Humboldt-Universität zu BerlinCharité – Universitätsmedizin Berlin Berlin Germany
| | | | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Complutense University of Madrid Madrid Spain
| | - Markus Ollert
- Department of Infection and Immunity Luxembourg Institute of Health Esch‐sur‐Alzette Luxembourg
- Department of Dermatology and Allergy Center Odense Research Center for Anaphylaxis University of Southern Denmark Odense C Denmark
| | - Mohamed H. Shamji
- Asthma UK Centre in Allergic Mechanisms of Asthma National Heart and Lung InstituteImperial College London London UK
| | - Victoria Cardona
- Allergy Section Department of Internal Medicine Hospital Valld'Hebron Barcelona Spain
- ARADyAL Research Network Cáceres Spain
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Dreborg S, Tsai G, Kim H. Epinephrine auto-injector needle length: The impact of winter clothing. Allergy Asthma Clin Immunol 2020; 16:24. [PMID: 32322286 PMCID: PMC7160976 DOI: 10.1186/s13223-020-00422-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 04/02/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND Epinephrine auto-injectors are expected to deliver the drug intramuscularly. OBJECTIVE To study whether injection through clothing influences the frequency of subcutaneous and intraosseous/periosteal deposition of epinephrine. METHODS Skin to muscle and skin to bone distances were measured for 303 children and adolescents and 99 adults. Distance was determined by ultrasound, with high or low pressure on the ultrasound probe. The risk/percentage of subcutaneous and intraosseous/periosteal injections was calculated using the lower and upper limits for the authority-approved length of EAI needles as provided by two high pressure EAI manufacturers and one low pressure EAI manufacturer. The addition winter clothing on the delivery of epinephrine was illustrated by comparing drug delivery fissue depth with no clothes. Furthermore, the riof non-intramuscular delivery for the shortest and longest approved needle length was calculated. RESULTS When using EpipenJr® in children < 15 kg the risk of intraosseous/periostal injection was reduced from 1% and 59% for the shortest and longest approved needle length to 0 and 15% with winter clothes. The Auvi-Q® 0.1 mg had no risk of intraosseous/periosteal injection. However, the subcutaneous deposition risk increased from 94% and 28% to 100% and 99% with winter clothes. The risk of subcutaneous injection using EpipenJr® in the youngest children increased from 13% and 0% to 81% and 1% with winter clothes, and with Epipen® in adults from 45% and 17% to 60% and 38%. Emerade®, had a risk of subcutaneous injection in adults increasing from 14% and 10% to 28% and 21% adding winter clothes. CONCLUSION The risk of intraosseous/periosteal injections decreases and the risk of subcutaneous injection increases when injecting through winter clothes for all EAIs.
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Affiliation(s)
- Sten Dreborg
- Department Child and Adolescent Allergology, Women’s and Children’s Health, University of Uppsala, Uppsala, Sweden
| | - Gina Tsai
- Department of Medicine, Western University, London, Canada
| | - Harold Kim
- Department of Medicine, Western University, London, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
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Dreborg S. Epinephrine auto-injectors: information, education, training and acceptance. Allergol Immunopathol (Madr) 2020; 48:1-2. [PMID: 31812329 DOI: 10.1016/j.aller.2019.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 09/02/2019] [Indexed: 01/16/2023]
Affiliation(s)
- S Dreborg
- Department of Child and Adolescent Allergology, Women's and Children's Health, Uppsala University, SE, 751 85 Uppsala, Sweden.
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Dreborg S, Kim H. Epinephrine autoinjectors: The needle length matters. Ann Allergy Asthma Immunol 2019; 124:449-450. [PMID: 31870726 DOI: 10.1016/j.anai.2019.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/03/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Sten Dreborg
- Department Child and Adolescent Allergology, Women's and Children's Health, University of Uppsala, Sweden.
| | - Harold Kim
- Department of Medicine, Western University, Canada; Department of Medicine, McMaster University, Canada
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Dreborg S, Tsai G, Kim H. Implications of variation of epinephrine auto-injector needle length. Ann Allergy Asthma Immunol 2019; 123:89-94. [PMID: 31071440 DOI: 10.1016/j.anai.2019.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The variation of needle lengths of epinephrine auto-injectors (EAIs) has not been investigated. OBJECTIVE To investigate the impact of the variation of the needle length of EAIs. METHODS Skin-to-muscle (STMD) and skin-to-bone distances (STBD) were measured for 303 children and adolescents and 99 adults. Distance was determined by ultrasound, applying high or low pressure on the probe. The risk of subcutaneous and periosteal/intraosseous injection was calculated using the lower and upper acceptance limits for length of EAI needles as provided for 3 high-pressure EAIs (HPEAI) and 1 low-pressure EAI (LPEAI). RESULTS The variation in needle length of the HPEAIs are for Epipen Jr/Epipen 5 mm, for Jext 2 mm, for Auvi-Q 2.5 mm, and for the LPEAI, Emerade, 1.5 mm. When using the longest acceptable needles for Epipen Jr, the risk of intraosseous/periosteal penetration was highest in children weighing less than 15 kg at 60% and for Jext at 43%. The risk was low for Auvi-Q and Emerade. The risk of subcutaneous injection was greatest with the shortest needles of the Auvi-Q 0.1 mg at 94% in children weighing less than 15 kg. In adults, the risk of subcutaneous injection using the shortest needles was for Epi-Pen at 41%, Jext at 36%, Auvi-Q at 38%, and Emerade at 12%. CONCLUSION The variation in needle length of EAIs influences the risk of subcutaneous and intraosseous/periosteal injections. Compared with Epipen Jr, the Auvi-Q 0.1 mg for children weighing less than 15 kg had a low risk of intraosseous/periosteal injection but a very high risk of subcutaneous injection. For adults, there is a significant risk of subcutaneous injection.
