Ara h 2 sIgE test is more accurate than whole peanut sIgE to distinguish peanut allergy from peanut tolerance

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Measurement of whole peanut-specific IgE (sIgE) is often used to confirm sensitization but does not reliably predict allergy. Ara h 2 is the dominant peanut allergen detected in 90% to 100% of patients with peanut allergy. Ara h 2 IgE could help improve diagnosis of peanut allergy.

This study from Australia included 200 infants from the population-based HealthNuts study who underwent:

- skin prick tests to determine peanut sensitization
- a peanut oral food challenge (OFC) to confirm allergy status

By using the previously published 95% positive predictive value of 15 kU(A)/L for whole peanut sIgE, a corresponding specificity of 98% was found in this study.

At the equivalent specificity of 98%, the sensitivity of Ara h 2 sIgE is 60%, correctly identifying 60% of subjects with true peanut allergy. This is compared with only 26% correctly identified by using whole peanut sIgE.

When using a combined approach of sIgE testing for whole peanut followed by Ara h 2 for the diagnosis of peanut allergy, the number of oral food challenges (OFC) required was reduced by almost two thirds.

The authors concluded that Ara h 2 plasma sIgE test levels provide higher diagnostic accuracy than whole peanut plasma sIgE levels. It is a new diagnostic tool to distinguish peanut allergy from peanut tolerance, which might reduce the need for an oral food challenge (OFC).

Editor's note: The test costs $300 in the U.S. and is not covered by most health insurances (uKnow Peanut from Phadia http://bit.ly/OJjRyI).



Molecular Allergy Component Testing, a video by the manufacturer of ImmunoCAP testing system.

This video by the manufacturer of sIgE assays Phadia tries to explain the concept of Molecular Allergology in two minutes:



References:

Increasing the accuracy of peanut allergy diagnosis by using Ara h 2. Dang TD, Tang M, Choo S, Licciardi PV, Koplin JJ, Martin PE, Tan T, Gurrin LC, Ponsonby AL, Tey D, Robinson M, Dharmage SC, Allen KJ; HealthNuts study. J Allergy Clin Immunol. 2012 Feb 29. [Epub ahead of print]

Image source: Roasted peanuts as snack food, Wikipedia, public domain.

Spectrum of gluten-related disorders: consensus on new nomenclature and classification

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A decade ago celiac disease was considered extremely rare outside Europe and, therefore, was almost completely ignored by health care professionals.

In only 10 years, key milestones have moved celiac disease from obscurity into the popular spotlight worldwide.

Now we are observing another interesting phenomenon that is generating great confusion among health care professionals. The number of individuals embracing a gluten-free diet (GFD) appears much higher than the projected number of celiac disease patients, fueling a global market of gluten-free products approaching $2.5 billion (US) in global sales in 2010.

This trend is supported by the notion that, along with celiac disease, other conditions related to the ingestion of gluten have emerged as health care concerns.

This review summarized the current knowledge about the 3 main forms of gluten reactions:

- allergic (wheat allergy)
- autoimmune (celiac disease, dermatitis herpetiformis and gluten ataxia)
- possibly immune-mediated (gluten sensitivity)

New nomenclature and classifications are proposed (see the figures below).



Key figures:

New nomenclature and classification of gluten-related disorders - http://www.biomedcentral.com/1741-7015/10/13/figure/F1

Algorithm for the differential diagnosis of gluten-related disorders, including celiac disease, gluten sensitivity and wheat allergy - http://www.biomedcentral.com/1741-7015/10/13/figure/F4

3 million Americans are living with celiac disease

Celiac disease, an immune system reaction to gluten in the diet, is four times as common today as it was 50 years ago. Lack of awareness of celiac could be contributing to a delay of up to 11 years in diagnosis of adults in North America (http://goo.gl/sy778).

This is an informative and beautifully designed video by the University of Chicago Celiac Disease Center. It looks like an infographic made into video - have a look:



New classification is being proposed for gluten-related disorders: celiac disease; dermatitis herpetiformis; gluten ataxia; wheat allergy; gluten sensitivity. WSJ, 2012.

