Science, lifestyle, and human health: Challenging trilogy for the allergist/immunologist

We live in a world awash with foreign substances, some inanimate and others, living microbes, in soil, water, and air that are potentially inimical to human health. Throughout evolution, deep seas and high peaks have long provided niches for these substances that are harsh yet permissive for the human species to both adapt to as well as to exploit not only by overwhelming them but at times by profiting from them and by yielding profit in return. Plants and animals, humans among them, for example, have had to cope with bacteria and parasites from the beginning stages of multicellular evolution due to the simple fact that they were here first. Successful adaptation to these foreign agents comprises the classic expressions of protective immunity.

Nowhere is maladaptation to these environmental agents better illustrated than in the field of allergy/immunology, in which, once the appearance of an IgE response, for example, at an early point of evolution provided a mechanism for successful expulsion of parasitic infestation but where its persistence, in later periods of evolution, is responsible for much of the deleterious expressions of allergic disease that afflict humans today. Although it is clear that mammalian immunity is deeply informed by how effectively we can adapt to these naturally occurring environmental agents, it is becoming equally apparent that both science and technology and lifestyle factors can play a major role in the successful adaptation or maladaptation to these environment challenges.

In keeping with this theme, this issue of the Proceedings features a spectrum of articles that focus on science and technology and on dietary and behavioral life style factors. These include the impact of electronic health record technology, allergy immunotherapy (AIT), the interplay between vitamin D and allergic disease, asthma treatment, cigarette smoking, obesity, and other lifestyle modifications on the expressions of allergic disease.

In the United States, the electronic health record was rapidly ushered in, with tremendous hope and hype but without an evidence-based evaluation of the impact that it would have. Frenkel¹ reviewed the background, goals, and potential benefits of electronic health records and explored solutions to the challenges that have delayed their widespread acceptance and implementation.

AIT is well into its second century of use and continues to evolve. A number of new approaches to AIT are being actively investigated. Nelson² reviewed these novel approaches, including delivering by patch and inguinal lymph node injection; altering the allergen molecules, which makes them less reactive with specific IgE; and shifting the immune response by stimulation of Toll-like receptors or suppressing Th responses; and, finally, the effects of adjuvants such as probiotics and vitamin D.

One of the unanswered questions concerning AIT is its potential effect on the risk of allergic disease development in the offspring of parents who were recipients of AIT. Bozek et al.³ reported a lower risk of allergic disease and asthma in 194 children who were offspring of at least one parent with allergy treated with AIT.

With all forms of AIT, the goal is to maximize efficacy and safety. Jerzynska et al.⁴ evaluated the clinical and immunologic effects of probiotic and vitamin D supplementation on sublingual immunotherapy administered as a five-grass pollen tablet in children with allergic rhinitis. They reported that probiotic supplementation was associated with a better clinical and immunologic outcome.

Many questions remain unanswered regarding the role of vitamin D in the development or exacerbation of allergic diseases. Yang et al.⁵ performed a nationwide cross-sectional survey in 3720 Korean children and reported finding low vitamin D levels to be associated with recent symptoms of atopic dermatitis and allergic rhinitis.

True to a core focus of the Proceedings to advance a better understanding and treatment of asthma, Miller et al.⁶ report on their efforts to determine the dose of salmeterol delivered by a novel fluticasone propionate/salmeterol multidose dry powder inhaler that could provide comparable efficacy and safety to an established, fixed-dose fluticasone propionate/salmeterol dry-powder inhaler. The authors reported greater efficacy with the novel device despite less salmeterol exposure.

Because the response to inhaled corticosteroid (ICS)/long-acting β₂-agonist combinations varies across ethnic groups, Lin et al.⁷ reported on the efficacy and safety evaluation of once-daily fluticasone furoate/vilanterol in Asian patients with asthma uncontrolled on a low- to midstrength ICS or low-dose ICS/long-acting β₂-agonist. In patients of Asian ancestry, once-daily fluticasone furoate/vilanterol 100/25 mcg produced statistically and clinically significant improvements in efficacy end points versus placebo, with an acceptable safety profile.