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Affiliation(s)
- Sten Dreborg
- Child and Adolescent Allergology, Women's and Children's Health, University of Uppsala, Uppsala, Sweden.
| | - Gina Tsai
- Department of Medicine, Western University, London, Canada
| | - Harold Kim
- Department of Medicine, Western University, London, Canada; Department of Medicine, McMaster University, Hamilton, Canada
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Dreborg S, Kim H. Tissue compression and epinephrine deposition. J Allergy Clin Immunol Pract 2019; 7:2096-2097. [PMID: 31056448 DOI: 10.1016/j.jaip.2019.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 03/27/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Sten Dreborg
- Department of Child and Adolescent Allergology, Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Harold Kim
- Division of Clinical Immunology and Allergy, Western University, London, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada
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Abstract
Allergens are molecules with the capacity to elicit IgE responses in humans. When stimulated with allergens, most allergic patients respond with production of IgE specific for several proteins/allergens in the source material. The standardization of allergen extracts is essential in order to control variability and to achieve consistency and reproducibility in a clinical setting.Because the IgE binding capacity of an allergen extract is related to the content of one or a few major allergens, it is important that the standardization procedure ensures consistency, not only in the overall IgE binding potency, but also in the content and ratio of individual major allergens. Owing to the complexity of allergen extracts, a key element in standardization of allergen extracts is the use of standards.This chapter describes the principles for standardization of allergen extracts to be used by research laboratories. Other chapters in this volume describe in vitro methods in detail.
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Affiliation(s)
| | - Sten Dreborg
- Department of Women's and Children's Health, Uppsala University and Academic Hospital, Uppsala, Sweden
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Dreborg S, Kim L, Tsai G, Kim H. Epinephrine auto-injector needle lengths: Can both subcutaneous and periosteal/intraosseous injection be avoided? Ann Allergy Asthma Immunol 2018; 120:648-653.e1. [PMID: 29499370 DOI: 10.1016/j.anai.2018.02.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/15/2018] [Accepted: 02/20/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epinephrine should be administered intramuscularly in the anterolateral aspect of the thigh. The length of the epinephrine auto-injector (EAI) needle should ensure intramuscular injection. OBJECTIVE To discuss suitable EAI needle lengths based on ultrasound measurements related to weight. METHODS The skin-to-muscle distance (STMD) and skin-to-bone distance (STBD) were measured by ultrasound in the mid-third of the anterolateral area of the right thigh when applying high pressure (8 lb; high-pressure EAI [HPEAI]) or low pressure (low-pressure EAI [LPEAI]) on the ultrasound probe. The study included 302 children and adolescents and 99 adults. The maximum and minimum STMD and the maximum and minimum STBD were estimated. RESULTS Using HPEAIs, the risk of periosteal or intraosseous penetration was 32% in children weighing less than 15 kg. The risk of subcutaneous injection was 12% in adolescents and 33% in adults. With LPEAIs, there was no risk of periosteal or intraosseous injection and the risk of subcutaneous injections in adolescents and adults was lower at 2% and 10%, respectively. A new EAI for injection in small children would have no risk of periosteal or intraosseous injection but would have 71% chance of subcutaneous deposit of epinephrine. CONCLUSION Common HPEAIs have a high risk of periosteal or intraosseous penetration in children and subcutaneous injections in overweight and obese adults. LPEAIs have some risk of subcutaneous injection in adults. HPEAIs with 0.1 mg of epinephrine and shorter needles have no risk of periosteal or intraosseous injection but have a high risk of subcutaneous deposit. For adult or overweight or obese patients, HPEAIs and LPEAIs should have longer needles. Future studies should focus on triggering pressures and variations in needle length.
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Affiliation(s)
- Sten Dreborg
- Child and Adolescent Allergology, Women's and Children's Health, University of Uppsala, Uppsala, Sweden.
| | - Laura Kim
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gina Tsai
- Department of Medicine, Western University, London, Ontario, Canada
| | - Harold Kim
- Department of Medicine, Western University, London, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Cardona V, Demoly P, Dreborg S, Kalpaklioglu AF, Klimek L, Muraro A, Pfaar O, Popov TA, Hoffmann HJ. Current practice of allergy diagnosis and the potential impact of regulation in Europe. Allergy 2018; 73:323-327. [PMID: 28905404 DOI: 10.1111/all.13306] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2017] [Indexed: 01/16/2023]
Abstract
In the European Union (EU), the regulatory framework regarding diagnostic allergen extracts is currently in the process of being implemented at the national level. Due to these regulations, the initial and periodic renewal expenses for the registration of diagnostic allergen extracts may render extract production unprofitable. Consequently, many extracts may be at risk of removal from the market. The current survey, which was conducted by a task force of the European Academy of Allergy and Clinical Immunology, aimed to assess the current practice of allergy diagnosis in Europe. This survey revealed that skin tests continue to be the main diagnostic procedure and are used as the first option in almost two-third of all types of allergic diseases and in 90% of individuals suffering from respiratory allergies. Therefore, there is a need to ensure the availability of high-quality allergen extracts to maintain the common diagnostic procedures used by EU professionals. To reach this goal, it is necessary to align efforts and establish active partnerships between manufacturers, relevant scientific societies, consumer organizations and authorities to maintain the availability of these diagnostic tools.
