Dissertations / Theses on the topic 'Childhood allergy'

Background: Childhood food allergies (FA) are increasing in Australia. Although death from anaphylaxis caused by FA is rare, food-induced anaphylaxis could be fatal. It is unclear if staff in Early Childhood Education and Care (ECEC) are well prepared to manage food-induced anaphylaxis. This cross-sectional study utilised an online survey to assess the preparedness of ECEC staff nationally to manage FA. Method: A survey addressing training, knowledge, skills and staff confidence to manage FA and anaphylaxis was emailed to 5956 ECEC centres nationally (excluding WA). Four hundred and ninety-four surveys were completed. Demographics were used to determine differences between State/Territory and socioeconomic status of the centres. Data was analysed using descriptive statistics and Chi-squared Test. Results: A high proportion (76.7%) of ECEC services had children with a medically confirmed FA. A small percent (9.5%) of ECEC services did not require staff to undertake anaphylaxis training, which was non-compliant with current legislation. Staff confidence in FA and anaphylaxis management was high regardless of whether they had undertaken training, which indicated perception of confidence is not reflective of staff skill set to manage FA and anaphylaxis within services. Most (93.9%) ECEC services had a FA policy requiring Action Plans be provided. Over one third (37%) ECEC services stored adrenaline autoinjectors (AAI) in a locked location (not recommended). Approximately half (51.4%) of ECEC services reported having an AAI training device. NSW and Queensland had a significantly lower proportion of services with AAI training devices than Victoria (p-value < 0.001). Victoria reported the highest level of anaphylaxis management training (p-value < 0.05). Victorian services were also significantly less likely to store their AAI devices in a locked location compared to NSW and QLD (p-value < 0.001). There was no significant difference in staff training, knowledge, skills and confidence based on socio-economic status (p-value > 0.05). Conclusion: ECEC staff self-reported a high level of training, knowledge, skills and confidence in FA and anaphylaxis management. However, this study revealed gaps in staff knowledge and skills, especially in how to correctly store and administer an AAI device. This study also identified a lack of awareness about the online FA and anaphylaxis training currently available. Better promotion of existing approved online training resources would increase the engagement of ECEC staff in anaphylaxis training

Introduction. The atopic diseases of asthma, eczema and hayfever are immunologically mediated diseases initiated and perpetuated by T-helper (Th) cells of the Th2 phenotype, in affluent countries the prevalence of atopic diseases has increased dramatically in the last 40 years. This increase has been attributed to declining dietary intake of naturally occurring antioxidants. Epidemiological data and in vitro studies demonstrating that antioxidant deficiency is associated with Th2 differentiation support this 'antioxidant' hypothesis. The 'hygiene' hypothesis attributes the recent increase in atopic disease to declining childhood infections. This proposal originated from the observation of an inverse association between atopic disease and birth order. There is increasing interest that in utero influences play a critical role in determining the development of childhood atopic disease. There are reports that Th-cells from genetically susceptible neonates and neonates who subsequently develop atopic disease exhibit altered in vitro proliferative and cytokine responses. A proposed in utero influence is the sensitisation of fetal Th- cells by allergens and this concept is supported by indirect evidence. This thesis describes a prospective study designed to test the hypothesis that maternal allergen exposure and dietary antioxidant intake during pregnancy influence fetal Th-cell differentiation and the subsequent development of childhood atopic disease. Methods. Advantage was taken of a prospective cohort study of 2,000 pregnant women. Cord blood samples were obtained from a random sample of the neonates at birth. Cord blood mononuclear cells (CBMC) were stimulated with mitogen, control antigens and allergens. CBMC proliferative responses were quantified and CBMC interleukin-4 (IL-4) and interferon-y (IFN-y) secretion was measured by the celELISA method. These responses were related to antenatal data collected prospectively relating to the pregnancy. In a small number of samples the CD45 isoform of the responding CBMC was determined to investigate whether in utero allergen