Characterizing the Impact of Race and Redlining on Receipt of Guideline-Compliant Locoregional Therapy among Older Women with Breast Cancer

PURPOSE/OBJECTIVE(S)

Breast cancer (BC) is one of few malignancies in which improved locoregional control has been shown to improve overall survival. Contemporary redlining, or mortgage lending bias on the basis of home location, is a form of structural racism which has been demonstrated to impact BC survival in older patients. Self-reported race has been thought to serve as a surrogate for interpersonal racism and has similarly been shown to have associations with survival, redlining, and access to care. We aim to examine the relationship between race, redlining, and the receipt of guideline compliant locoregional therapy (LRT) in older women with BC.

MATERIALS/METHODS

Women aged 66-90 years with an initial Stage I-III BC diagnosis in 2010-2017 and known metropolitan statistical area (MSA) were identified in SEER-Medicare. Redlining was estimated using Home Mortgage Disclosure Act data (2010-2017). Guideline compliant LRT was assessed based on whether patients underwent surgery (lumpectomy or mastectomy), and if surgery was performed, whether they received adjuvant radiation treatment per the National Quality Forum and National Comprehensive Cancer Network guidelines in effect during the study period. A multiple logistic regression model was fitted to estimate ORs for the relationship between redlining and receipt of guideline compliant LRT, accounting for covariates (age, race/ethnicity, comorbidities, dual enrollment, tumor stage, hormone receptor status, census region, and year of diagnosis). Cluster bootstrap at the MSA-level was used to obtain P-values and confidence intervals.

RESULTS

The cohort included 64,987 women: 31% aged 66-70, 82% Non-Hispanic (NH) White, 7.4% NH Black, 24% with 2+ comorbidities, 12% with dual Medicaid/Medicare enrollment, 60% stage I, 31% stage II, and 77% HR+/HER2-. Overall, 6.4% did not undergo surgery; 84% received guideline compliant LRT. Women in the highest redlining areas had 81% guideline compliant LRT compared to 84-85% in the least, low and moderate redlined areas (p<0.001). However, model results revealed that contemporary redlining was not a predictor of guideline compliant LRT. NH Black women were less likely than NH White women to receive guideline-compliant LRT (OR 0.77, 95% CI 0.71-0.84, p<0.001). No significant differences were noted between NH White and NH Asian or Hispanic women.

CONCLUSION

In this population-based cohort of older women with breast cancer, NH Black race, even after adjusting for several important clinical and demographic factors, was associated with a lower likelihood of receiving guideline-compliant LRT. This finding demonstrates the profound impact of interpersonal racism on receipt of cancer-directed therapies. Though contemporary redlining did not significantly impact guideline-compliant LRT, further work is needed to identify systematic factors explaining known associations between contemporary redlining and BC survival.

The current use of the EORTC QLQ-NMIBC24 and QLQ-BLM30 questionnaires for the assessment of health-related quality of life in bladder cancer patients: a systematic review

PURPOSE

Investigating the use of the EORTC bladder cancer (BC) modules by evaluating: (a) study contexts/designs; (b) languages/countries in which the modules were administered; (c) their acceptance by patients/investigators; and (d) their psychometric properties.

METHODS

A systematic review was performed with studies from 1998 until 20/10/2021 in five databases. Articles/conference abstracts using the EORTC-QLQBLM30 (muscle invasive BC) and the EORTC-QLQNMIBC24 (previously referred to as QLQ-BLS24; non-muscle invasive BC) were included. Two authors independently screened titles/abstracts/full-texts and performed data extraction.

RESULTS

A total of 76 eligible studies were identified. Most studies included the BLM30 (n = 53), were in a urological surgery context (n = 41) and were cross-sectional (n = 35) or prospective (n = 30) in design. The BC modules were administered in 14 languages across 19 countries. Missing data were low-moderate for all non-sex related questions (< 1% to 15%). Sex-related questions had higher rates of missing data (ranging from 6.9% to 84%). Most investigators did not use all scales of the questionnaires. One validation study for the original BLS24 led to the development of the NMIBC24, which adopted a new scale structure for which good structural validity was confirmed (n = 3). Good reliability and validity was shown for the NMIBC24 module, except for malaise and bloating/flatulence scales. Psychometric evidence for BLM30 is lacking.

CONCLUSION

These results provide insight into how the EORTC BC quality of life modules could be further improved. Current work is ongoing to update the modules and to determine if the two modules can be combined into a single questionnaire that works well in both the NMIBC and MIBC settings.