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Affiliation(s)
- V. Cardona
- Allergy Section; Department of Internal Medicine; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - P. Demoly
- UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR; Département de Pneumologie et Addictologie; Hôpital Arnaud de Villeneuve; CHRU de Montpellier and Sorbonnes Universités; Paris France
| | - S. Dreborg
- Section on Child and Adolescent Allergology; Women's and Children's Health; Academic Hospital; University of Uppsala; Uppsala Sweden
| | - A. F. Kalpaklioglu
- Department of Immunology and Allergic Diseases; Kirikkale University Hospital; Kirikkale Turkey
| | - L. Klimek
- Centre for Rhinology and Allergology; Wiesbaden Germany
| | - A. Muraro
- Food Allergy Referral Centre Veneto Region; Department of Women and Child Health; Padua General University Hospital; Padua Italy
| | - O. Pfaar
- Centre for Rhinology and Allergology; Wiesbaden Germany
- Department of Otorhinolaryngology; Head and Neck Surgery; Universitätsmedizin Mannheim; Medical Faculty Mannheim; Heidelberg University; Mannheim Germany
| | - T. A. Popov
- Clinic of Allergy and Asthma; Medical University; Sofia Bulgaria
| | - H. J. Hoffmann
- Department of Respiratory Diseases and Allergy; Department of Clinical Medicine; Aarhus University; Aarhus C Denmark
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Dreborg S, Wen X, Kim L, Tsai G, Nevis I, Potts R, Chiu J, Dominic A, Kim H. Erratum to: Do epinephrine auto-injectors have an unsuitable needle length in children and adolescents at risk for anaphylaxis from food allergy? Allergy Asthma Clin Immunol 2017; 13:33. [PMID: 28694830 PMCID: PMC5501593 DOI: 10.1186/s13223-017-0205-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 06/27/2017] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sten Dreborg
- Women's and Children's Health, University of Uppsala, Uppsala, Sweden
| | - Xia Wen
- Faculty of Science, McGill University, Montreal, Canada
| | - Laura Kim
- Faculty of Medicine, University British Columbia, Vancouver, Canada
| | - Gina Tsai
- Department of Medicine, Western University, London, Canada
| | - Immaculate Nevis
- Goodman School of Business, Brock University, St. Catharines, Canada
| | - Ryan Potts
- Farncombe Family Digestive Health Unit, McMaster University, Hamilton, Canada
| | - Jack Chiu
- Department of Medicine, Western University, London, Canada
| | | | - Harold Kim
- Department of Medicine, Western University, London, Canada.,Department of Medicine, McMaster University, Hamilton, ON Canada
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Epstein TG, Calabria C, Cox LS, Dreborg S. Current Evidence on Safety and Practical Considerations for Administration of Sublingual Allergen Immunotherapy (SLIT) in the United States. J Allergy Clin Immunol Pract 2016; 5:34-40.e2. [PMID: 27815065 DOI: 10.1016/j.jaip.2016.09.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/06/2016] [Accepted: 09/13/2016] [Indexed: 12/17/2022]
Abstract
Liquid sublingual allergen immunotherapy (SLIT) has been used off-label for decades, and Food and Drug Administration (FDA)-approved grass and ragweed SLIT tablets have been available in the United States since 2014. Potentially life-threatening events from SLIT do occur, although they appear to be very rare, especially for FDA-approved products. Practice guidelines that incorporate safety precautions regarding the use of SLIT in the United States are needed. This clinical commentary attempts to address unresolved issues including controversy regarding the FDA mandate for the prescription of epinephrine autoinjectors for patients on SLIT; how to approach polysensitized patients; optimal timing and duration of SLIT administration; how to address gaps in therapy; whether antihistamines can prevent local reactions, if certain patient populations (such as persistent asthmatics) should not receive SLIT; and when to instruct patients to self-administer epinephrine. Key points are that physicians should focus on educating patients regarding: (1) when not to administer SLIT; (2) how to recognize a potentially serious allergic reaction to SLIT; and (3) when to administer epinephrine and seek emergency care.
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Affiliation(s)
- Tolly G Epstein
- Division of Immunology, Allergy, and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | | | - Linda S Cox
- University of Miami Miller School of Medicine at Holy Cross Hospital, Ft. Lauderdale, Fla
| | - Sten Dreborg
- Department of Pediatric Allergy, Women's and Children's Health, University of Uppsala, Uppsala, Sweden
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Dreborg S, Wen X, Kim L, Tsai G, Nevis I, Potts R, Chiu J, Dominic A, Kim H. Do epinephrine auto-injectors have an unsuitable needle length in children and adolescents at risk for anaphylaxis from food allergy? Allergy Asthma Clin Immunol 2016; 12:11. [PMID: 26949403 PMCID: PMC4779571 DOI: 10.1186/s13223-016-0110-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/04/2016] [Indexed: 01/22/2023] Open
Abstract
Background Food allergy is the most common cause of anaphylaxis in children. Intramuscular delivery of epinephrine auto-injectors (EAI) is the standard of care for the treatment of anaphylaxis. We examined if children and adolescents at risk of anaphylaxis weighing 15–30 kg and >30 kg would receive epinephrine into the intramuscular space with the currently available EAI in North America and Europe. Methods The distance from skin to muscle (STMD) and skin to bone (STBD) on the mid third anterolateral area of the right thigh was measured by ultrasound applying either high pressure (max) or slight pressure (min) in 102 children weighing 15–30 kg (group 1) and 100 children and adolescents, weighing more than 30 kg (group 2). Results Using a high pressure EAI (HPEAI), Epipen Jr® and Auvi-Q®/Allerject® 0.15 mg, 11/102 (11 %) children in group 1 and 38/102 (38 %) using another HPEAI, Jext®, had a STMDmax that showed a risk of intraosseous injection. There was a 1 % risk of subcutaneous injection with these devices. There was no risk of intraosseous injection using a low pressure EAI (LPEAI), Emerade®. In group 2, the risk of intraosseous injection using a HPEAI was 3 % and no risk using a LPEAI. However, the risk of subcutaneous injection using HPEAI was 9 % and using LPEAI was 2 %. Conclusion There is a risk of intraosseous injection using HPEAI (Epipen®/Epipen Jr®, Auvi-Q®/Allerject® and especially Jext®) in children at risk of anaphylaxis. There was also a risk of subcutaneous injection using the currently available HPEAI in children and adolescents. Electronic supplementary material The online version of this article (doi:10.1186/s13223-016-0110-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sten Dreborg
- Women's and Children's Health, University of Uppsala, Uppsala, Sweden
| | - Xia Wen
- Faculty of Science, McGill University, Montreal, Canada
| | - Laura Kim
- Faculty of Medicine, University British Columbia, Vancouver, Canada
| | - Gina Tsai
- Department of Medicine, Western University, London, Canada
| | - Immaculate Nevis
- Goodman School of Business, Brock University, St. Catharines, Canada
| | - Ryan Potts
- Farncombe Family Digestive Health Unit, McMaster University, Hamilton, Canada
| | - Jack Chiu
- Department of Medicine, Western University, London, Canada
| | | | - Harold Kim
- Department of Medicine, Western University, London, Canada ; Department of Medicine, McMaster University, Hamilton, ON Canada
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Affiliation(s)
- Sten Dreborg
- Pediatric Allergology Department of Women's and Children's Health Uppsala University Uppsala Sweden
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Dreborg S, Basomba A. Evaluation of Skin Reactivity during (Immuno-) Therapy. Validation of Methods for Estimation of Changes in Skin Reactivity and Correlation to Shock Organ Sensitivity. ACTA ACUST UNITED AC 2016. [DOI: 10.4172/2471-9552.1000109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Background The term “intolerance” is not mentioned in the World Allergy Organization (WAO) document on allergy nomenclature. “Intolerance” has been used to describe some non-immunological diseases. However, pediatric gastroenterologists mix allergy and intolerance, e.g. by using the term “cow’s milk protein allergy/intolerance (CMPA/I)”, lumping together all types of mechanisms for not tolerating cow’s milk. The basis for this mix is the fact that double-blind oral food challenges are time-consuming and expensive. Therefore, cow’s milk exclusion and reintroduction is proposed to be used in primary care for the diagnosis of CMPA in children with common gastrointestinal (GI) problems such as colic and constipation. This may lead to a widespread use of hypoallergenic formulas in children without proven CMPA. In lay language, intolerance describes “not tolerating”. Objective To discuss the reasons why the term “intolerance” should not be used in the area of allergy. Results Presently, intolerance is not part of the allergy nomenclature. It is used by lay persons to describe “not tolerating”. Pediatricians use intolerance to describe non-immunological hypersensitivity such as lactose intolerance which is acceptable. However, using the mixed term CMPA/I describing a variety of gastrointestinal symptoms in children, should be avoided. The WAO Nomenclature does not clearly distinguish between non-IgE-mediated allergy and non-allergic hypersensitivity. Conclusion The term “intolerance” should not be used within the area of allergy. Intolerance should be better defined and the term restricted to some non-immunological/non-allergic diseases and not mixed with allergy, e.g. by using the term CMPA/I. A revision of the WAO nomenclature is proposed.