sensitisation of fetal Th-cells occurs. CBMC responses were also related to respiratory symptoms and atopic disease during the first year of infant life. Results. CBMC responses from 223 cord blood samples were characterised. CBMC culture conditions were optimised and the celELISA successfully detected secreted IFN-y and IL-4. CBMC proliferative responses were detected in 27-91% of cord blood samples, IL-4 responses in 18-31% and IFN-y responses in 19-88%. CD45 isoform analysis indicated that in utero sensitisation of timothy grass specific Th-cells occurs in 38% of pregnancies. CBMC proliferative responses were positively associated with a family history of atopic disease and maternal smoking. CBMC proliferative responses were negatively associated with birth order and maternal dietary vitamin E intake during pregnancy. CBMC IFN-gamma and IL-4 cytokine responses were positively associated with each other and a family history of atopic disease. CBMC IFN-gamma responses were negatively associated with birth order. Wheezing illness in the first year tended to be associated with increased CBMC proliferative responses at birth. Conclusions. Previously identified risk factors for atopic disease, which have been considered to be manifestations of post-natal influences, exert significant antenatal influences. The accepted adverse effects of maternal smoking on children's respiratory health may be a consequence of in utero influences. This study demonstrates a major in utero component to the association between birth order and atopy, contradicting the widely held assumption that it is a consequence of the protective effect of childhood infections. The maternal influence of dietary vitamin E intake raises the possibility of preventing childhood allergy by modifying the maternal diet during pregnancy. This study also provides the most direct evidence to date of the in utero sensitisation of Th-cells by allergens.

Nickel allergy is the most prevalent contact allergy and has been discussed as a possible riskfactor for hand eczema. However, hand eczema is one of the most frequently occurring skindiseases and has multifactorial origin. The aim of this thesis was to study the association between nickel allergy and hand eczema in the general population. There are only a fewpopulation-based studies previously published, that include patch testing. In addition, this thesis aimed to evaluate methods to follow the prevalence of nickel allergy.The study cohort consisted of 908 women who had been patch tested for the occurrence of nickel allergy as schoolgirls. Twenty years later, they were invited to participate in a follow-up questionnaire study. The response rate was 81%. In total, 17.6% of respondents reported handeczema after the age of 15 years and there was no statistically significant difference in the occurrence of hand eczema between those who were nickel-positive and those who were nickel negativeas schoolgirls. To further investigate possible links, another study was performed,which included a second questionnaire, a clinical investigation and patch testing. All schoolgirls from the baseline study who were still living in the area as adults were invited to participate and the participation rate was 77%. Patch test showed 30.1% nickel-positive individuals.When all participants were included in the analysis, there was no statistically significant difference between nickel-positive and nickel-negative women regarding occurrence of hand eczema. The most important risk factor for hand eczema was childhood eczema. Adjusted prevalence proportion ratio (PPR) for hand eczema after age 15 in relation to nickel patch testresults was 1.03 (95% CI 0.71--1.50) and in relation to childhood eczema 3.68 (95% CI 2.45--5.54). When women with and without history of childhood eczema were analyzed separately, the hand eczema risk was doubled in nickel-positive women without history of childhood eczema. In conclusion, the risk of hand eczema in nickel-positive women may previously havebeen overestimated. Next, the validity of self-reported nickel allergy was investigated. In the established cohort; two questions regarding nickel allergy were compared with patch test results. The validity of self-reported nickel allergy was low, and the questions regarding nickel allergy overestimated the true prevalence of nickel allergy. The positive predictive values were 59% and 60%. Another method for estimating the prevalence of nickel allergy, namely self-patch testing, was validated in the last study. In total, 191 patients from three different dermatology departments participated. The validity of self-testing for nickel allergy was adequate, with sensitivity 72%and proportion of agreement 86%.