For all inhalers, instruction for the proper use is important for maximizing delivery to the lung. Pepper et al.⁸ compared various inhaler devices and their techniques for use, including steps necessary to prime the inhaler devices. They proposed a set of simplified techniques that may limit inhaler misuse and aid in proper medication delivery and treatment.

Because the obesity-asthma phenotype is frequently encountered in clinical practice, Çelebi Sözener et al.⁹ reported the findings of a study to determine the effect of obesity on asthma control in a group of adult patients. In a defined population, the authors reported a significant relationship among obesity, weight gain, and asthma control. Extrapolating their findings to clinical application, they suggested that weight loss may potentially improve the clinical course of asthma. Because of the importance of this topic to patients with asthma, the article was chosen for this issue's “For the Patient” section. This segment, found in the final pages of the print version of this issue and also available online, consists of a one-page article synopsis written in a readily comprehensible fashion to help patients better understand the clinical implications of the full article.

As with obesity, cigarette smoking is another potentially modifiable risk factor for poorly controlled asthma. The occurrence of asthma exacerbations that requires hospitalization in smokers provides a unique opportunity to implement smoking cessation efforts. Bittner et al.¹⁰ investigated the prevalence of cigarette smoking and the proportion of a cohort of 215 patients who were currently smoking and who were recipients of inpatient smoking cessation intervention. Their findings revealed a surprisingly high prevalence of smoking among patients hospitalized for asthma exacerbations in the United States and an underused opportunity to provide this at-risk population with smoking cessation interventions.

In an attempt to provide further insight into the pathophysiology of cigarette smoke–induced lung disease, Shimoda et al.¹¹ evaluated the influence of smoking on airway inflammation in patients with asthma and also compared the effect of ICS between patients with asthma and who smoked and patients with asthma and who did not smoke. They reported that cigarette smokers with asthma manifest both neutrophilic and eosinophilic airway inflammation and that cigarette smoking impaired the efficacy of ICS treatment.

By providing further evaluation of the role of life style modification in patients with asthma, Guarnaccia et al.¹² examined the influence of a clinical health promotion initiative on asthma control in a pediatric population and found that its utilization was beneficial. In transitioning to atopic dermatitis, Sol et al.¹³ investigated serum levels of clusterin, a small heat shock protein associated with the clearance of cellular debris and apoptosis, as a potential predictive biomarker of the disease in 140 children with atopic dermatitis. Their findings indicated that serum clusterin may be a candidate molecule that reflects the severity of the disease.

This issue's Patient-Oriented Problem Solving, “POPS,” case presentation shifts our focus to angioedema. The POPS case presentation is a periodic feature of the Proceedings, which, as per tradition, is written by an allergy/immunology fellow-in-training from one of the U.S. allergy/immunology training programs. The purpose of the POPS series is to provide an innovative and practical learning experience for the novice allergist/immunologist in-training by using a didactic format of clinical presentation and deductive reasoning. In this issue's POPS, Rodriguez-Roa et al.,¹⁴ from the University of Puerto Rico, Medical Sciences Campus, lead the reader through this process by describing the evaluation of a 47-year-old man who presented with episodic tongue swelling. This case report illustrated the complexity of the differential diagnostic process for this clinical presentation and the importance of a detailed history, physical examination, and appropriate laboratory assessment in arriving at a correct diagnosis.

In summary, the collection of articles found within the pages of this issue provides further insight into important allergic, cutaneous, and respiratory disorders that afflict patients whom the allergist/immunologist serves. In keeping with the overall mission of the Proceedings, which is to distribute timely information regarding advancements in the knowledge and practice of allergy, asthma, and immunology to clinicians entrusted with the care of patients, it is our hope that the articles found within this issue will help foster enhanced patient management through efficient workup and optimal therapy for a great diversity of clinical problems. On behalf of the editorial board, we hope you enjoy the diversity of the literature offered in this issue of the Proceedings.