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State of World Allergy Report 2008
As allergic diseases continue to increase in prevalence and
complexity worldwide, there is an urgent need to create
awareness of the global burden of allergies and the need to
train more physicians to care for allergy sufferers. WAO
announces the June publication of the State of World Allergy
2008 Report, an analysis of current global trends in the
prevalence of allergic disease, a look to the future, and a
call to action for all those involved in the provision of
allergy patient care.
1. Budesonide/formoterol (B/F) maintenance and reliever
therapy: impact on airway inflammation in asthma
1,538 patients were randomized for six months to open-label B/F
maintenance (160/4.5 µg twice daily) and B/F as needed reliever
therapy. They were compared to guideline-based practices (GBP)
as managed by individual investigators. There were no
differences in time to severe exacerbation and severe asthma
exacerbation rate. However, there were fewer ER visits and
hospitalizations with B/F maintenance and reliever therapy (not
statistically significant). Mean daily inhaled corticosteroid
dose, reliever use, asthma medication costs and total annual
costs per patient were all significantly lower with the B/F
maintenance and reliever therapy vs. GBP. The authors conclude
that B/F maintenance and reliever therapy vs. GBP achieves
similar outcomes with significant lower costs. Editor's
comment: More data demonstrating that B/F maintenance and
reliever therapy is an effective means to control asthma.
Sears MR, et al.,
Eur Respir J 2008; 31:982
2. Impaired TH17 cell differentiation in
subjects with autosomal dominant hyper-IgE syndrome (HIES,
TH17 cells, a subset of helper T cells, are critical
to clear fungal and extracellular bacterial infections. These
authors show that interleukin (IL)-17 production ex vivo
by T cells from HIES individuals fails to produce IL-17, but not
IL-2, tumour-necrosis factor or interferon-γ, on mitogenic
stimulation with staphylococcal enterotoxin B or on antigenic
stimulation with Candida albicans or streptokinase.
Purified naïve T cells did not differentiate into IL-17
producing (TH17) T helper cells in vitro and
had lower expression of retinoid-related orphan receptor (ROR)-γt,
consistent with a crucial role for STAT3 signaling in the
generation of TH17 cells. Mutations in HIES patients
have been identified in stat3, the gene encoding STAT3
(signal transducer and activator of transcription 3), presumed
to underlie HIES. These data suggest that a lack of TH17
cells in HIES is a mechanism for recurrent infections.
Editor's Comment: Improving IL-17 production may help patients
with HIES. Milner JD, et al.,
Nature 2008; 452:773.
3. Allergens are distributed into few protein families and
possess a restricted number of biochemical functions
Allergen data from the Allergome database and protein family
definitions from the Pfam database were merged into a databased,
AllFam, accessible on the Internet at
http://www.meduniwien.ac.at/allergens/allfam/. 707 allergens
were classified by sequence into 134 AllFam families containing
184 Pfam domains or 2% of 9318 Pfam families. These data
indicate a similarity in protein structure in all allergens. The
small number of protein families that contain allergens, and the
narrow functional distribution of most allergens, confirm the
existence of yet unknown factors that render these proteins
allergenic. Editor's comment: Brilliant research bringing
together 2 databases to show that most allergenic structures are
contained in relatively few protein families. Radauer C, et
J Allergy Clin Immunol 2008; 121:847.
4. Recapitulation of IVIG anti-inflammatory activity with
a recombinant IgG Fc
The use of monomeric immunoglobulin G (IgG) confers
anti-inflammatory activity for a variety of autoimmune diseases.
This article demonstrates that the anti-inflammatory activity of
IgG is dependent on sialylation of the N-linked glycan of the
IgG Fc fragment. The authors identified the precise glycan
requirements for this anti-inflammatory activity, allowing them
to engineer an appropriate IgG1 Fc fragment, thus generating a
fully recombinant, sialylated IgG1 Fc with greater enhanced
potency, thereby precisely defining the biological active
component of IVIG. They conclude that it may be possible to
develop an IVIG replacement with improved activity and
availability. Editor's comment: It would be ideal to capture
the anti-inflammatory effect of IVIG without the need for human
donors. Anthony RM, et al.,
Science 2008; 320:373.