Cancer care for Ukrainian refugees: Strategic impact assessments in the early days of the conflict

BACKGROUND

The invasion of Ukraine by Russia in February 2022 has resulted in destruction of healthcare infrastructure and triggered the largest wave of internally displaced populations and refugees since World War Two. Conflicts in transitioned countries such as Ukraine create new non-communicable disease (NCD) challenges, especially for cancer care for refugees and humanitarian assistance in host countries. In the early days, rapid attempts were made to model possible impacts.

METHODS

By evaluating open source intelligence used in the first three months of the conflict through snowball search methods, we aimed to address: (i) burden of cancer in Ukrainian population, specifically considering translating to the refugees population, and its cancer care capacity; ii) baseline capacity/strengths of cancer systems in initial host countries. Moreover, using a baseline scenario based on crude cancer incidence in Ukraine, and considering data from UNHCR, we estimated how cancer cases would be distributed across host countries. Finally, a surveillance assessment instrument was created, intersecting health system's capacity and influx of internally displaced populations and refugees.

FINDINGS AND CONCLUSIONS

The total new cancer patients per month in pre-conflict Ukraine was estimated as 13,106, of which < 1 % are paediatric cases. The estimated cancer cases in the refugee population (combining prevalent and incident), assuming 7.5 million refugees by July 2022 and a female:male ratio of 9:1, was 33,121 individuals (Poland: 19284; Hungary: 3484; Moldova: 2651; Slovakia: 2421; Romania: 5281). According to our assessments, Poland is the only neighbouring country classified as green/yellow for cancer capacity, i.e. sufficient ablility to absorb additional burden into national health system; Slovakia we graded as yellow, Hungary and Romania as yellow/red and Moldova as red.

Software-based perfusion assessment of the ileal J-pouch – a standardized and objective approach of interpreting intraoperative indocyanine green near-infrared fluorescence

Objective

For ileal J-pouch after restorative proctocolectomy, intraoperative perfusion assessment is vital to prevent complications such as anastomotic leak (AL) of the pouch. Indocyanine green derived near-infrared fluorescence (ICG-NIRF) is gaining popularity for intraoperative visualization, while its interpretation and relevance remain subjective. Standardized NIRF protocols with objective and quantifiable data are not yet established. This study aimed to evaluate a standardized approach of intraoperative ICG-NIRF imaging combined with a novel, software-based perfusion assessment for the detection of AL of the pouch. We hypothesized that an analysis of fluorescence intensity over time would result in novel, quantifiable and objective indicators of perfusion.

Methods

In this prospective single centre study patients undergoing restorative proctocolectomy with ileal J-pouch formation were included. Intraoperatively, ICG-NIRF visualization was performed at three time points in a strictly standardized setting and video recorded. Postoperatively, a special software was used to depict fluorescence intensity over time, generating perfusion graphs for each recorded pouch visualization. The characteristics of these perfusion graphs were correlated with postoperative outcome, including AL of the pouch within 30 days precisely defined and screened for by pouchoscopy.

Results

18 patients were included, of which 4 developed AL of the ileal pouch-anal anastomosis (IPAA). Distinctive perfusion curves were generated for regions of interest (ROIs) across each pouch. Novel characteristics of perfusion were identified (ingress, maximum slope, egress and maximum egress). Differences in the shape of the perfusion graphs became evident when comparing pouches with a normal to those with an AL. In cases of AL, the pouch apex displayed lower ingress, maximum slope and egress values, indicating impaired perfusion. This was confirmed by comparing the maximum slope of the perfusion curve versus the egress on the pouch apex.

Conclusion

We present a novel methodology to assess anastomotic perfusion in pouch surgery with ICG-NIRF in real-time. By dynamically analyzing fluorescence intensity over time in the form of perfusion graphs and correlation with outcome, novel parameters of perfusion were identified. These have the potential to improve the objectivity and quantifiability of intraoperative perfusion assessment.

[Diagnostic and therapeutic approach to anaphylaxis in childhood and adolescence]

Anaphylaxis is a suddenly occurring potentially life-threatening systemic allergic reaction. In childhood, food allergens play a major role but insect stings and drugs are also potential triggers. The symptoms appear in minutes up to few hours on the skin, airways, gastrointestinal tract and/or the cardiovascular system. Intramuscular adrenaline is the drug of first choice due to its rapid effectiveness and its low side effect potential. A detailed patient history and the determination of potential IgE antibodies must be carried out to identify the triggers. The register for anaphylaxis has improved knowledge on epidemiology. An education in anaphylaxis is useful for every patient as well as parents and caregivers. Allergen-specific immunotherapy is currently the only causal treatment option; however, at the present time it is only available for insect bites and peanut allergy.