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Affiliation(s)
- Sten Dreborg
- Women's and Children's Health, University of Uppsala, Uppsala, Sweden
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Dreborg S. Allergen skin prick test should be adjusted by the histamine reactivity. Int Arch Allergy Immunol 2015; 166:77-80. [PMID: 25765942 DOI: 10.1159/000371848] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 01/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Skin prick test results are mostly reported as mean wheal diameter obtained with one concentration of allergen. Differences in technique between personnel causes variation in wheal size. The research question was whether the influence of differences in skin prick test technique among assistants and centers can be reduced by relating the allergen wheal response to that of histamine. METHODS Two methods for estimating skin reactivity, the method of Nordic Guidelines using histamine as a reference and the method of Brighton et al. [Clin Allergy 1979;9:591-596] not using histamine as a reference, were applied to data from two biological standardization trials, using the same batch of freeze-dried timothy pollen preparation. RESULTS The concentration defining the Nordic biological unit, defined as a concentration of allergen eliciting a wheal of the same size as that of histamine dihydrochloride 10 mg/ml, did not differ between the centers. When not using histamine as a reference, applying the method of Brighton et al., there was a 15-fold difference in the estimate of the biological activity between the trials that was eliminated by adjusting the allergen response to that of the histamine reference. CONCLUSIONS To reduce the influence of differences in test technique among assistants and centers responses to allergen-induced skin prick tests should be compared to that of histamine.
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Affiliation(s)
- Sten Dreborg
- Department of Women's and Children's Health, Department of Pediatric Allergology, Uppsala University Hospital, Uppsala, Sweden
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Dreborg S, Holgersson M. Evaluation of Methods for the Estimation of Threshold Concentrations by the Skin Prick Test. Int Arch Allergy Immunol 2015; 166:71-6. [DOI: 10.1159/000366203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 07/23/2014] [Indexed: 11/19/2022] Open
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Dreborg S. Evaluation of allergen immunotherapy. J Allergy Clin Immunol Pract 2015; 3:267-268. [PMID: 25754719 DOI: 10.1016/j.jaip.2014.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 06/04/2023]
Affiliation(s)
- Sten Dreborg
- Department of Women's and Children's Health, University of Uppsala, Uppsala, Sweden.
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Dreborg S. [Reported research fraud just the tip of the iceberg?]. Lakartidningen 2013; 110:1584-1585. [PMID: 24163930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Sten Dreborg
- Kvinnors och barns halsa, Uppsala universitet; Barn- och ungdomsallergologi, Uppsala.
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Dreborg S, Roberts G, Lau S, Santos AF, Halken S, Høst A. The history of pediatric allergy in Europe - from a working group to ESPACI and SP-EAACI. Pediatr Allergy Immunol 2013; 24:88-96. [PMID: 23331532 DOI: 10.1111/pai.12029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2012] [Indexed: 01/12/2023]
Abstract
A Working Group on Pediatric Allergology was formed in 1984, which rapidly developed to become the European Society on Pediatric Allergology and Clinical Immunology (ESPACI) in 1988 with its own journal, Pediatric Allergology and Immunology. ESPACI worked together with the European Academy of Allergology and Clinical Immunology (EAACI) to form a Section of Pediatrics within EAACI (SP-EAACI) in 1996. The ESPACI and the SP-EAACI formally merged in 2001. Within the EAACI organization, the Pediatric Section has continued to grow. The Pediatric Section is working to develop pediatric allergology across Europe, focusing on postgraduate education, facilitating the research agenda and advocating for children and adolescents with allergies.
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Affiliation(s)
- Sten Dreborg
- Department of Pediatric Allergy, Women's and Children's Health, University of Uppsala, Uppsala, Sweden.
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Affiliation(s)
- Sten Dreborg
- Department of Women's and Children's Health; Uppsala University; SE-751 85; Uppsala; Sweden
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Fiocchi A, Burks W, Bahna SL, Bielory L, Boyle RJ, Cocco R, Dreborg S, Goodman R, Kuitunen M, Haahtela T, Heine RG, Lack G, Osborn DA, Sampson H, Tannock GW, Lee BW. Clinical Use of Probiotics in Pediatric Allergy (CUPPA): A World Allergy Organization Position Paper. World Allergy Organ J 2012; 5:148-67. [PMID: 23282383 PMCID: PMC3651185 DOI: 10.1097/wox.0b013e3182784ee0] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND : Probiotic administration has been proposed for the prevention and treatment of specific allergic manifestations such as eczema, rhinitis, gastrointestinal allergy, food allergy, and asthma. However, published statements and scientific opinions disagree about the clinical usefulness. OBJECTIVE : A World Allergy Organization Special Committee on Food Allergy and Nutrition review of the evidence regarding the use of probiotics for the prevention and treatment of allergy. METHODS : A qualitative and narrative review of the literature on probiotic treatment of allergic disease was carried out to address the diversity and variable quality of relevant studies. This variability precluded systematization, and an expert panel group discussion method was used to evaluate the literature. In the absence of systematic reviews of treatment, meta-analyses of prevention studies were used to provide data in support of probiotic applications. RESULTS : Despite the plethora of literature, probiotic research is still in its infancy. There is a need for basic microbiology research on the resident human microbiota. Mechanistic studies from biology, immunology, and genetics are needed before we can claim to harness the potential of immune modulatory effects of microbiota. Meanwhile, clinicians must take a step back and try to link disease state with alterations of the microbiota through well-controlled long-term studies to identify clinical indications. CONCLUSIONS : Probiotics do not have an established role in the prevention or treatment of allergy. No single probiotic supplement or class of supplements has been demonstrated to efficiently influence the course of any allergic manifestation or long-term disease or to be sufficient to do so. Further epidemiologic, immunologic, microbiologic, genetic, and clinical studies are necessary to determine whether probiotic supplements will be useful in preventing allergy. Until then, supplementation with probiotics remains empirical in allergy medicine. In the future, basic research should focus on homoeostatic studies, and clinical research should focus on preventive medicine applications, not only in allergy. Collaborations between allergo-immunologists and microbiologists in basic research and a multidisciplinary approach in clinical research are likely to be the most fruitful.