Nickelallergi är vanligt förekommande. Prevalensen i Skandinavien är 15--25% hos kvinnor och cirka 3% hos män. Sambandet mellan nickelallergi och uppkomst av handeksem har tidigare diskuterats och i vissa studier anges att 30--45% av alla individer med nickelallergi får handeksem. Det finns dock endast ett fåtal publicerade studier där personer ur normalbefolkningen har lapptestats för nickel. Handeksem ärvanligt och har ofta flera olika kombinerade orsaker. Det övergripande syftet med avhandlingen var att studera nickelallergins betydelse för uppkomst av handeksem. Detfinns ett intresse av att följa förekomsten av nickelallergi över tid, speciellt sedan det i början av 2000-talet infördes ett EU-direktiv som begränsar nickelinnehåll i klockor,smycken, metallknappar etc. Ytterligare ett syfte med avhandlingen var att utvärderaepidemiologiska metoder för att följa förekomsten av nickelallergi.Den första studien var en uppföljningsstudie av 908 flickor ur normalbefolkningen,vilka i skolåldern lapptestats med nickel. Tjugo år senare skickades en enkät till dessa kvinnor, svarsfrekvensen var hög (81%). Förekomsten av självrapporterat handeksemefter 15 års ålder var 17.6%. Det förelåg ingen signifikant skillnad i förekomst avhandeksem mellan de kvinnor som var nickelallergiska som barn jämfört med dem som inte var nickelallergiska. År 2006 utfördes ytterligare en studie, som inkluderade de kvinnor som fortfarande bodde i Örebro län. Studien omfattade en klinisk undersökning av händerna samt ett lapptest. 30% av kvinnorna var positiva för nickel.Det förelåg ingen signifikant skillnad i förekomst av handeksem mellan de som var positiva för nickel och de som var negativa. Vid separat analys av de kvinnor som angav tidigare barneksem jämfört med dem som aldrig hade haft barneksem visade det sig att risken för handeksem var dubbelt så stor hos nickelallergiker i den gruppen som aldrig hade haft barneksem. Båda studierna visade att barneksem var den största riskfaktorn för att få handeksem som vuxen, med en 3-4 gånger ökad risk. Den tredje studien var en validering av självrapporterad nickelallergi. Överensstämmelsen var låg mellan enkätfrågor gällande nickelallergi och lapptestverifierad nickelallergi. Av dem som själva bedömde sig vara nickelallergiska var endast 59% positiva enligt lapptest. För att följa förekomsten av nickelallergi i befolkningen behövs därför andra metoder. I den fjärde studien utvärderades ett självtest för nickelallergi. 191 patienter från tre olika hudkliniker i Sverige deltog i studien. Validiteten för metoden självtest var tillfredsställande, sensitiviteten var 72%och graden av överensstämmelse var 86%.

Atopic allergy is the most common chronic disease among children in the developed world. This high prevalence could be associated with low microbial exposure. The early gut microbiota appears to be important for immune maturation. Immunomodulatory components in human milk might differ between mothers and could therefore explain the contradictory results seen regarding breastfeeding and allergy development. The aim of this thesis was to investigate whether early colonization with certain gut microbiota species influences childhood immune responses and allergy development up to age five. Also, as human milk oligosaccharides (HMOs) might stimulate the growth of certain gut microbiota species, the consumption of neutral colostrum HMOs was investigated for their role in allergy development up to 18 months. The concentrations of neutral colostrum HMOs varied considerably between women; however this variation could not be explained by their allergic status. Neither was the consumption of neutral colostrum HMOs related to allergy development in their children up to 18 months. Infants who harboured lactobacilli group I and Bifidobacterium adolescentis one week after birth developed allergic disease less frequently during their first five years than infants who did not harbour these bacteria at the same time. Also, colonization with several Bifidobacterium species was associated with higher levels of house dust endotoxin and larger family size. The early Bifidobacterium flora influenced levels of salivary secretory IgA at six and 12 months but not during later childhood. Moreover, the intensity of early Bacteroides fragilis colonization was inversely associated with spontaneous Toll-like receptor 4 mRNA expression in peripheral blood cells collected 12 months after birth. In conclusion, these results indicate that the early infant gut microbiota influences systemic and mucosal immune maturation during infancy, and that it might be altered in infants developing allergic disease.