Residential history in cancer research: Utility of the annual billing ZIP code in the SEER-Medicare database and mobility among older women with breast cancer in the United States

There is a rise in attention to residential history in cancer epidemiology aimed at more effective estimation of social and physical environmental exposures and the influence of place of residence on cancer outcomes. However, in the United States, as in many other countries, residential history data are not readily available. In this paper we explore the feasibility of using the annual Medicare billing ZIP code history available in the SEER-Medicare database to study residential mobility among older cancer survivors in the U.S. In a cohort of women diagnosed with breast cancer between 2007 and 2015, we examine the completeness of the data along with the overall characteristics of residential moves based on race and stage at diagnosis. Findings indicate that residential mobility among older women with breast cancer in the U.S. is limited, but differences by race/ethnicity, stage at diagnosis and before/after diagnosis are statistically significant. And breast cancer survivors from minority groups move more frequently than their non-Hispanic White counterparts. The results also show that move rate slightly, but statistically significantly, increases after diagnosis. We conclude that SEER-Medicare can be utilized to study residential mobility among older cancer survivors. We recommend the creation of sub-cohorts based on specific research questions to account for variability in residential mobility due to very short survival times or a diagnosis shortly after Medicare enrollment. Studying residential history provides the opportunity for assigning socioecological and exposure metrics for future survival studies.

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

BACKGROUND

Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents.

METHODS

Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre.

RESULTS

3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004).

CONCLUSIONS

The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

Historical Housing Discrimination, Indicators of Disinvestment, and Breast Cancer Outcomes Nearly a Century Later

Purpose: We investigated associations between 1930's era records of mortgage lending discrimination (i.e., “redlining”), a present-day indicator of disinvestment (i.e., residential physical disorder), and tumor clinicopathologic features (stage, grade, subtype) and survival among women diagnosed with breast cancer in New Jersey. Methods: Historical, Home Owners' Loan Corporation (HOLC) data were recently geocoded from the University of Richmond's Digital Scholarship Lab. Risk grades of ‘A'/‘Best', ‘B'/‘Still Desirable', ‘C'/‘Definitely Declining', and ‘D'/‘Hazardous' – available for six metropolitan areas of New Jersey – were collapsed into C/D (‘redlined') and A/B (‘not redlined') for analyses. Sociodemographics (age, race, ethnicity, geocoded residential address, date of diagnosis), tumor features (stage at diagnosis, grade, subtype), and vital status (cause and date of death) were ascertained from the New Jersey State Cancer Registry for all primary, histologically-confirmed, invasive breast cancer cases diagnosed between 2008 and 2017, among female residents of a HOLC-graded area, who were ≥ 20 years at diagnosis (N = 11,980). Residential physical disorder was estimated based on residential address at diagnosis using spatial prediction models of virtually audited Google Street View scenes of 6,132 locations. Logistic regression models of tumor features and accelerated failure time models of survival time to BrCa-specific death (follow-up through 2019) were built to investigate associations with redlining and physical disorder, while controlling for covariates. Results: There were 1,215 BrCa-specific deaths, a median follow-up time of 5.1 years, and a 5-year survival of 89.6%. Living in a historically redlined neighborhood was associated with higher odds of late-stage and high-grade tumors. Living in a non-redlined neighborhood was associated with a 47.5% (95% CI: 20.1, 79.8) longer survival time in low physical disorder areas. This survival benefit decreased as physical disorder increased. Conclusions: Historical racial housing discrimination might interact with present-day measures of disinvestment to influence BrCa survival. Future studies should collect more comprehensive data including potential confounders and residential history.

The role of residential history in cancer research: A scoping review

The role of residential history in cancer prevention, diagnosis, treatment, and survivorship is garnering increasing attention in cancer research. To our knowledge, there is no comprehensive synthesis of the current state of knowledge in the field. We reviewed the extant literature on this topic and conducted a scoping analysis to examine two main research questions: (a) To what degree, and how, have researchers accounted for residential history/mobility in cancer research? and (b) What are the gaps in the literature based on a knowledge synthesis using scoping review and concept mapping? To answer these questions, this scoping analysis focuses on how researchers compile, analyze and discuss residential history/mobility in studies on cancer. The study is focused on peer-reviewed articles from 6 different datasets (PubMed, Cinahl, Scopus, Web of Science and JSTOR, ERIC) from 1990 to August 2020. The review captured 1951 results in total, which was scoped to 281 relevant peer-reviewed journal articles. First, we examined these articles based on cancer continuum, cancer type and the main theme. Second, we identified 21 main themes and an additional 16 sub-themes in the pool of the selected articles. We utilized concept mapping to provide a conceptual framework and to highlight the underlying socioecological assumptions and paradigms. Results show that cancer research incorporating residential histories is primarily focused on incidence and estimating cumulative exposure, with little consideration across the cancer continuum. Additionally, our review suggests that although the social environment plays an important role across the cancer continuum, a small number of articles were focused on such factors and this area remains relatively unexplored. Additionally, the expansion of interdisciplinary research on residential mobility before and after cancer diagnosis will enhance understanding of the role of environmental and socioeconomic characteristics and exposures on cancer continuum.