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Affiliation(s)
- Alessandro Fiocchi
- Department of Pediatrics - Division of Allergy - Pediatric Hospital Bambino Gesù - Rome, Vatican City
| | - Wesley Burks
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Sami L Bahna
- Department of Pediatrics and Medicine, Section of Allergy and Immunology, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Leonard Bielory
- Department of Medicine, University of Medicine and Dentistry of New Jersey Medical School, Newark, NJ
| | - Robert J Boyle
- Department of Paediatrics, Imperial College London, London, UK
| | - Renata Cocco
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
| | - Sten Dreborg
- Department of Pediatric Allergology, Women's and Children's Health, University of Uppsala, Uppsala, Sweden
| | - Richard Goodman
- Department of Food Science & Technology University of Nebraska, Lincoln, NE, USA
| | - Mikael Kuitunen
- Skin and Allergy Hospital, University of Helsinki, Helsinki, Finland
| | - Tari Haahtela
- Skin and Allergy Hospital, University of Helsinki, Helsinki, Finland
| | - Ralf G Heine
- Department of Allergy and Immunology, Royal Children's Hospital, University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Gideon Lack
- King's College London, Asthma-UK Centre in Allergic Mechanisms of Asthma, Department of Paediatric Allergy, St Thomas' Hospital, London, UK
| | - David A Osborn
- Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Hugh Sampson
- Jaffe Food Allergy Institute, Mount Sinai School of Medicine, New York, NY
| | - Gerald W Tannock
- Department of Microbiology and Immunology, University of Otago, Dunedin, New Zealand
| | - Bee Wah Lee
- Department of Paediatrics, National University of Singapore, Singapore
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Dreborg S. The risk of allergic reactions to allergen extracts in personnel. J Allergy Clin Immunol 2012; 129:870-1; author reply 871. [DOI: 10.1016/j.jaci.2011.11.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 11/07/2011] [Accepted: 11/11/2011] [Indexed: 10/14/2022]
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Dreborg S, Lee TH, Kay AB, Durham SR. Immunotherapy is allergen-specific: a double-blind trial of mite or timothy extract in mite and grass dual-allergic patients. Int Arch Allergy Immunol 2011; 158:63-70. [PMID: 22212720 DOI: 10.1159/000330649] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 06/22/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND One hundred years ago, Noon [Lancet 1911;1:1572-1573], using conjunctival provocation testing (CPT), was the first to demonstrate the effectiveness of subcutaneous immunotherapy (SCIT) in grass-allergic subjects with hay fever. In this centenary year, we present data that, by use of CPT and allergen-specific IgG, replicate this observation and additionally confirm the allergen specificity of SCIT by using a double-blind design employing either grass or mite SCIT in dual grass- and mite-allergic individuals. METHODS Twenty adults (11 females) with perennial rhinoconjunctivitis and exacerbation of symptoms during the grass pollen season and in the autumn had immediate skin and conjunctival sensitivity and raised specific IgE to both Dermatophagoides farinae and Phleum pratense. Participants were randomly assigned to either timothy or D. farinae immunotherapy for 3 years. CPT and specific IgG tests to both allergens were performed annually. After 3 years, subjects gave their blinded overall evaluation. RESULTS Six mild-to-moderate general reactions occurred in 2 timothy- and 4 mite-treated patients. Four of these patients and 2 other patients withdrew from the study. Seven patients in each group completed the study. After 3 years of immunotherapy, the timothy CPT threshold concentration had increased 16- fold in timothy-treated patients (p < 0.05; between-group change, p < 0.05). The increase in the mite CPT threshold in mite- compared to grass-treated patients was 31-fold (p < 0.05). The overall assessment of conjunctival sensitivity was highly significant in favour of treatment (p < 0.015), as was that of allergen-specific IgG (p < 0.0001). CONCLUSIONS Allergen immunotherapy is allergen species-specific, as judged by decreased conjunctival sensitivity and changes in allergen-specific IgG concentrations.