5. Nonsurgical management of obesity (O) in adults
O is a major risk factor for asthma, particularly in women. This
article reviews the strategies involved in the non-surgical
management of O. Assessing co-existing conditions, such as
hypertension, glucose intolerance, dyslipidemia, and obstructive
sleep apnea is important, and a reduction as low as 5-10% of
body weight may be sufficient to favorably modify a variety of
outcomes for these diseases. Lifestyle approaches include
low-fat diets, low-glycemic-index diets, high-protein diets, and
specific commercialized diets. The most interesting section of
the article discusses drugs prescribed for weight loss, none of
which are extremely effective vs. placebo. These medications
include diethylpropion, orlistat, phentermine, sibutramine, and
rimonabant. Not only is weight reduction difficult, maintaining
it is equally difficult. Eating a low-fat diet, frequent
self-monitoring of weight and food intake, high levels of
physical activity, long-term patient-physician contact, and the
careful use of medications are essential measures for successful
outcomes. Editor's comment: This is a wonderful discussion
outlining the treatment of obesity, a risk factor for severe
asthma. Eckel RH,
N Engl J Med 2008; 358:1941.
肥満は特に女性において喘息発症の主要なリスクファクターである。これはN Engl J
6. Severe atopic dermatitis (AD) is associated with a high
burden of environmental Staphylococcus aureus (S. aureus)
These authors quantified the S. aureus burden in homes of
patients with AD of varying severities and normal subjects. Dust
was collected from their bed, bedroom floor, and home vacuum
cleaner bag and the DNA extracted and quantified for the S.
aureus-specific femB gene using quantitative
real-time PCR. In general, participants with severe AD had
significantly more S. aureus DNA in their bed dust than
those with moderate, mild or no AD. Similar patterns were
observed for dust from the bedroom floors and vacuum bags. The
authors conclude that the high levels of S. aureus could
contribute to disease severity and persistence in AD patients.
Editor's comment: Patients with AD are colonized with S.
aureus. Higher levels of this same organism are found in
homes of AD subjects and correlate with its severity. Leung
AD, et al.,
Clin Exp Allergy 2008; 38:789.
7. Safety of long-acting β-agonists in stable COPD (A
This meta-analysis of 27 randomized clinical trials (≥ one month
in duration) compares LABAs with placebo (P) or anticholinergics
in stable, poorly reversible, and reversible COPD. LABAs reduced
severe exacerbations vs. placebo (RR, 0.78; 95% confidence
interval [CI], 0.67 to 0.91). There was no significant
difference between LABA and P groups for respiratory deaths.
LABAs used with inhaled corticosteroids (ICS) reduced the risk
of respiratory deaths compared to LABAs alone (RR, 0.35; 95% CI,
0.14 to 0.93) and significantly improved airflow limitation
measures, health-related quality-of-life and decreased the use
of rescue medication. Tiotropium bromide vs. LABAs decreased the
incidence of severe COPD exacerbations (RR, 0.52; 95% CI, 0.31
to 0.87). There is no increased risk of respiratory deaths
associated with the use of LABAs. Editor's comment:
Tiotropium bromide is first-line therapy for stable COPD
followed by a LABA preferably used with an ICS. Rodrigo GJ,
Chest 2008; 133:1079. (editorial: Sears, p. 1057).
8. Issues in the diagnosis of α1-antitrypsin
This is a thorough review of AATD, an under-recognized and
underdiagnosed worldwide problem. The authors outline the
diagnostic challenges, guidelines to confirm the diagnosis, and
a call to physicians to have a high index of suspicion for this
deficiency. Those at highest risk are those who have early signs
or symptoms of emphysema, unexplained liver disease, necrotizing
panniculitis, anti-proteinase 3-positive vasculitis,
bronchiectasis, or a family history of any of these diseases.
The method to diagnose this disease is outlined in an algorithm.
The authors conclude with treatment options which include α1
proteinase inhibitor therapy. Editor's comment: AATD is a
common problem, with a similar prevalence to cystic fibrosis,
but remains greatly underdiagnosed and treated. Rachelefsky
G, Hogarth K,
J Allergy Clin Immunol 2008; 121: 833.
9. Nasal and sinus endoscopy for medical management of
resistant rhinosinusitis, including postsurgical patients
This paper outlines the utility of performing nasal endoscopy,
practiced by some allergists since 1980. However, for reasons
unexplained, allergists, in general, have not embraced its use.
