This is a monthly digest of interesting information that is being added to Allergy Advisor. While we add a great deal of information every month, here we highlight some of the more interesting articles.
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The usefulness of casein-specific IgE and IgG4 antibodies in cow's milk allergic children.

The functional connection between oral allergy syndrome and united airways disease assessed by oral challenge.

The ability of adults and children to visually identify peanuts and tree nuts.

Wheat anaphylaxis or wheat-dependent exercise-induced anaphylaxis caused by use of a soap product which contains hydrolyzed wheat proteins. -a report of 12 cases-

Food-dependent exercise-induced anaphylaxis that was difficult to evoke by a provocation test.

Paradigm shift in the management of milk and egg allergy: baked milk and egg diet.

Profilin as an aeroallergen by means of conjunctival allergen challenge with purified date palm profilin.

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2011.

Significance of ovomucoid- and ovalbumin-specific IgE/IgG(4) ratios in egg allergy.

Abstracts shared in January 2012 Advisor Digest Newsletter

The usefulness of casein-specific IgE and IgG4 antibodies in cow's milk allergic children.
IgE antibodies to milk, IgE and IgG4 antibodies to casein, alpha-lactalbumin and beta-lactoglobulin in cow's milk allergic (CMA) and non-allergic (non-CMA) children were studied for their clinical usefulness. Eighty-three children with suspected milk allergy (aged 0.8-15.8 years), diagnosed as CMA (n=61) or non-CMA (n=22) based on an open milk challenge or convincing clinical history were studied. Serum specific IgE and IgG4 antibodies were measured. For the sIgG4 analysis, additional children were included (all non-milk sensitized). The CMA group had significantly higher levels of milk-, casein- and beta-lactoglobulin-sIgE antibodies as compared to the non-CMA group. Serum specific casein showed the best discriminating performance 6.6 kUA/L corresponding to 100% specificity. All but one of the CMA children aged >5 years had casein-sIgE levels >6.6 kUA/L. The non-CMA group had significantly higher sIgG4 levels against all three milk allergens compared to the CMA group. This was most pronounced for casein-sIgG4 in non-CMA children without history of previous milk allergy. Therefore high levels of casein-sIgE antibodies are strongly associated with milk allergy in children and might be associated with prolonged allergy. Elevated casein-sIgG4 levels in milk-sensitized individuals on normal diet indicate a modified Th2 response. However, the protective role of IgG4 antibodies in milk allergy is unclear.

Allergic and immunologic reactions to food additives.
"For centuries, food additives have been used for flavouring, colouring and extension of the useful shelf life of food, as well as the promotion of food safety. During the last 20 years, the studies implicating the additives contained in foods and medicine as a causative factor of allergic reactions have been proliferated considerably. In this review, we aimed to overview all of the food additives which were approved to consume in EU and find out how common and serious allergic reactions come into existence following the consuming of food additives."

Development of a standardized low-dose double-blind placebo-controlled challenge vehicle for the EuroPrevall project.
Standardized materials and protocols are essential for comparing DBPCFC results for multicentre studies such as EuroPrevall. This required the development and piloting of a standardized vehicle and low-dose protocol for confirming food allergy and determination of minimum eliciting doses (MEDs). A low-dose DBPCFC protocol was developed, with eight titrated protein doses from 3 mug to 1 g. This was delivered using a simple, microbiologically stable food base incorporating allergenic food ingredients manufactured at three sites and centrally distributed to clinical centres. Allergen blinding was assessed by a professional sensory testing panel using a triangle test. Homogeneity and allergen content were confirmed by ELISA and clinical efficacy was assessed in a pilot study, using celeriac and hazelnut as exemplars. Celeriac and hazelnut ingredients were sufficiently blinded in the dessert. The dessert meals were successfully piloted with hazelnut in allergy clinics in Spain, the Netherlands and Italy and with celeriac and hazelnut in Zurich. The challenges elicited a range of subjective and objective reactions ranging in severity from mild itching of the oral mucosa to bronchospasm.