Novel methods for in vitro modeling of pancreatic cancer reveal important aspects for successful primary cell culture

Background

Pancreatic cancer remains a fatal disease. Experimental systems are needed for personalized treatment strategies, drug testing and to further understand tumor biology. Cell cultures can serve as an excellent preclinical platform, but their generation remains challenging.

Methods

Tumor cells from surgically removed pancreatic ductal adenocarcinoma (PDAC) specimens were cultured under novel protocols. Cellular growth and composition were analyzed and culture conditions were continuously optimized. Characterization of cell cultures and primary tumors was performed via hematoxylin and eosin (HE) and immunofluorescence (IF) staining.

Results

Protocols for two- and three-dimensional PDAC primary cell cultures could successfully be established. Primary cell culture depended on dissociation techniques, growth factor supplementation and extracellular matrix components containing Matrigel being crucial for the transformation to three-dimensional PDAC organoids. The generated cultures showed to be highly resemblant to established PDAC primary cell cultures. HE and IF staining for cell culture and corresponding primary tumor characterization could successfully be performed.

Conclusions

The work presented herein shows novel and effective methods to successfully establish primary PDAC cell cultures in a distinct time frame. Factors contributing to cell growth and differentiation could be identified with important implications for further primary cell culture protocols. The established protocols might serve as novel tools in personalized tumor therapy.

The legacy of the Home Owners' Loan Corporation and the political ecology of urban trees and air pollution in the United States

This study examines the persistent impacts of historical racebased discriminatory housing policies on contemporary urban environments in the United States. Specifically, we examine the relationships between Home Owners' Loan Corporation (HOLC) grades assigned to neighborhoods in the 1930s and the current distribution of tree canopy and level of exposure to air pollution hazards. Our results indicate a clear gradient in tree canopy by HOLC grade, with better neighborhood grades associated with significantly higher percentage of tree canopy coverage. The pattern also exists for airborne carcinogens and respiratory hazards, with worse neighborhood grades associated with significantly higher hazards exposure. Our findings indicate that early 20th century discriminatory housing policies exert a contemporary influence on patterns of green space exposure in American cities, with implications for health and health inequities. Our findings suggest that, in order to achieve equitable access to the benefits of urban greenspace, we must acknowledge these historical influences and consider policies and practices that directly counter these influences, for example, through targeted greenspace development in areas historically identified as unfit for investment.

Comparison of a 3D head-mounted display (HMS-3000MT) and 3D passive polarizing display with 2D technique for first laparoscopic inguinal hernia repair by novice surgeons

BACKGROUND

Three-dimensional (3D) laparoscopy improves the surgical skills of novice surgeons and positively affects the learning curve in experimental settings. This study aimed to investigate the effect of a 3D passive polarizing display (3DPPD) and a novel 3D head-mounted display (3DHMD; HMS-3000MT) on the performance of the first laparoscopic inguinal hernia repair by novices and compare both systems with standard high-definition 2D (HD2D) laparoscopy.

METHODS

Patients with symptomatic inguinal hernia underwent transabdominal preperitoneal (TAPP) approach hernia repair using 3DHMD, 3DPPD, or a conventional HD2D laparoscopic system. All surgeries were performed for the first time by three laparoscopically novice surgeons. Operative performance was compared in terms of the time taken for mesh placement and peritoneal suturing under standardized conditions. Additionally, visual perception parameters and adverse effects were assessed.

RESULTS

The use of both 3D techniques shortened the time required for mesh placement and peritoneal suturing compared with the conventional HD2D approach. Generally, 3D laparoscopy was superior to HD2D laparoscopy in terms of visual perception parameters such as depth perception, sharpness, ghosting, and contrast. However, compared with the use of HD2D laparoscopy, the use of 3DHMD significantly impaired a surgeon's comfort, with the greatest impairment caused by ear discomfort, headaches, and facial and physical discomforts.

CONCLUSIONS

The 3DHMD and 3DPPD systems showed clear improvement in first hernia repair laparoscopy by novice surgeons in terms of surgical performance, as well as visual perception; however, the 3DHMD system was not superior to the 3DPPD system. The reduction in training time for new surgeons is obviously advantageous. In this respect, the 3D equipment may be a worthwhile investment.

