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Medical Journal Review

February 2017

WAO Reviews - Editors' Choice

The Editors select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible they seek articles that everyone can access freely. The Editors’ Choice comes to you from Juan Carlos Ivancevich, MD, WAO Web Managing Editor, and summary author, John J. Oppenheimer, MD, FACAAI, FAAAAI, WAO Reviews Editor.

1. The frequency of sleep-disordered breathing in children with asthma and its effects on asthma control

Ginis T, Alper Akcan F, Capanoglu M, Toyran M, Ersu R et al. The frequency of sleep-disordered breathing in children with asthma and its effects on asthma control. Journal of Asthma 2017; Published online ahead of print (January 6). (doi:10.1080/02770903.2016.1220012)

Abstract

There is concern that sleep-disordered breathing (SDB) in children with asthma may cause difficult to control asthma. Thus, the aim of this study was to determine the frequency of SDB in children with asthma, to evaluate its effects on asthma control and to assess the risk factors associated with the presence of SDB. They found that almost 40% of asthmatic children were not well controlled according to GINA and 34.6% of all patients had SDB according to the Parents of children who Sleep Questionnaire. Multivariate logistic regression analysis revealed that coexistence of SDB [OR: 6.62, 95% CI (4.21–10.41); p < 0.001)] and tonsillar hypertrophy [OR: 3.47; 95% CI (1.05– 11.5); p < 0.041] were independent risk factors for not-well-controlled asthma in asthmatic children after other established contributors to asthma control were adjusted.

2. Innate and adaptive immune traits are differentially affected by genetic and environmental factors

Mangino M, Roederer M, Beddall MH, Nestle FO, Spector TD. Innate and adaptive immune traits are differentially affected by genetic and environmental factors. Nature Communications 2017; 8:13850. (doi:10.1038/ncomms13850)

Full Text

It is known that the diversity and activity of leukocytes is controlled by both genetic and environmental influences in the balance of immune responses; however, the relative contribution of these factors that affect variations in immune traits is unknown. In this study, the authors analyzed 23,394 immune phenotypes in 497 adult female twins. Seventy-six percent (76%) of these traits show a predominantly heritable influence, whereas 24% are mostly influenced by environment. These data highlight the importance of shared childhood environmental influences, including diet, infections and microbes in shaping immune homeostasis for monocytes, B1 cells, gd Tcells and NKT cells, whereas dendritic cells, B2 cells, CD4þ T and CD8þ T cells are more influenced by genetics. The authors conclude that adaptive immune traits are more affected by genetics, whereas innate immune traits are more affected by the environment.

3. Elemental diet decreases inflammation and improves symptoms in adult eosinophilic oesophagitis patients.

Warners MJ, Vlieg-Boerstra BJ, Verheij J, van Rhijn BD, Van Ampting MT et al. Elemental diet decreases inflammation and improves symptoms in adult eosinophilic oesophagitis patients. Alimentary Pharmacology and Therapeutics 2017; Published online ahead of print (23 January 2017). (doi:10.1111/apt.13953)

Full Text

It is known that food allergy may drive the development of eosinophilic oesophagitis (EoE). While studies in children have demonstrated that an elemental diet is often effective in resolving the eosinophilic inflammation, there are little data regarding such diets in adults.    To assess the effect of an elemental diet (Neocate, Nutricia, Utrecht, the Netherlands) on the inflammation, symptoms and endoscopic signs in adult EoE patients, Warners and colleagues performed a prospective study involving 21 EoE adult patients (having both symptoms and biopsy proven disease).

Patients underwent endoscopy before and 4 weeks after this diet. Histological disease activity (peak eosinophil count/HPF) and endoscopic signs were scored by physicians, while adherence to the diet was evaluated by questionnaire. Serum total IgE levels and total eosinophil counts were determined and the expression of inflammatory cytokines was analyzed by qPCR. Seventeen (81%) of the patients completed the diet, of which 12 (71%) demonstrated complete histological response (≤15 eosinophils/HPF) and 4 (24%) demonstrated partial histological response (≥50% reduction of baseline eosinophil count).

Symptoms decreased significantly in all subjects, and 15 patients (88%) became completely asymptomatic (P ≤ 0.001). In 14 patients (82%), blood eosinophil count and serum IgE decreased (P ≤ 0.05). In light of the above, the authors conclude that an elemental diet reduces eosinophilic inflammation and induces clinical remission in adult patients with eosinophilic oesophagitis.

4. Biomarkers for monitoring clinical efficacy of allergen immunotherapy for allergic rhinoconjunctivitis and allergic asthma: an EAACI Position Paper

Shamji MH, Kappen JH, Akdis M, Jensen-Jarolim E, Knol EF et al. Biomarkers for monitoring clinical efficacy of allergen immunotherapy for allergic rhinoconjuctivitis and allergic asthma: an EAACI Position Paper. Allergy 2017; Accepted manuscript; published online ahead of print (2 February 2017). (doi:10.111/all.13138)

Full Text Available

The aim of this EAACI task force was to evaluate surrogate immunologic and clinical biomarker data on the effects of allergy immunotherapy (AIT) on allergic rhinitis with and without asthma obtained from clinical trials of AIT and from this developed recommendations regarding a consensus position on candidate biomarkers for monitoring AIT and how these biomarkers could be used and implemented in future clinical trials of AIT and daily practice.

They conclude that presently there are no validated or generally accepted candidate biomarkers that are predictive/indicative of the clinical response to AIT. Furthermore, following review of all of the candidate biomarkers used in clinical trials of AR patients with/without asthma the panel suggested that in order to raise the evidence level for candidate biomarkers, it is critical to conduct biomarker studies with a novel approach in design, such as responders vs. non-responders, and determine their clinical relevance as surrogate or predictive markers of the efficacy of AIT.

In light of the data analysis, this EAACI task force recommended the exploration of the use of allergen specific sIgG4 as a biomarker for compliance. They further suggest that candidate biomarkers for clinical outcome should include sIgE/tIgE ratio and IgE-FAB but note that more studies are needed to confirm and to interpret their association with the clinical response to immunotherapy and how they relate to persistence of clinical benefit after discontinuation of immunotherapy. Certainly, this task force document represents a good starting point.

5. Stinging insect hypersensitivity. A practice parameter update 2016

Golden DVK, Demain J, Freeman T, Graft D, Tankersley M et al. Stinging insect hypersensitivity. A practice parameter update 2016. Annals of Allergy, Asthma & Immunology 2017; 118(1): 28-54. (doi:http://dx.doi.org/10.1016/j.anai.2016.10.031)

Full Text

This is an update of the practice parameter on stinging insects. Every section of this update contains new evidence with references and discussion. This includes: new sections on the discussion of: indication for VIT in adults with cutaneous systemic reactions, mast cell disorders and measurement of basal serum tryptase, technique and interpretation of venom skin tests, and risk of cardiovascular medications in insect allergic patients to name just a few new additions. This is a must-read for those treating venom allergy.