Science, lifestyle, and human health: Challenging trilogy for the allergist/immunologist
W 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. Frenkel 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. Nelson 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. 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. 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. performed a nationwide crosssectional 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. 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 2 agonist combinations varies across ethnic groups, Lin et al. reported on the efficacy and safety evaluation of once daily fluticasone furoate/vilanterol in Asian patients with asthma uncontrolled on a lowto midstrength ICS or low dose ICS/long acting 2 agonist. In patients of Asian ancestry, once daily fluticasone furoate/vilanterol 100/25 mcg produced statistically and
Allergy and asthma proceedings