The urgent need for a harmonized severity scoring system for acute allergic reactions

The accurate assessment and communication of the severity of acute allergic reactions are important to patients, clinicians, researchers, the food industry, and public health and regulatory authorities. Severity has different meanings to different stakeholders with patients and clinicians rating the significance of particular symptoms very differently. Many severity scoring systems have been generated, most focusing on the severity of reactions following exposure to a limited group of allergens. They are heterogeneous in format, none has used an accepted developmental approach, and none has been validated. Their wide range of outcome formats has led to difficulties with interpretation and application. Therefore, there is a persisting need for an appropriately developed and validated severity scoring system for allergic reactions that work across the range of allergenic triggers and address the needs of different stakeholder groups. We propose a novel approach to develop and then validate a harmonized scoring system for acute allergic reactions, based on a data-driven method that is informed by clinical and patient experience and other stakeholders' perspectives. We envisage two formats: (i) a numerical score giving a continuum from mild to severe reactions that are clinically meaningful and are useful for allergy healthcare professionals and researchers, and (ii) a three-grade-based ordinal format that is simple enough to be used and understood by other professionals and patients. Testing of reliability and validity of the new approach in a range of settings and populations will allow eventual implementation of a standardized scoring system in clinical studies and routine practice.

How does dose impact on the severity of food-induced allergic reactions, and can this improve risk assessment for allergenic foods?: Report from an ILSI Europe Food Allergy Task Force Expert Group and Workshop

Quantitative risk assessment (QRA) for food allergens has made considerable progress in recent years, yet acceptability of its outcomes remains stymied because of the limited extent to which it has been possible to incorporate severity as a variable. Reaction severity, particularly following accidental exposure, depends on multiple factors, related to the allergen, the host and any treatments, which might be administered. Some of these factors are plausibly still unknown. Quantitative risk assessment shows that limiting exposure through control of dose reduces the rates of reactions in allergic populations, but its impact on the relative frequency of severe reactions at different doses is unclear. Food challenge studies suggest that the relationship between dose of allergenic food and reaction severity is complex even under relatively controlled conditions. Because of these complexities, epidemiological studies provide very limited insight into this aspect of the dose-response relationship. Emerging data from single-dose challenges suggest that graded food challenges may overestimate the rate of severe reactions. It may be necessary to generate new data (such as those from single-dose challenges) to reliably identify the effect of dose on severity for use in QRA. Success will reduce uncertainty in the susceptible population and improve consumer choice.

Fish oil in infancy protects against food allergy in Iceland-Results from a birth cohort study

BACKGROUND

Consumption of oily fish or fish oil during pregnancy, lactation and infancy has been linked to a reduction in the development of allergic diseases in childhood.

METHODS

In an observational study, Icelandic children (n = 1304) were prospectively followed from birth to 2.5 years with detailed questionnaires administered at birth and at 1 and 2 years of age, including questions about fish oil supplementation. Children with suspected food allergy were invited for physical examinations, allergic sensitization tests, and a double-blind, placebo-controlled food challenge if the allergy testing or clinical history indicated food allergy. The study investigated the development of sensitization to food and confirmed food allergy according to age and frequency of postnatal fish oil supplementation using proportional hazards modelling.

RESULTS

The incidence of diagnosed food sensitization was significantly lower in children who received regular fish oil supplementation (relative risk: 0.51, 95% confidence interval: 0.32-0.82). The incidence of challenge-confirmed food allergy was also reduced, although not statistically significant (0.57, 0.30-1.12). Children who began to receive fish oil in their first half year of life were significantly more protected than those who began later (P = .045 for sensitization, P = .018 for allergy). Indicators of allergy severity decreased with increased fish oil consumption (P = .013). Adjusting for parent education and allergic family history did not change the results.

CONCLUSION

Postnatal fish oil consumption is associated with decreased food sensitization and food allergies in infants and may provide an intervention strategy for allergy prevention.