Allergic diseases are influenced by genetics and the environment. Maternal allergy appears to confer a higher risk for allergic sensitization than paternal allergy, suggesting an in utero influence. A decrease in particular infections or a lower exposure to microbial components during infancy is suggested to contribute to the high allergy prevalence in affluent societies. Toll-like receptors (TLR) 2 and 4 recognize peptidoglycan (PGN) and LPS respectively, are expressed on e.g. monocytes, and have been implicated in modulating the risk of IgE-sensitization. This thesis aimed to study the influence of maternal allergy and early microbial exposure on monocyte function and allergic sensitization during childhood. Blood samples from children participating in a prospective allergy cohort were used. Two-year old infants with allergic mothers had lower IL-6 production and reduced activation of the TLR-signalling intermediate p38-MAPK in response to PGN than children with non-allergic mothers. In 5-year old children, allergic disease and not maternal allergy influenced monocytic TLR2-regulation. Five-year olds who were seropositive for Epstein-Barr virus (EBV) at 2-years of age had a lower risk of persistent IgE-sensitization while EBV contraction after 2-years of age related to a higher risk of IgE-sensitization. Upon in vitro stimulation, NK cells from EBV+ 2-year olds produced lower IFN-g levels. EBV+ 2-year olds had also lower systemic IFN-g. In comparison to CD14++CD16- monocytes, CD14+CD16+ cells induced NK-cell IFN-g more potently in vitro, and EBV+ infants tended to have lower proportions of these CD14+CD16+ monocytes. This thesis highlights the importance of early-life microbial (EBV) exposure for a proper allergy-protective immunity. Also, maternal allergic heredity appears to influence monocytic microbial responses in early infancy. All these aspects relate to altered monocyte functionality, which suggest that they could have a role in allergic sensitization.

In 1974 Random House published a popular and controversial book entitled Why Your Child is Hyperactive. The author, San Francisco allergist Ben F. Feingold, claimed that hyperactivity was caused by food additives and was best prevented and treated with a diet, subsequently dubbed the 'Feingold diet', free of such substances. Reaction to the idea was swift. The media and parents found Feingold's environmentally-based theory intriguing, as it provided an aetiological explanation for hyperactivity that was both sensible and topical. The medical community, in contrast, was suspicious and designed double-blind trials to test his theory. The dominant perception emerging out of these tests was that Feingold's hypothesis was incorrect and, soon after Feingold's death in 1982, medical and media attention faded away. Drawing on unpublished archival material, medical literature, popular media sources and oral history interviews, this thesis explores the rise and fall of the Feingold diet. It examines the origins of Feingold's idea, the manner in which his theory was disseminated to the medical community and the broader public, and analyses how physicians and patients evaluated whether or not Feingold's hypothesis was correct. Aiming to contribute to the histories of allergy, psychiatry and nutrition, the thesis contends that social factors, rather than scientific testing, were largely responsible for the fate of the Feingold diet. Some of these factors include Feingold's methods and approach to describing and promoting his diet, the professional and economic interests of medical practitioners and the food, chemical and pharmaceutical industries, and the difficulties inherent in following the diet. From a broader historiographical perspective, the history of the Feingold diet suggests that in order to understand how medical controversies are resolved it is essential to analyse the historical context within which they emerge.