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Affiliation(s)
- S Dreborg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Dreborg S, Lee T, Kay A, Durham S. Subcutaneous Immunotherapy (SCIT) Is Allergen-specific: A Double-blind Trial Of Mite Or Timothy Extract In Mite And Grass Dual Allergic Patients. J Allergy Clin Immunol 2011. [DOI: 10.1016/j.jaci.2010.12.872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Høst A, Halken S, Muraro A, Dreborg S, Niggemann B, Aalberse R, Arshad SH, von Berg A, Carlsen KH, Duschén K, Eigenmann PA, Hill D, Jones C, Mellon M, Oldeus G, Oranje A, Pascual C, Prescott S, Sampson H, Svartengren M, Wahn U, Warner JA, Warner JO, Vandenplas Y, Wickman M, Zeiger RS. Dietary prevention of allergic diseases in infants and small children. Pediatr Allergy Immunol 2008; 19:1-4. [PMID: 18199086 DOI: 10.1111/j.1399-3038.2007.00680.x] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Because of scientific fraud four trials have been excluded from the original Cochrane meta-analysis on formulas containing hydrolyzed protein for prevention of allergy and food intolerance in infants. Unlike the conclusions of the revised Cochrane review the export group set up by the Section on Paediatrics, European Academy of Allergology and Clinical Immunology (SP-EAACI) do not find that the exclusion of the four trials demands a change of the previous recommendations regarding primary dietary prevention of allergic diseases. Ideally, recommendations on primary dietary prevention should be based only on the results of randomized and quasi-randomized trials (selection criteria in the Cochrane review). However, regarding breastfeeding randomization is unethical, Therefore, in the development of recommendations on dietary primary prevention, high-quality systematic reviews of high-quality cohort studies should be included in the evidence base. The study type combined with assessment of the methodological quality determines the level of evidence. In view of some methodological concerns in the Cochrane meta-analysis, particularly regarding definitions and diagnostic criteria for outcome measures and inclusion of non peer-reviewed studies/reports, a revision of the Cochrane analysis may seem warranted. Based on analysis of published peer-reviewed observational and interventional studies the results still indicate that breastfeeding is highly recommended for all infants irrespective of atopic heredity. A dietary regimen is effective in the prevention of allergic diseases in high-risk infants, particularly in early infancy regarding food allergy and eczema. The most effective dietary regimen is exclusively breastfeeding for at least 4-6 months or, in absence of breast milk, formulas with documented reduced allergenicity for at least the first 4 months, combined with avoidance of solid food and cow's milk for the first 4 months.
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Affiliation(s)
- Arne Høst
- Department of Pediatrics, Odense University Hospital, Odense, Denmark
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Jacobsen L, Niggemann B, Dreborg S, Ferdousi HA, Halken S, Høst A, Koivikko A, Norberg LA, Valovirta E, Wahn U, Möller C. Specific immunotherapy has long-term preventive effect of seasonal and perennial asthma: 10-year follow-up on the PAT study. Allergy 2007. [PMID: 17620073 DOI: 10.1111/j.1398-9995.2007.01451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND 3-year subcutaneous specific immunotherapy (SIT) in children with seasonal allergic rhinoconjunctivitis reduced the risk of developing asthma during treatment and 2 years after discontinuation of SIT (5-year follow-up) indicating long-term preventive effect of SIT. OBJECTIVE We evaluated the long-term clinical effect and the preventive effect of developing asthma 7-years after termination of SIT. METHODS One hundred and forty-seven subjects, aged 16-25 years with grass and/or birch pollen allergy was investigated 10 years after initiation of a 3-year course of SIT with standardized allergen extracts of grass and/or birch or no SIT respectively. Conjunctival provocations were performed outside the season and methacholine bronchial provocations were performed during the season and winter. Asthma was assessed by clinical evaluation. RESULTS The significant improvements in rhinoconjunctivitis and conjunctival sensitivity persisted at the 10-year follow-up. Significantly less actively treated subjects had developed asthma at 10-year follow-up as evaluated by clinical symptoms [odds ratio 2.5 (1.1-5.9)]. Patients who developed asthma among controls were 24/53 and in the SIT group 16/64. The longitudinal treatment effect when adjusted for bronchial hyper-responsiveness and asthma status at baseline including all observations at 3, 5 and 10 years follow-up (children with or without asthma at baseline, n = 189; 511 observations) was statistically significant (P = 0.0075). The odds ratio for no-asthma was 4.6 95% CI (1.5-13.7) in favor of SIT. CONCLUSION A 3-year course of SIT with standardized allergen extracts has shown long-term clinical effects and the potential of preventing development of asthma in children with allergic rhinoconjunctivitis up to 7 years after treatment. CLINICAL IMPLICATION Specific immunotherapy has long-term clinical effects and the potential of preventing development of asthma in children with allergic rhino conjunctivitis up to 7 years after treatment termination.
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Jacobsen L, Niggemann B, Dreborg S, Ferdousi HA, Halken S, Høst A, Koivikko A, Norberg LA, Valovirta E, Wahn U, Möller C. Specific immunotherapy has long-term preventive effect of seasonal and perennial asthma: 10-year follow-up on the PAT study. Allergy 2007; 62:943-8. [PMID: 17620073 DOI: 10.1111/j.1398-9995.2007.01451.x] [Citation(s) in RCA: 626] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND 3-year subcutaneous specific immunotherapy (SIT) in children with seasonal allergic rhinoconjunctivitis reduced the risk of developing asthma during treatment and 2 years after discontinuation of SIT (5-year follow-up) indicating long-term preventive effect of SIT. OBJECTIVE We evaluated the long-term clinical effect and the preventive effect of developing asthma 7-years after termination of SIT. METHODS One hundred and forty-seven subjects, aged 16-25 years with grass and/or birch pollen allergy was investigated 10 years after initiation of a 3-year course of SIT with standardized allergen extracts of grass and/or birch or no SIT respectively. Conjunctival provocations were performed outside the season and methacholine bronchial provocations were performed during the season and winter. Asthma was assessed by clinical evaluation. RESULTS The significant improvements in rhinoconjunctivitis and conjunctival sensitivity persisted at the 10-year follow-up. Significantly less actively treated subjects had developed asthma at 10-year follow-up as evaluated by clinical symptoms [odds ratio 2.5 (1.1-5.9)]. Patients who developed asthma among controls were 24/53 and in the SIT group 16/64. The longitudinal treatment effect when adjusted for bronchial hyper-responsiveness and asthma status at baseline including all observations at 3, 5 and 10 years follow-up (children with or without asthma at baseline, n = 189; 511 observations) was statistically significant (P = 0.0075). The odds ratio for no-asthma was 4.6 95% CI (1.5-13.7) in favor of SIT. CONCLUSION A 3-year course of SIT with standardized allergen extracts has shown long-term clinical effects and the potential of preventing development of asthma in children with allergic rhinoconjunctivitis up to 7 years after treatment. CLINICAL IMPLICATION Specific immunotherapy has long-term clinical effects and the potential of preventing development of asthma in children with allergic rhino conjunctivitis up to 7 years after treatment termination.