Component-resolved diagnosis of vespid venom-allergic individuals: phospholipases and antigen 5s are necessary to identify Vespula or Polistes sensitization.
Cross-reactivity between hymenoptera species varies according to the different allergenic components of the venom. The true source of sensitization must therefore be established. In the Mediterranean region, Polistes dominulus and Vespula spp. are clinically relevant cohabitating wasps. A panel of major vespid venom allergens was used to investigate whether serum-specific IgE (sIgE) could be used to distinguish sensitization to either vespid. Fifty-nine individuals with allergic reactions to vespid stings and positive ImmunoCAP and/or intradermal tests to vespid venoms were studied. sIgE against recombinant and natural venom components from each wasp species was determined. sIgE against recombinant antigen 5s sensitization to be detected in 52% of the patients tested (13/25). The sensitivity increased to 80% (20/25), when using natural antigen 5s, and to 100% with the complete panel of purified natural components, because the sIgE was positive to either the antigen 5s (Pol d 5/Ves v 5) or to the phospholipases (Pol d 1/Ves v 1) of the two vespids, or to both components at the same time. In 69% of cases, it was possible to define the most probable sensitizing insect, and in the rest, possible double sensitization could not be excluded. Vespula hyaluronidase was shown to have no additional value as regards the specificity of the assay. Therefore the major allergens of P. dominulus' and Vespula vulgaris' venom, namely phoshpholipases and antigen 5s, are required to discriminate the probable sensitizing species in vespid-allergic patients.

The functional connection between oral allergy syndrome and united airways disease assessed by oral challenge.
The airways and the upper digestive tract have a common embryonic origin. In sensitized subjects they can respond to allergens with an immediate reaction (asthma, rhinitis, or oral allergy syndrome [OAS]). This study investigated the possible functional connection between respiratory and upper digestive tract by means of specific oral allergen challenges. Patients sensitized to birch and apple were subdivided into group A (n = 12; asthma + rhinitis caused by birch and OAS caused by apple); group B (n = 10; OAS caused by apple without asthma/rhinitis); group C (n = 8; asthma and rhinitis caused by birch without OAS). Oral provocation test with apple was performed out of the pollen season. The study concludes that in the case of birch-apple syndrome, eating apple does not functionally or clinically affect the respiratory tract.

The ability of adults and children to visually identify peanuts and tree nuts.
One-thousand one-hundred five subjects completed the study. The mean number of peanuts and tree nuts identified by all subjects was 8.4 (44.2%) out of a possible 19. The mean for children ages 6 to 18 was 4.6 (24.2%), compared with 11.1 (58.4%) for adults older than 18. The most commonly identified items were peanut in the shell and without the shell. The least identified was hazelnut (filbert) in the shell and without the shell. Overall, both children and adults are unreliable at visually identifying most nuts.

Wheat anaphylaxis or wheat-dependent exercise-induced anaphylaxis caused by use of a soap product which contains hydrolyzed wheat proteins. -a report of 12 cases-
Hydrolyzed wheat protein in facial soap can induce wheat allergy including wheat-dependent exercise-induced anaphylaxis (WDEIA). This article (in Japanese) describes the clinical characteristics of 12 patients with this disorder. All the patients were female. The mean age was 36.0+/- 9.9 years. All had had no prior symptoms of wheat allergy: they gradually developed wheat anaphylaxis or WDEIA on average of 2 years after they started to use the soap product which contains hydrolyzed wheat proteins. Most patients suffered immediate contact allergic reactions after or at the time of washing their face with the soap product. 10 of 12 patients showed a low level of IgE to CAP-recombinant omega-5-gliadin. The authors conclude that the epicutaneous sensitization to hydrolyzed wheat proteins in the soap product had occurred.

