Is there a role for telemedicine in adult allergy services?

Telemedicine refers to the application of telecommunication and information technology (IT) in the delivery of health and clinical care at a distance or remotely and can be broadly considered in two modalities: store‐and‐forward and real‐time interactive services. Preliminary studies have shown promising results in radiology, dermatology, intensive care, diabetes, rheumatology and primary care. However, the evidence is limited and hampered by small sample sizes, paucity of randomized control studies and lack of data relating to cost‐effectiveness, health‐related quality of life and patient and clinician satisfaction. This review appraises the evidence from studies that have employed telemedicine tools in other disciplines and makes suggestions for its potential applications in specific clinical scenarios in adult allergy services. Possible examples include: triaging patients to determine the need for allergy tests; pre‐assessment for specialized treatments such as allergen immunotherapy, follow‐up to assess treatment response and side effects; and education in self‐management plan including training updates for self‐injectable adrenaline and nasal spray use. This approach might improve access for those with limited mobility or living far away from regional centres, as well as bringing convenience and cost savings for the patient and service provider. These potential benefits need to be carefully weighed against evidence of service safety and quality. Keys to success include delineation of appropriate clinical scenarios, patient selection, training, IT support and robust information governance framework. Well‐designed prospective studies are needed to evaluate its role.     

Novel in silico technology in combination with microarrays: a state-of-the-art technology for allergy diagnosis and management?

‘Allergen microarrays, in poly-sensitized allergic patients, represent a real value added in the accurate IgE profiling and in the identification of allergen(s) to administer for an effective allergen immunotherapy.’ Allergen microarrays (AMA) were developed in the early 2000s to improve the diagnostic pathway of patients with allergic reactions. Nowadays, AMA are constituted by more than 100 different components (either purified or recombinant), representing genuine and cross-reacting molecules from plants and animals. The cost of the procedure had suggested its use as third-level diagnostics (following in vivo– and in vitro–specific IgE tests) in poly-sensitized patients. The complexity of the interpretation had inspired the development of in silico technologies to help clinicians in their work. Both machine learning techniques and expert systems are now available. In particular, an expert system that has been recently developed not only identifies positive and negative components but also lists dangerous components and classifies patients based on their potential responsiveness to allergen immunotherapy, on the basis of published algorithms. For these characteristics, AMA represents the state-of-the-art technology for allergy diagnosis in poly-sensitized patients.     

Threshold levels in food challenge and specific IgE in patients with egg allergy: is there a relationship?

BACKGROUND: Previously published articles described a relationship between food-specific IgE and the outcome of food challenge in children with egg allergy. These investigations defined different levels of predictive values in different study populations and thus pointed toward the possibility of a certain level of specific IgE to egg white predicting a positive outcome in food challenge. OBJECTIVE: The purpose of this study was to determine the utility of specific IgE in estimating threshold level to predict a positive outcome in food challenge. METHODS: Fifty-six children were evaluated for egg allergy by titrated oral challenges. Sera were analyzed for specific IgE to egg white in 56 patients by using the Magic Lite test and 32 of 56 patients also by the CAP test. Values of specific IgE to egg white were compared to the outcome of challenges and the threshold level. RESULTS: The diagnostic level of specific IgE predicting clinical reactivity in this population with greater than 95% certainty was identified as 10.8 standardized units/mL (Magic Lite) and 1.5 kilounits of allergen-specific IgE/L (CAP), respectively. We found no significant relationship between the specific IgE concentration (egg white) and the challenge threshold level. CONCLUSION: Although the specific IgE concentration correlated to a positive outcome in food challenge, there was no significant relationship between the quantification of specific IgE and the challenge threshold level. Therefore the standardized food challenge still remains the gold standard in the diagnosis of food allergy.     

Atopic and nonatopic IgE-mediated allergy: a new interpretation of old facts?

Coined 80 years ago, the term 'atopy' to designate a group of diseases associated with IgE and a hereditary background has raised many discussions. In particular, it is difficult to consider as part of an atopic syndrome cases of IgE-mediated allergies to isolated allergens without evidence of a familial inheritance. The postulate expressed in this essay is that in humans we are essentially dealing with an atopic IgE-mediated allergy, which is the equivalent of a genetically determined high IgE response, and with a nonatopic IgE-mediated allergy, which is the equivalent of a low IgE response in mammals and rodents.     

Soybean glycinin- and β-conglycinin-induced intestinal immune responses in a murine model of allergy

Glycinin and β-conglycinin are major soybean allergens involved in food hypersensitivity. The study was aimed to investigate the soybean protein-induced intestinal immune responses and its possible mechanism. Balb/c mice were sensitised intragastrically with glycinin and β-conglycinin without an adjuvant for five weeks. Results showed that the sensitised mice displayed diarrhoea symptoms and jejunal morphological changes, including decreased villous height and thickened crypt depth. Both the histamine and immunoglobulin A levels in jejunum were increased in soybean allergen-sensitised mice. Moreover, the number of IgA+B cells and CD4+T cells in the jejunal lamina propria of sensitised mice were significantly increased. The expression levels of interleukin-4 and interferon-γ were increased, whereas the levels of IL-10 and transforming growth factor-β (TGF-β) were decreased in the jejunum mucosa. In conclusion, glycinin and β-conglycinin induce a mixed Th1/Th2 immune response. The suppression of IL-10 and TGF-β may play important roles in the development of intestinal allergic reactions.     

Oesophagitis in children: reflux or allergy?

The prevalence of eosinophilic oesophagitis appears to be increasing in many countries, sometimes rapidly, although this may be partly due to increased disease recognition. Histological methods of assessment and diagnostic criteria vary considerably between major clinical centres. Oesophagitis with over 20 intraepithelial eosinophils per high power field is more likely to be due to allergy than gastro-oesophageal reflux induced acid-peptic mucosal injury. Typical eosinophilic oesophagitis shows involvement of the entire oesophagus, with basal cell proliferation occupying more than 50% of the thickness of the surface epithelium, and high numbers of intraepithelial eosinophils, sometimes concentrated on the surface or as contiguous clusters. Ulceration and prominent neutrophils are atypical and should suggest an alternative or co-existent disease. On endoscopy, the oesophagus may display the typical 'corrugated' mucosal appearance. Clinically, dysphagia or food impaction are the most characteristic symptoms. There is a strong association with other atopic diseases, especially asthma and eczema. To date no evidence has emerged of an increased malignancy risk. Patients with eosinophilic oesophagitis typically fail to respond to acid suppressive medications but respond well to either elemental/elimination diets or aerosolised swallowed corticosteroids. Long-term uncontrolled oesophageal eosinophilic inflammation may lead to progressive subepithelial fibrosis, potentially resulting in strictures or oesophageal narrowing.