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Niggemann B, Jacobsen L, Dreborg S, Ferdousi HA, Halken S, Høst A, Koivikko A, Koller D, Norberg LA, Urbanek R, Valovirta E, Wahn U, Möller C. Five-year follow-up on the PAT study: specific immunotherapy and long-term prevention of asthma in children. Allergy 2006; 61:855-9. [PMID: 16792584 DOI: 10.1111/j.1398-9995.2006.01068.x] [Citation(s) in RCA: 215] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A 3-year course of specific immunotherapy (SIT) in children with hay fever to grass and/or birch pollen significantly reduced the risk of developing asthma. To investigate the long-term preventive effect, we performed a follow up--2 years after termination of immunotherapy. METHODS A total of 183 children, aged 6-14 years with grass and/or birch pollen allergy could be investigated 2 years after discontinuation of SIT or no treatment. Conjunctival provocation tests (CPTs) and methacholine bronchial provocation tests were carried out during the season and winter after 5 years. The development of asthma was assessed by clinical evaluation. RESULTS The significant improvement in hay fever and CPT results observed after 3 years of SIT persisted at the 5-year follow-up. No difference in bronchial responsiveness to methacholine was found after 5 years because of spontaneous improvement during the follow-up period in the control patients. The immunotherapy-treated children had significantly less asthma after 5 years as evaluated by clinical symptoms [odds ratio 2.68 (1.3-5.7)] in favor of SIT for prevention of development of asthma and significantly less patients reported an increase in asthma scores (P < 0.01). CONCLUSION Immunotherapy for 3 years with standardized allergen extracts of grass and/or birch shows long-term clinical effect and preventive effect on development of asthma in children with seasonal rhinoconjunctivitis.
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Affiliation(s)
- B Niggemann
- Department of Pediatric Pneumology and Immunology, Charité, Berlin, Germany
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Dreborg S. [Do breast milk and cow's milk hydrolysate protect against cow milk allergy or allergic disease?]. Lakartidningen 2006; 103:1627-8. [PMID: 16800090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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Ferdousi HA, Zetterström O, Dreborg S. Bronchial hyper-responsiveness predicts the development of mild clinical asthma within 2 yr in school children with hay-fever. Pediatr Allergy Immunol 2005; 16:478-86. [PMID: 16176394 DOI: 10.1111/j.1399-3038.2005.00296.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In children with mild asthma, symptoms are not always apparent. Therefore, results of tests play an important role for the diagnosis. First, to investigate whether children with bronchial hyper-responsiveness (BHR) but no symptoms of asthma in 1992 had developed clinical asthma at follow up in 1994. The second aim was to find out the diagnostic properties of tests for asthma/allergic inflammation, using either doctor diagnosed asthma (DDA), self-assessed symptoms of asthma or iso-capnic hyperventilation of cold air (IHCA), as the standard, to diagnose asthma in a group of children with hay fever. Twenty-eight children with pollinosis, 12 of them with a history of asthma for the first time during the season 1992, were studied during the birch pollen season and in the autumn of 1994. During both periods, the bronchial hyper-reactivity was estimated by methacholine bronchial provocation tests (MBPT), bronchial variability by peak expiratory flow rate variability, subjective symptoms of asthma by visual analogue scale (VAS) and bronchial inflammation by serum and urine levels of inflammatory mediators. In 1994 IHCA was added during both seasons. Eight of 16 children with BHR but without clinical asthma in 1992 had developed asthma in 1994, 14 of 16 reacted to IHCA and 13 to MBPT. All 12 children with DDA in 1992 had still asthma in 1994 and 14 children with BHR in 1992 had persistent BHR in 1994. Of 23 children with BHR in 1992, 17 had DDA in 1994 and all maintained their BHR. Furthermore, 20 of them reacted to IHCA in 1994. In 1994, 24 of 28 hay-fever children had a positive IHCA tests and 24 had positive MBPT. In relation to VAS, the sensitivity of IHCA and MBPT to predict present asthma was high, but the specificity low, whereas the specificity of most other tests was high, but based on few individuals. In relation to DDA both the IHCA test (65-80%) and the MBPT test (79-85%) had a high sensitivity and it was three to six times more likely to find a positive test among asthmatics than in non-asthmatics. Children with hay fever without clinical asthma have a high risk of developing asthma within 2 yr. In relation to DDA, inhalation of cold air and the MBPT showed a high sensitivity.
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Affiliation(s)
- Hosne Ara Ferdousi
- Department of Paediatrics, University Hospital of Linköping, Linköping, Sweden
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Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, Aalberse R, Arshad SH, Berg Av AV, Carlsen KH, Duschén K, Eigenmann P, Hill D, Jones C, Mellon M, Oldeus G, Oranje A, Pascual C, Prescott S, Sampson H, Svartengren M, Vandenplas Y, Wahn U, Warner JA, Warner JO, Wickman M, Zeiger RS. Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol 2004; 15:291-307. [PMID: 15305938 DOI: 10.1111/j.1399-3038.2004.00127.x] [Citation(s) in RCA: 194] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The role of primary prevention of allergic diseases has been a matter of debate for the last 40 years. In order to shed some light on this issue, a group of experts of the Section of Pediatrics EAACI reviewed critically the existing literature on the subject. An analysis of published peer-reviewed observational and interventional studies was performed following the statements of evidence as defined by WHO. The results of the analysis indicate that breastfeeding is highly recommended for all infants irrespective of atopic heredity. A dietary regimen is unequivocally effective in the prevention of allergic diseases in high-risk children. In these patients breastfeeding combined with avoidance of solid food and cow's milk for at least 4-6 months is the most effective preventive regimen. In the absence of breast milk, formulas with documented reduced allergenicity for at least 4-6 months should be used.
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Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, Aalberse R, Arshad SH, von Berg A, Carlsen KH, Duschén K, Eigenmann P, Hill D, Jones C, Mellon M, Oldeus G, Oranje A, Pascual C, Prescott S, Sampson H, Svartengren M, Vandenplas Y, Wahn U, Warner JA, Warner JO, Wickman M, Zeiger RS. Dietary prevention of allergic diseases in infants and small children. Part II. Evaluation of methods in allergy prevention studies and sensitization markers. Definitions and diagnostic criteria of allergic diseases. Pediatr Allergy Immunol 2004; 15:196-205. [PMID: 15209950 DOI: 10.1111/j.1399-3038.2004.00128.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The role of primary prevention of allergic disease has been a matter of debate for the last 40 years. In order to shed some light into this issue a group of experts of the Section of Pediatrics EAACI critically reviewed the existing literature on the subject. The design of observational and interventional studies was evaluated with relevance to the important factors influencing outcome of studies on allergy development/prevention. in this analysis the statements of evidence as defined by WHO were applied. Best evidence of recommendations are those fulfilling the criteria for statements category 1 and 2 and grade of recommendations A and B as proposed by WHO. This survey include target group for dietary prevention and methods and diagnostic criteria of atopic dermatitis, asthma and food allergy for prevention studies.