EAACI Guidelines on allergen immunotherapy: IgE-mediated food allergy

Food allergy can result in considerable morbidity, impairment of quality of life, and healthcare expenditure. There is therefore interest in novel strategies for its treatment, particularly food allergen immunotherapy (FA-AIT) through the oral (OIT), sublingual (SLIT), or epicutaneous (EPIT) routes. This Guideline, prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Task Force on Allergen Immunotherapy for IgE-mediated Food Allergy, aims to provide evidence-based recommendations for active treatment of IgE-mediated food allergy with FA-AIT. Immunotherapy relies on the delivery of gradually increasing doses of specific allergen to increase the threshold of reaction while on therapy (also known as desensitization) and ultimately to achieve post-discontinuation effectiveness (also known as tolerance or sustained unresponsiveness). Oral FA-AIT has most frequently been assessed: here, the allergen is either immediately swallowed (OIT) or held under the tongue for a period of time (SLIT). Overall, trials have found substantial benefit for patients undergoing either OIT or SLIT with respect to efficacy during treatment, particularly for cow's milk, hen's egg, and peanut allergies. A benefit post-discontinuation is also suggested, but not confirmed. Adverse events during FA-AIT have been frequently reported, but few subjects discontinue FA-AIT as a result of these. Taking into account the current evidence, FA-AIT should only be performed in research centers or in clinical centers with an extensive experience in FA-AIT. Patients and their families should be provided with information about the use of FA-AIT for IgE-mediated food allergy to allow them to make an informed decision about the therapy.

Hen's egg allergen in house and bed dust is significantly increased after hen's egg consumption-A pilot study

Environmental exposure to food allergens may be a risk factor for cutaneous sensitization. Previous studies could detect peanut allergen in house dust. In this pilot study, we wanted to investigate whether hen's egg allergen is detectable in house dust collected from different household areas and whether levels are increased after intentional hen's egg consumption. Hen's egg protein levels of dust samples were measured using ELISA. In 8 of 8 households, hen's egg was detectable in dust samples of eating area and bed. Forty-eight hours after intentional hen's egg consumption, hen's egg protein levels were significantly increased in both. Still, further research is necessary to investigate whether hen's egg allergen in house and bed dust plays a role in sensitization via skin.

Natural tolerance development in cow's milk allergic children: IgE and IgG4 epitope binding

BACKGROUND

Although most of cow's milk (CM) allergic children will outgrow their allergy, the pathomechanism of the natural development of tolerance remains poorly understood. It has been suggested that the balance between milk-specific IgE and IgG4 plays a major role.

OBJECTIVE

We aimed to investigate differences in IgE and IgG4 antibody binding to CM epitopes between patients with persistent CM allergy (CMA) and those that naturally became tolerant.

METHODS

Sera from 35 children with proven CMA (median age at inclusion of 10 months) were analyzed retrospectively; 22 patients have become tolerant (median age at tolerance acquisition of 51 months) during the study period as confirmed by a negative oral food challenge. IgE and IgG4 binding to sequential epitopes derived from five major CM proteins were measured with a peptide microarray-based immunoassay.

RESULTS

At baselines, greater intensity and broader diversity of IgE and IgG4 binding have been found in children with persistent CMA beyond 5 years of age compared to patients with transient CMA. Moreover, children with transient CMA had IgE and IgG4 antibodies that more often recognized the same epitopes, compared to those with persistent CMA. From baseline to the time of tolerance development, both IgE and IgG4 binding intensity decreased significantly, particularly in areas of α-s- and β-casein (P<.01, false discovery rate [FDR]<.1). Interestingly, differences between IgE and IgG4 binding intensity to CM peptides decreased when the patients became tolerant.

CONCLUSIONS

Our results suggest that the overlap between IgE and IgG4 might be important in natural tolerance acquisition. Further studies are needed to confirm our data and can eventually lead to development of more targeted treatment of food allergy.

Allergen immunotherapy for IgE-mediated food allergy: a systematic review and meta-analysis

BACKGROUND

The European Academy of Allergy and Clinical Immunology (EAACI) is developing Guidelines for Allergen Immunotherapy (AIT) for IgE-mediated Food Allergy. To inform the development of clinical recommendations, we sought to critically assess evidence on the effectiveness, safety and cost-effectiveness of AIT in the management of food allergy.

METHODS

We undertook a systematic review and meta-analysis that involved searching nine international electronic databases for randomized controlled trials (RCTs) and nonrandomized studies (NRS). Eligible studies were independently assessed by two reviewers against predefined eligibility criteria. The quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs and the Cochrane ACROBAT-NRS tool for quasi-RCTs. Random-effects meta-analyses were undertaken, with planned subgroup and sensitivity analyses.