Recent studies support the existence of the new condition nonceliac gluten sensitivity which is defined as symptoms with negative celiac antibodies and biopsy (http://goo.gl/57IlB).

References:

Spectrum of gluten-related disorders: consensus on new nomenclature and classification. Anna Sapone et al. BMC Medicine 2012, 10:13 doi:10.1186/1741-7015-10-13.
Image source: Colon (anatomy), Wikipedia, public domain.
Disclaimer: I am an Assistant Professor of Medicine and Pediatrics at University of Chicago.
The text was cross-posted at my general medicine blog called CasesBlog.

Comments from Twitter:

Karen Price @brookmanknight: reflects well what we see in clinical practice, though haven't seen or dx'd too much derm herpetiformis.

The man who probably did more to benefit patients with asthma and COPD than anyone else in history

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Sir David Jack, the former Director of Research and Development at Glaxo, died in November 2011 at the age of 87 years. He probably did more to benefit patients with asthma and chronic obstructive pulmonary disease than anyone else in history, according to his obituary in the journal Thorax written by Peter J Barnes.

Sir David Jack discovered:

- the first beta-2-selective agonist (salbutamol, called albuterol in the U.S.)
- the first inhaled corticosteroid (beclomethasone dipropionate)
- the first long-acting beta-2-agonist (salmeterol)
- the most widely used inhaled corticosteroid (fluticasone propionate)
- the best-selling asthma treatment of all time (Seretide. called Advair in the U.S.).

He also discovered several other important drugs, including the histamine H2-receptor antagonist ranitidine (Zantac), which became the best-selling drug of its day, and sumatriptan (Imigran), a novel therapy for migraine.

David Jack was born in is a small town in Scotland, the sixth and youngest child of a coal miner.

It is extraordinary that the other great drug discoverer of our time, Sir James Black, who went on to discover beta-blockers and histamine H2-receptor antagonists, was born in the same year (1924) in a nearby village.

References:

David Jack (1924–2011) who revolutionised the treatment of asthma. Thorax 2012;67:266-267 doi:10.1136/thoraxjnl-2011-201522
Sir David Jack. The Lancet.
Sir David Jack. The Telegraph.
Sir David Jack: Pioneering chemist who revolutionised the treatment of asthma. The Independent.
Image source: Levosalbutamol (INN) or levalbuterol (USAN), trade name Xopenex, is the R-enantiomer of the short-acting β2-adrenergic receptor agonist albuterol (salbutamol). Wikipedia, public domain.

Comments from Google Plus and Twitter:

Nick Watts, Feb 19, 2012: I can't believe that one man discovered what is basically the entire first couple of steps of the modern treatment for asthma. Thanks for the share.

Dr John Weiner @AllergyNet: Thanks Ves, I was unaware of this. His obit: http://www.telegraph.co.uk/news/obituaries/finance-obituaries/8897458/Sir-David-Jack.html

Chitinase 3-like 1 Protein (YKL-40) Increases Bronchial Smooth Muscle Remodeling in Asthma

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Chitin (C8H13O5N) is a long-chain polymer of a glucose derivative. It is the main component of the cell walls of fungi, the exoskeletons of arthropods, such as crustaceans (crab, lobster and shrimp) and insects, including ants, beetles, etc. The English word "chitin" was derived from the Latin word "chit�n", meaning mollusk. Chitinases are digestive enzymes that break down glycosidic bonds in chitin.


A cicada sheds its chitinous exoskeleton. Image source: Wikipedia, Creative Commons "Attribution ShareAlike 2.0 France" Licence.


Structure of the chitin molecule. Image source: Wikipedia, public domain.

Chitinases are digestive enzymes that break down glycosidic bonds in chitin. Because chitin composes the cell walls of fungi and exoskeletal elements of some animals (including worms and arthropods), chitinases are generally found in organisms that either need to reshape their own chitin or to dissolve and digest the chitin of fungi or animals (source: Wikipedia).