HISTORICAL PERSPECTIVE: It has recently been shown that intensive prophylactic dietary and environmental control measures during early infancy may reduce the incidence and/or postpone the onset of atopic disease. In order to institute this prophylactic regime, early identification of the infants genetically "at risk" for atopic disease is essential, since sensitisation begins at birth, or even during intra-uterine life. European and Scandinavian studies have shown that a raised concentration of cord blood serum immunoglobulin E (CBsIgE) is an excellent predictive marker for the subsequent development of atopic disease. Other potential predictive atopic markers such as cord blood eosinophils, platelets and anti-cow's milk serum IgG have also been suggested as having possible predictive relevance for newborns in terms of the development of subsequent atopic disease. PROBLEM DEFINITION: Most of the work in this field has been done on Caucasian neonates, in Westernised, First World countries. In South Africa, it has been shown that the Black adult ethnic group has serum immunoglobulin E concentrations (sIgE) which are significantly higher than that found in the South African White adult ethnic group. Furthermore, it has been suggested that the elevated sIgE in the adult Blacks may be raised independently of allergic disease. It is, therefore, important to ascertain whether this elevation of sIgE in Black South African adults is evident already at birth in the cord blood sera of Black South African newborns. If so, it is imperative to ascertain whether any such elevation is reflective of a high genetic load for atopy in these Black newborns, and furthermore whether these Black newborns are consequently "high-risk" for the development of subsequent atopic disease, as has been previously reported in the literature for White newborns. Arising from an awareness of these specific South African problems, the following hypothesis was developed. HYPOTHESIS: The hypothesis states that: "Black South African newborns without an atopic family history (aFH) have significantly higher CBslgE values than similar White and Mixed newborns. An aFH does not influence the CBsIgE values in the Black newborns, as it does in the White and Mixed newborns. The CBsIgE values in Black newborns are not, furthermore, predictive for the development of subsequent atopy in infancy, as they are in the other ethnic groups". A description of the three South African ethnic groups considered in this study is provided in Section IV, (Pg. 74). AIMS OF THE STUDY: The aims of the study were three-fold: 1. To test the hypothesis. 2. To assess the relevance of alternative cord blood markers (eosinophils, platelets and anti-cow's milk serum IgG) as predictive atopic markers in each of the three ethnic groups. 3. To provide epidemiological information with regard to genetic and environmental influences on CBslgE, cord blood total eosinophil counts (CBTEC's) cord blood platelet counts (CBPlC's) and cord blood anti-cow's milk serum IgG concentrations (CBacmlgG).

Background: An altered microbial exposure may be partly responsible for the increase of allergic diseases in populations with a western lifestyle. Activation of the immune system by microbes early in life is probably required for an accurate maturation of the immune system. Probiotics, live bacteria which are considered to confer health when ingested, have been suggested to prevent eczema and sensitisation infants. Aim: The general aim of this thesis was to assess the effect of oral supplementation with the probiotic bacterium Lactobacillus reuteri (L. reuteri) in infancy on the development of allergic disease and sensitisation during the first 2 years of life and to examine mechanisms possibly underlying eventual effects on allergic manifestations. Subjects: The thesis is based on results obtained from a prospective double-blind placebo-controlled multicenter trial, comprising 232 families with allergic disease, of whom 188 completed the study. Methods: The families were recruited at the antenatal clinic, and the mothers received L. reuteri ATCC 55730 (1 x 108 colony forming units) or placebo daily from gestational week 36 until delivery. Their babies then continued with the same study product from birth until 12 months of age and were followed up for another year. The primary outcomes were allergic disease, with or without positive skin prick test or circulating IgE to food allergens. Bacterial counts and prevalence were assessed in maternal breast milk and faeces and infant faeces, employing conventional cultivation methods. Cytokines and IgA antibodies were analysed in colostrum and mature milk from the mothers with ELISA, and Na/K- ratio in breast milk with ion selective electrodes. Circulating Th1/Th2-associated chemokines were analysed in cord and peripheral blood in the infants with Luminex or ELISA technique. Results: The incidence of eczema was similar, 36% in the treated versus 34% in the placebo group. The L. reuteri group had a lower cumulative incidence of IgE-associated allergic disease, 20% versus 35% (p=0.04), and less IgE-associated eczema during the second year, 8% versus 20% (p=0.02). The prevalence of L. reuteri was higher during the first year of life in stool samples from infants, as well as in colostrum, in the active as compared to the placebo treated group. Colostrum from L. reuteri supplemented mothers had lower levels of TGF-β2, and low levels of this cytokine were associated with less sensitisation. Low Th1- and high Th2-associated chemokine levels preceded allergic disease. The presence of L. reuteri in stool was associated with lower levels of the Th2-associated chemokines CCL17 and CCL22 and higher levels of the Th1-associated CXCL11. Conclusion: Although a preventive effect of probiotics on infant eczema was not confirmed, the L. reuteri treated infants had lower incidence of IgE-associated allergic disease at two years of age, and therefore possibly run a reduced risk to develop later respiratory allergic disease. The mechanisms underlying this effect require further elucidation.