RESULTS

We identified 1814 potentially relevant papers from which we selected 31 eligible studies, comprising of 25 RCTs and six NRS, studying a total of 1259 patients. Twenty-five trials evaluated oral immunotherapy (OIT), five studies investigated sublingual immunotherapy, and one study evaluated epicutaneous immunotherapy. The majority of these studies were in children. Twenty-seven studies assessed desensitization, and eight studies investigated sustained unresponsiveness postdiscontinuation of AIT. Meta-analyses demonstrated a substantial benefit in terms of desensitization (risk ratio (RR) = 0.16, 95% CI 0.10, 0.26) and suggested, but did not confirm sustained unresponsiveness (RR = 0.29, 95% CI 0.08, 1.13). Only one study reported on disease-specific quality of life (QoL), which reported no comparative results between OIT and control group. Meta-analyses revealed that the risk of experiencing a systemic adverse reaction was higher in those receiving AIT, with a more marked increase in the risk of local adverse reactions. Sensitivity analysis excluding those studies judged to be at high risk of bias demonstrated the robustness of summary estimates of effectiveness and safety of AIT for food allergy. None of the studies reported data on health economic analyses.

CONCLUSIONS

AIT may be effective in raising the threshold of reactivity to a range of foods in children with IgE-mediated food allergy whilst receiving (i.e. desensitization) and post-discontinuation of AIT. It is, however, associated with a modest increased risk in serious systemic adverse reactions and a substantial increase in minor local adverse reactions. More data are needed in relation to adults, long term effects, the impact on QoL and the cost-effectiveness of AIT.

Comparison of paperpoint and curette sampling of subgingival microbiome composition as analyzed by 16S rRNA gene amplicon sequencing

Objective: Our aim was to compare the subgingival microbiome composition in samples collected by curettes and paperpoints.

Methods: Subgingival plaque of rheumatoid arthritis patients with periodontitis (N=66) or gingivitis (N=15) was collected at two timepoints by sterile curettes and paperpoints. Unused sterile paperpoints were included as controls. The microbial DNA was processed for 16S rRNA gene amplicon sequencing. The data was processed and clustered into Operational Taxonomic Units (OTUs) and assessed by multivariate analyses.

Results: Unused paperpoints showed various levels of DNA contamination. The OTUs specific for unused paperpoints were classified as Exiguobacterium, Enterococcus, Methylobacterium, Aquabacterium and Pseudomonas and were removed from the dataset.

Microbial profiles of curette samples differed significantly from the paperpoint samples (PERMANOVA, p=0.0009, F=3.167). The paperpoint samples had significantly higher proportion of OTUs classified as Streptococcus, Gemella, Parvimonas, Haemophilus, Aggregatibacter and Clostridiales family XIII incertae sedis (p<0.05). Curette samples harbored higher proportion of Corynebacterium, Prevotella, Selenomonas, Actinomyces and Treponema (p<0.05).

Curette samples had significantly higher species richness (p=0.01) and Shannon Diversity Index (p=0.009) than the paperpoint samples.

Conclusions: Different subgingival plaque sampling techniques result in different microbiome profiles. Samples by paperpoints introduce microbial DNA contaminants and show underestimated microbial diversity compared to samples obtained by curettes.

Ana o 3-specific IgE is a good predictor for clinically relevant cashew allergy in children

INTRODUCTION

Component-resolved diagnostics using specific IgE to 2 S albumins has shown to be a valuable new option in diagnostic procedure. Ana o 3 is a 2 S albumin from cashew. The aim of this study was to investigate the role of Ana o 3-specific serum IgE in the diagnosis of cashew allergy and to identify cut-off levels to replace oral food challenges. Moreover, the value of additional determination of total IgE has been investigated.

METHODS

In a multicentre study, we analysed specific IgE to cashew extract and Ana o 3 as well as total IgE in children with suspected cashew allergy using the ImmunoCAP-FEIA and a standardized diagnostic procedure including oral challenges where indicated.

RESULTS

A total of 61 patients were included in the study. Forty-two were allergic to cashew, and 19 were tolerant. In receiver operating curves, Ana o 3 discriminates between allergic and tolerant children better than cashew-specific IgE with an area under the curve of 0.94 vs 0.78. The ratio of Ana o 3-specific IgE to total IgE did not further improve the diagnostic procedure. Probability curves for Ana o 3-specific IgE have been calculated, and a 95% probability could be estimated at 2.0 kU/l.

CONCLUSION

Specific IgE to Ana o 3 is a valuable tool for the diagnosis of cashew allergy. Considering its positive predictive value, it might allow to make a considerable number of oral challenges superfluous.

A new framework for the documentation and interpretation of oral food challenges in population-based and clinical research

BACKGROUND

The conduct of oral food challenges as the preferred diagnostic standard for food allergy (FA) was harmonized over the last years. However, documentation and interpretation of challenge results, particularly in research settings, are not sufficiently standardized to allow valid comparisons between studies. Our aim was to develop a diagnostic toolbox to capture and report clinical observations in double-blind placebo-controlled food challenges (DBPCFC).