Chitinase from barley seeds. Image source: Wikipedia, public domain.

Bronchial remodeling, including increased bronchial smooth muscle (BSM) mass, contributes to bronchial obstruction in asthma. A role of the chitinase 3-like 1 protein (YKL-40) has been evoked in asthma.

This study from France enrolled 40 patients with asthma. Bronchial specimens obtained by fiberoptic bronchoscopy or lobectomy, and cell proliferation was assessed. The involvement of protease activated receptor (PAR)-2 and YKL-40 was analyzed in both asthmatics and controls.

YKL-40 increased BSM cell proliferation and migration through PAR-2 dependent mechanisms. YKL-40 epithelial expression was correlated with smooth muscle mass in asthma.

This study suggests that YKL-40 promotes smooth muscle cell proliferation and migration through a PAR-2–dependent mechanism.

References:

Role of YKL-40 in Bronchial Smooth Muscle Remodeling in Asthma. Imane Bara et al. Am. J. Respir. Crit. Care Med. April 1, 2012 vol. 185 no. 7 715-722.

Immunodeficiency - top articles for August 2012

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Here are my suggestions for some of the top articles about immunodeficiency for August 2012:

Primary immunodeficiency disease can be overlooked for years - one patient's story: http://goo.gl/P8VCk - People with primary immunodeficiency also face another hurdle with insurance, largely because antibody replacement therapy is very expensive — $200,000 or more a year.

TLR9 and MyD88 play central role in protective immunity to malaria http://goo.gl/VVF07

Interpretation of antibody response to pneumococcal vaccines - AAAAI Ask the Expert http://goo.gl/J2HEc

T(H)17 deficiency leads to chronic mucocutaneous candidiasis - 2012 JACI review http://goo.gl/F5ydt

ImmunoDeficiencySearch.com - interesting website but not authorship info http://goo.gl/QzSxr

In adult community-acquired pneumonia, the most common pneumococcal serotypes implicated were 14, 1, 8, 3, 19A http://goo.gl/5g4Ze

The reason one gives IgG therapy is to replace missing antibodies, not to build up the protein level of IgG http://goo.gl/51t7f

Prevnar and Pneumovax are not interchangeable when it comes their utility in evaluating humoral immune function http://goo.gl/E3LST

All board-certified allergists / immunologists in the U.S. are certified to treat primary immunodeficiency disorders http://goo.gl/YGLxW

Adults with immunocompromising conditions should receive Prevnar 13, PCV13 in addition to Pneumovax 23, PPSV23 http://goo.gl/DTQwt

Clinical Allergy and Immunology - 2011 free full text review in Ulster Med J. http://goo.gl/1GE0o

Combating chronic T-cell exhaustion http://goo.gl/rIXCD

The immunological life cycle of tuberculosis http://bit.ly/QGLvy6

The articles were selected from my Twitter stream @Allergy and Google Reader RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @JuanCIvancevich @AllergyNet @IgECPD4 @DrAnneEllis @AACMaven @AllergieVoeding @allergistmommy @mrathkopf @wheezemd.

Please feel free to send suggestions for articles to allergycases@gmail.com and you will receive acknowledgement in the next edition of this publication.

Image source: Wikipedia.

Weight Loss Tips 2011 – Effective Weight Loss with Diet Pills

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Day by Day, Obesity among men and women is a reality all over the world and it is increasing regular.

Obesity Definition – It’s nothing but a lot of fat in the human body which puts a person’s health in danger which leads to a number of illnesses like diabetes, high blood pressure, cardiac diseases, sleeping sickness, arthritis and lastly stroke.

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Just right choice of Natural Weight Loss Pills will help for Obesity Prevention easily and with spending less amount of money.

Lose Weight Fast Naturally for Women – but might they affect badly to our health

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Possibly on the quiet but these girls are always bubbling with extra energy, maybe because of Safe Diet Pills.

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They are usually containing dangerous substances which combine with active ingredients like Sibutramine or Orlistat.