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Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, Aalberse R, Arshad SH, Berg Av AV, Carlsen KHK, Duschén K, Eigenmann P, Hill D, Jones C, Mellon M, Oldeus G, Oranje A, Pascual C, Prescott S, Sampson H, Svartengren M, Vandenplas Y, Wahn U, Warner JA, Warner JO, Wickman M, Zeiger RS. Dietary prevention of allergic diseases in infants and small children. Part I: immunologic background and criteria for hypoallergenicity. Pediatr Allergy Immunol 2004; 15:103-11. [PMID: 15059185 DOI: 10.1046/j.1399-3038.2003.00129.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The role of primary prevention of allergic diseases has been a matter of debate for the last 40 years. In order to shed some light into this issue, a group of experts of the Section of Pediatrics EAACI critically reviewed the existing literature on the subject. In this paper, the immunology of the fetus and newborn is reviewed as well as the post-natal development of the immune system. The influence of post-natal environment and breastfeeding on tolerance induction and sensitization are examined. Allergic diseases result from a strong relationship between genetic and environmental factors. Sensitization to food allergens occurs in the first year of life and cow's milk allergy is the first food allergy to appear in the susceptible infants. Hypoallergenicity of food formulas to be used is a critical issue both for treatment of cow's milk-allergic children and for prevention. Methods to document hypoallergenicity are discussed and evaluated in the preclinical and clinical steps.
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Abstract
Allergen exposure is a risk to develop an IgE-mediated sensitization. The amount of allergen inhaled per unit time should be related to the amount present in the air, i.e. airborne allergen. Thus, measuring allergen levels in the air would be more relevant than measuring allergen levels in dust. Allergens are present in the air in very minute quantities and usually become airborne after disturbance. Large variation of allergen levels have been found in dust. In this study, we measured variability of airborne cat allergen, Fel d1, in a public place using a high-volume air-sampler. We also studied the distribution and relationship between dust and airborne cat allergens in homes and schools. Air samples were collected at three different airflow rates, i.e. 55, 40, and 30 m3 of air per hour. The concentration of airborne Fel d1 in the community gymnastic hall varied from 1 to 10 pg/m3 within a period of 3 weeks, at airflow rates 55-30 m3/h. The coefficient of variation for repeated samplings was 14-43% (day-to-day variation) and 27-38% (within-day variation). As expected, higher levels of airborne cat allergens were found in homes with cats than in cat-free environments. There was a significant relationship between cat allergen levels in dust and air (r=0.7, P<0.01). Our study demonstrates that when measuring airborne cat allergen a large variation is observed within a day and between days. The large variability of measurement may be explained by the disturbance in the environments. We suggest, that when exposure assessment is made the environment in question should be analyzed, if possible in several occasions.
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Affiliation(s)
- A K M Munir
- Department of Health and Environment, Division of Pediatrics, University Hospital, Linköping, Sweden.
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Høst A, Andrae S, Charkin S, Diaz-Vázquez C, Dreborg S, Eigenmann PA, Friedrichs F, Grinsted P, Lack G, Meylan G, Miglioranzi P, Muraro A, Nieto A, Niggemann B, Pascual C, Pouech MG, Rancé F, Rietschel E, Wickman M. Allergy testing in children: why, who, when and how? Allergy 2003; 58:559-69. [PMID: 12823111 DOI: 10.1034/j.1398-9995.2003.00238.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Dreborg S. LUNG BIOAVAILABILITY OF SPACERS. Ann Allergy Asthma Immunol 2003. [DOI: 10.1016/s1081-1206(10)61879-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Johansson SGO, Hourihane JO, Bousquet J, Bruijnzeel-Koomen C, Dreborg S, Haahtela T, Kowalski ML, Mygind N, Ring J, van Cauwenberge P, van Hage-Hamsten M, Wüthrich B. Eine revidierte Nomenklatur der Allergie. Allergo J 2003. [DOI: 10.1007/bf03361182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Matricardi PM, Bjorksten B, Bonini S, Bousquet J, Djukanovic R, Dreborg S, Gereda J, Malling HJ, Popov T, Raz E, Renz H, Wold A. Microbial products in allergy prevention and therapy. Allergy 2003; 58:461-71. [PMID: 12757444 DOI: 10.1034/j.1398-9995.2003.00175.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- P M Matricardi
- Asthma and Allergy Research Unit, Ospedale Pediatrico Bambino Gesu Research Institute - IRCCS, Piazza S. Onofrio, 4, 00165 Rome, Italy
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Schneider T, Sundell J, Bischof W, Bohgard M, Cherrie JW, Clausen PA, Dreborg S, Kildesø J, Kaergaard SK, Løvik M, Pasanen P, Skyberg K. 'EUROPART'. Airborne particles in the indoor environment. A European interdisciplinary review of scientific evidence on associations between exposure to particles in buildings and health effects. Indoor Air 2003; 13:38-48. [PMID: 12608924 DOI: 10.1034/j.1600-0668.2003.02025.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The relevance of particle mass, surface area or number concentration as risk indicators for health effects in non-industrial buildings has been assessed by a European interdisciplinary group of researchers (called EUROPART) by reviewing papers identified in Medline, Toxline, and OSH. Studies dealing with dermal effects or cancer or specifically addressing environmental tobacco smoke, house dust-mite, cockroach or animal allergens, microorganisms and pesticides were excluded. A total of 70 papers were reviewed, and eight were identified for the final review: Five experimental studies involving mainly healthy subjects, two cross-sectional office studies and one longitudinal study among elderly on cardiovascular effects. From most studies, no definite conclusions could be drawn. Overall, the group concluded that there is inadequate scientific evidence that airborne, indoor particulate mass or number concentrations can be used as generally applicable risk indicators of health effects in non-industrial buildings and consequently that there is inadequate scientific evidence for establishing limit values or guidelines for particulate mass or number concentrations.
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Affiliation(s)
- T Schneider
- National Institute of Occupational Health, Copenhagen, Denmark.
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