METHODS

A group of experienced allergists, paediatricians, dieticians, epidemiologists and data managers developed generic case report forms and standard operating procedures for DBPCFCs and piloted them in three clinical centres. The follow-up of the EuroPrevall/iFAAM birth cohort and other iFAAM work packages applied these methods.

RECOMMENDATIONS

A set of newly developed questionnaire or interview items capture the history of FA. Together with sensitization status, this forms the basis for the decision to perform a DBPCFC, following a standardized decision algorithm. A generic form including details about severity and timing captures signs and symptoms observed during or after the procedures. In contrast to the commonly used dichotomous outcome FA vs no FA, the allergy status is interpreted in multiple categories to reflect the complexity of clinical decision-making.

CONCLUSION

The proposed toolbox sets a standard for improved documentation and harmonized interpretation of DBPCFCs. By a detailed documentation and common terminology for communicating outcomes, these tools hope to reduce the influence of subjective judgment of supervising physicians. All forms are publicly available for further evolution and free use in clinical and research settings.

Can we identify patients at risk of life-threatening allergic reactions to food?

Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.

EAACI Molecular Allergology User's Guide

The availability of allergen molecules ('components') from several protein families has advanced our understanding of immunoglobulin E (IgE)-mediated responses and enabled 'component-resolved diagnosis' (CRD). The European Academy of Allergy and Clinical Immunology (EAACI) Molecular Allergology User's Guide (MAUG) provides comprehensive information on important allergens and describes the diagnostic options using CRD. Part A of the EAACI MAUG introduces allergen molecules, families, composition of extracts, databases, and diagnostic IgE, skin, and basophil tests. Singleplex and multiplex IgE assays with components improve both sensitivity for low-abundance allergens and analytical specificity; IgE to individual allergens can yield information on clinical risks and distinguish cross-reactivity from true primary sensitization. Part B discusses the clinical and molecular aspects of IgE-mediated allergies to foods (including nuts, seeds, legumes, fruits, vegetables, cereal grains, milk, egg, meat, fish, and shellfish), inhalants (pollen, mold spores, mites, and animal dander), and Hymenoptera venom. Diagnostic algorithms and short case histories provide useful information for the clinical workup of allergic individuals targeted for CRD. Part C covers protein families containing ubiquitous, highly cross-reactive panallergens from plant (lipid transfer proteins, polcalcins, PR-10, profilins) and animal sources (lipocalins, parvalbumins, serum albumins, tropomyosins) and explains their diagnostic and clinical utility. Part D lists 100 important allergen molecules. In conclusion, IgE-mediated reactions and allergic diseases, including allergic rhinoconjunctivitis, asthma, food reactions, and insect sting reactions, are discussed from a novel molecular perspective. The EAACI MAUG documents the rapid progression of molecular allergology from basic research to its integration into clinical practice, a quantum leap in the management of allergic patients.

Incidence and natural history of hen's egg allergy in the first 2 years of life-the EuroPrevall birth cohort study

BACKGROUND

Parents and health staff perceive hen's egg allergy (HEA) as a common food allergy in early childhood, but the true incidence is unclear because population-based studies with gold-standard diagnostic criteria are lacking.

OBJECTIVE

To establish the incidence and course of challenge-confirmed HEA in children, from birth until the age of 24 months, in different European regions.

METHODS

In the EuroPrevall birth cohort study, children with a suspected HEA and their age-matched controls were evaluated in 9 countries, using a standardized protocol including measurement of HE-specific immunoglobulin E-antibodies in serum, skin prick tests, and double-blind, placebo-controlled food challenges (DBPCFC).

RESULTS

Across Europe, 12 049 newborns were enrolled, and 9336 (77.5%) were followed up to 2 years of age. In 298 children, HEA was suspected and DBPCFC was offered. HEA by age two was confirmed in 86 of 172 challenged children (mean raw incidence 0.84%, 95% confidence interval (95% CI) 0.67-1.03). Adjusted mean incidence of HEA was 1.23% (95% CI 0.98-1.51) considering possible cases among eligible children who were not challenged. Centre-specific incidence ranged from United Kingdom (2.18%, 95% CI 1.27-3.47) to Greece (0.07%). Half of the HE-allergic children became tolerant to HE within 1 year after the initial diagnosis.

CONCLUSIONS

The largest multinational European birth cohort study on food allergy with gold-standard diagnostic methods showed that the mean adjusted incidence of HEA was considerably lower than previously documented, although differences in incidence rates among countries were noted. Half of the children with documented HEA gained tolerance within 1 year postdiagnosis.