Food-dependent exercise-induced anaphylaxis that was difficult to evoke by a provocation test.
An 8-year-old boy repeatedly experienced dyspnea and urticaria while exercising following eating wheat- and soybean-based food products. He was assumed to have experienced a food-dependent exercise-induced anaphylactic reaction. Examination using various combinations of food products (wheat and soybeans), medicine (aspirin), and exercise was performed but failed to elicit any symptoms. Although the food products was eliminated from the examination, dyspnea caused by exercising after ingesting only wheat products was observed again. A provocation test using wheat products was conducted, but symptoms were observed only on increasing the amount of ingested food and the momentum of exercise. The possibility that wheat is a more potent inducing factor than aspirin in increasing the momentum of exercise and amount of ingestion in food-dependent exercise-induced anaphylaxis is suggested.

Paradigm shift in the management of milk and egg allergy: baked milk and egg diet.
Heat treatment of several foods, including all types of cooking, has been mainly used to minimize the number of viable microbes, reduce pathogenicity, and destroy the undesirable enzymes, maintaining food quality. In addition, food processing improves sensory, nutritional, and physical properties of the foods, due to food protein denaturation. Heat-induced alterations of food proteins can attenuate allergenicity. In this article, the authors review the important role of thermal processing on milk and egg proteins, which comprise the commonest food allergies in infancy and early childhood

Profilin as an aeroallergen by means of conjunctival allergen challenge with purified date palm profilin.
The aim of this study was to find out whether or not profilin can cause symptoms in sensitized individuals which would be compatible with its role as an airborne allergen. Conjunctival allergen challenges were performed with date palm profilin in a series of consecutive pollen-allergic patients with rhino-conjunctivitis, divided in two groups: profilin sensitized (n = 17) and not sensitized (n = 14), who served as controls. None of the patients from the not profilin-sensitized group had a positive result in conjunctival allergen challenges. In contrast, 65% of profilin sensitized patients had a positive conjunctival allergen challenge and were considered allergic to profilin. A significant statistical association between being profilin allergic and being profilin sensitized (p < 0.005) was demonstrated. Therefore profilin seems to work as an aeroallergen in a significant proportion of profilin-sensitized patients.

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2011.
"This review highlights some of the research advances in anaphylaxis; hypersensitivity reactions to foods, drugs, and insects; and allergic skin diseases that were reported in the Journal in 2011. Food allergy appears to be increasing in prevalence and carries a strong economic burden. Risk factors can include dietary ones, such as deficiency of vitamin D and timing of complementary foods, and genetic factors, such as filaggrin loss-of-function mutations. Novel mechanisms underlying food allergy include the role of invariant natural killer T cells and influences of dietary components, such as isoflavones. Among numerous preclinical and clinical treatment studies, promising observations include the efficacy of sublingual and oral immunotherapy, a Chinese herbal remedy showing promising in vitro results, the potential immunotherapeutic effects of having children ingest foods with baked-in milk if they tolerate it, and the use of anti-IgE with or without concomitant immunotherapy. Studies of allergic skin diseases, anaphylaxis, and hypersensitivity to drugs and insect venom are elucidating cellular mechanisms, improved diagnostics, and potential targets for future treatment. The role of skin barrier abnormalities, as well as the modulatory effects of the innate and adaptive immune responses, are major areas of investigation."

Significance of ovomucoid- and ovalbumin-specific IgE/IgG(4) ratios in egg allergy.
The specific IgE/IgG(4) ratio might add value to the measurement of absolute amounts of IgE for assessing the ongoing status of egg reactivity. One hundred seven egg-allergic children were challenged to baked egg. The outcomes of the challenges were related to the level of specific IgE and IgG(4) to OVM and OVA, component IgE/IgG(4) ratios, and mediator release in a functional assay based on the rat basophil leukemia cell line. Baked egg-reactive children had significantly higher OVA and OVM ratios of IgE/IgG(4) and mediator release in the rat basophil leukemia-based assay than did tolerant children (P < .05 for both). The areas under the curve for a logistic regression model including specific IgE and IgG(4) to OVA and OVM were significantly greater compared with the areas under the curve for egg white-specific IgE and OVM-specific IgE. The balance between IgE and IgG(4) to OVA and OVM has functional consequences. A model that includes the interactions between IgE and IgG(4) to OVA and OVM accurately predicts reactivity to baked egg and warrants further investigation.