It discusses the history of nasal endoscopy and outlines the
advantages of flexible vs. the rigid endoscope. There are few
safety issues for its routine use. The article explains how
endoscopy can assist the physician to understand and follow
patients with a variety of nasal problems, particularly, chronic
rhinosinusitis. Editor's comment: Nasal endoscopy is not only
used to diagnose and assess nasal pharyngeal problems but also
oral and laryngeal problems. It should be utilized by allergists
throughout the world. Tichenor WS, et al.,
J Allergy Clin Immunol 2008; 121:917.
10. Irritable Bowel Syndrome (IBS)
IBS has a worldwide prevalence of 10 - 15%. It is always
included in differential diagnosis of most chronic GI problems,
and, in particular, in the differential diagnosis by many
physicians and patients of food allergy. This is an excellent
review of IBS and its differential diagnosis, which includes
celiac sprue, microscopic and collagenous colitis and atypical
Crohn's disease, and chronic constipation. An algorithm of the
differential diagnosis is included as well as an extensive list
of medications to treat IBS. Editor's Comment: Patients with
IBS frequently present to the allergist because they wonder
whether or not they are allergic to certain foods. IBS is always
in the differential. Mayer EA,
N Engl J Med 2008; 358:1692.
過敏性腸症候群についてN Engl J Medに最近掲載されたClinical
11. Screening for osteoporosis in men: A systematic review
for an American College of Physicians guideline
This study identifies men at risk for low bone mineral density (BMD)
and fracture. The most important risk factors for low BMD-mediated
osteoporotic fracture in men without a known diagnosis of
osteoporosis or fracture are increased age (>70 years) and low
body weight (body mass index <20 to 25 kg/m2) or weight <
approximately 70 kg. Additional risk factors include a variety
of health conditions and medications, particularly, weight loss,
physical inactivity, prolonged corticosteroid use, previous
osteoporotic fracture and androgen deprivation therapy.
Cigarette smoking is associated with lower BMD, but there is
less evidence in men to determine its association with fracture.
Editor's comment: Osteoporosis is a risk factor for patients
with chronic obstructive lung disease (COPD) as well as those
treated with glucocorticosteroids. Appropriate screening of men
is as equally important as is screening of women for this
disease. Liu H, et al.,
Annals Int Med 2008;148:685.
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WAO invites member societies to republish in national allergy journals the WAO Position Papers, "What is and Allergist?" and "Requirements for Physician Competencies in Allergy." Click here for more details.
Allergic Diseases: Diagnosis and Treatment, 3rd
Author: Phil Lieberman
Available from: Humana Press List Price: $99.00
Reviewer: Josh Phillips, MD Division of Allergy &
Immunology University of South Florida College of Medicine
Allergic Diseases: Diagnosis and Treatment in its third
edition provides a thorough and comprehensive review of the
pathophysiology, diagnosis, and treatment of common allergic
diseases. Emphasis is placed on the allergic history and
physical examination with further attention to appropriate
diagnostic tests and information on when to refer to an
allergist/immunologist. Each of the more than 40
contributors is an expert.
The textbook is designed as a guide to the general
approach and management of allergic diseases.
As noted in the preface, this textbook is intended for
use by primary care physicians but also would be an
excellent book for a new trainee in the subspecialty of
allergy and immunology.
Content / Features
Chapters are presented as review articles, with
abstract-style summaries and medical subject heading (MeSH)
keywords. Introductory chapters address the pathophysiology
of allergic diseases and the approach to the allergic
patient. Subsequent chapters focus on individual allergic
problems such as anaphylaxis, sinusitis, allergic rhinitis
and many others. There are also chapters dedicated to
specific therapies such as corticosteroids, monoclonal anti-IgE,
antihistamines, and leukotrienes, as well as a chapter
dedicated to the workup of recurrent respiratory tract
infections in children.
Assessment / Comparison
At 484 pages, this textbook is more of a comprehensive
resource than a "pocket" guide. Individual points are not
specifically referenced; rather there is a list of suggested
reading at the end of each chapter. Additionally,
illustrations and photographs rather than being in color are
in black & white. A few minor spelling errors are noted.
Despite these minor problems, this text is a highly detailed
and practical guide for all physicians but particularly, for
primary care physicians.
Find more allergy book reviews on the WAO Website here.