Immunotherapy for house dust mite sensitivity: where are the knowledge gaps?

House dust mites (HDMs) are found in the environments where human habitation exists. Their density is dependent on environmental relative humidity; therefore, higher populations are present in areas of the world with higher humidity levels, e.g., coastal areas and tropics. To date, 24 HDM allergens have been identified. Many of these represent digestive enzymes since HDM feces are the major source of allergen exposure. IgE- medicated sensitization to HDM allergens is an important factor in the pathogenesis of allergic diseases since it is the most common aeroallergen detected by skin testing or in vitro IgE assays. Sensitization to HDM allergens often occurs early in life and appears to play an important role in the progression from allergic rhinitis to asthma (the so-called Allergic March) in children. HDM sensitization is also associated with asthma across all age groups. Efforts to control environmental exposure to HDM allergens have often proven to be unsuccessful. While medications can improve symptoms, only immunotherapy currently provides disease-modifying effects in allergic rhinitis and asthma. Several systemic reviews and meta-analysis indicate that both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are effective in the treatment of allergic rhinitis and asthma for HDM sensitivity. In this report, we review recent studies and the evidence for the use of HDM SCIT and SLIT. Fundamental gaps in knowledge are identified which could lead to improved approaches to HDM allergy.

Actionable diagnosis of neuroleptospirosis by next-generation sequencing.

A 14-year-old boy with severe combined immunodeficiency presented three times to a medical facility over a period of 4 months with fever and headache that progressed to hydrocephalus and status epilepticus necessitating a medically induced coma. Diagnostic workup including brain biopsy was unrevealing. Unbiased next-generation sequencing of the cerebrospinal fluid identified 475 of 3,063,784 sequence reads (0.016%) corresponding to leptospira infection. Clinical assays for leptospirosis were negative. Targeted antimicrobial agents were administered, and the patient was discharged home 32 days later with a status close to his premorbid condition. Polymerase-chain-reaction (PCR) and serologic testing at the Centers for Disease Control and Prevention (CDC) subsequently confirmed evidence of Leptospira santarosai infection.

The role of autoimmune testing in chronic idiopathic urticaria.

BACKGROUND: The clinical implications of autoimmune testing in chronic idiopathic urticaria (CIU) are not well established. OBJECTIVE: To identify the association of autoimmune biomarkers in CIU with disease severity. METHODS: We retrospectively evaluated 195 patients with a diagnosis of CIU for the presence of antinuclear antibody (ANA), anti-thyroglobulin antibody (ATG), anti-thyroperoxidase antibody (ATPO), and Chronic Urticaria (CU) Index. The patients were categorized into controlled and refractory subgroups based on their response to antihistamines with or without a leukotriene receptor antagonist. RESULTS: The percentage of patients with a positive test for ANA (titer>1:160), ATG, ATPO, and CU Index were 29%, 6%, 26%, and 38%, respectively. Among those tested, the percentage of patients categorized as refractory was significantly higher in those with a positive CU index (80% vs 46%; P = .01) or a positive ANA titer (50% vs 30%; P = .04) than those with negative test results; however, a similar relationship was not observed for ATPO or ATG antibodies. Odds ratios of individual or combinations of autoimmune biomarkers in CIU were examined for associations with refractoriness to antihistamines with or without a leukotriene receptor antagonist. The CU Index alone has an odds ratio of 4.5 (P = .005), whereas the combination of ANA, ATG, and ATPO has an odds ratio of 3.1 (P = .01) and ANA alone has an odds ratio of 2.3 (P = .04) for correlating with a refractory outcome. CONCLUSION: Our data indicate the CU Index independently has the strongest correlation with disease severity followed by the combination of ANA, ATG, and ATPO and the ANA alone.

Characterizing hospice services in the United States.

PURPOSE: Although caregivers desire specific information about hospice programs, there is little descriptive information available. We characterized agencies that provide formal or informal hospice care in the United States according to four types of services considered important by caregivers: medications and treatments; rehabilitative care; emotional, social, and spiritual support; and practical support (e.g., continuous home care). DESIGN AND METHODS: Data were from the nationally representative 2000 National Home and Hospice Care Survey. We categorized agencies into service mixes reflecting combinations of the four service types by using a grade-of-membership model to score each agency. RESULTS: Of the 11,419 agencies represented in our data, slightly more than half (52%) reflected some mix of services from all four service types. The remaining agencies provided service mixes that reflected relatively few or no services from at least one of the four service types. Specifically, approximately 7% lacked (i.e., had relatively few or no) medications and treatment services, 6% lacked rehabilitative care, 26% lacked emotional/social/spiritual support, and about 10% lacked multiple services. When compared to agencies that reflected a mix of all four services, agencies that lacked multiple services could be distinguished by their lack of formal certification as either a hospice or home health agency. IMPLICATIONS: Few U.S. agencies that provide formal or informal hospice care incorporate a balanced mix of all types of services, but most agencies lack only one type of service. Categorization of agencies based on services that are relevant to caregivers may assist providers in describing hospice care.