Allergic rhinitis is a global health problem that causes major illness and disability. Inherited and environmental factors influence its development. This thesis examined the role of traffic-related air pollution, genetic variants and their potential interactions, on childhood allergic rhinitis. Global spatial associations with climatic factors known to influence aeroallergen distributions were also studied. Data from two Canadian (CAPPS and SAGE) and four European birth cohorts (BAMSE, GINIplus, LISAplus and PIAMA) participating in the Traffic, Asthma and Genetics collaboration were pooled. No consistent associations between individual-level traffic-related air pollutants (NO2, PM2.5 mass, PM2.5 absorbance and ozone) estimated to the home address and childhood allergic rhinitis were observed in a longitudinal analysis (up to ten years) of two cohorts (GINIplus and LISAplus; N=6,604) and a pooled analysis of all six cohorts (N=15,299). These latter null associations were not modified by ten tested single nucleotide polymorphisms in the GSTP1, TNF, TLR2 and TLR4 genes. Although these results do not support an adverse role of traffic-related air pollution on childhood allergic rhinitis, much remains to be learned regarding for whom, when and how air pollution may impact disease. In further analyses, genetic variants in the TNF and TLR4 genes and at the 17q21 gene locus were found to be associated with childhood allergic rhinitis in pooled analyses of the six cohorts. As genetic variability in these regions has also been linked to asthma, the observed associations support the hypothesis of shared genetic susceptibility between asthma and allergic rhinitis. These results may be important for public health given the large proportion of the population carrying the studied risk variants. Lastly, using cross-sectional data from 6-7 and 13-14 year-olds participating in the International Study of Asthma and Allergies in Childhood, several ecological spatial associations between climatic factors (temperature, precipitation and vapour pressure) and intermittent and persistent rhinitis symptom prevalences were identified. Although not conclusive, these results represent a first step in investigating how climate change may affect rhinitis symptom prevalence. Collectively, this dissertation contributes to our understanding of the effects of air pollution, genetic variability and climate on childhood allergic rhinitis.
Medicine, Faculty of
Population and Public Health (SPPH), School of
Graduate

[Truncated abstract] Asthma affects millions of people worldwide and places a substantial burden on the healthcare system. Despite advances in our understanding of disease mechanisms and the role of respiratory viruses in asthma exacerbations, there is little known regarding the role of the epithelium in commonly observed structural changes in the airway wall. The epithelium of the airways provides an essential protective barrier between the environment and underlying structures and is responsible for the secretion of diverse compounds. Since it is likely that dysregulated epithelial characteristics and function in childhood asthma are critical determinants of disease progression in adults, it is pertinent to investigate the cellular mechanisms involved in paediatric asthma. However, full comprehension of paediatric respiratory diseases and the childhood antecedents of adult respiratory disease are currently hampered by the difficulty in obtaining relevant target organ tissue and most of the data to date have been generated from studies involving adults or commercially derived cell lines. This laboratory has successfully developed methodologies of obtaining and studying samples of paediatric primary airway epithelial cells (pAECs) and has identified significant biochemical and functional differences between healthy non-atopic (pAECHNA) and atopic asthmatic (pAECAA) airway cells, which have assisted in the identification of potential mechanisms responsible for abnormal epithelial function. Stevens 2009 ... Exposure of pAECs with RV resulted in elevated PAI-1 mRNA expression and reduced MMP-9 release in both pAECAA and pAECHNA samples. Collectively, the data presented indicate that RV exposure induces a pronounced antiproliferative and retardative repair effect in pAECAA and that the presence of virus may have a role in the PAI-1 and MMP expression witnessed in these cells. In conclusion, this investigation has further characterised the essential role the airway epithelium plays in childhood asthma by demonstrating for the first time that pAECs from asthmatic children lack the ability to successfully repair mechanically induced wounds. This investigation also showed that PAI-1 is elevated in pAECAA and has a functional role in the pAEC proliferative and regenerative processes. It was demonstrated that MMP-2 and MMP-9 activities and the MMP-9/TIMP-1 as well as MMP2/TIMP2 ratios were significantly reduced in pAECAA thereby providing additional evidence that there is a dysregulation in the mechanisms that monitor the turnover of the ECM in childhood asthma. Furthermore, this study has shown for the first time that pAECs from untreated mild atopic-asthmatic children are more sensitive to the pathogenic effects of RV than healthy control cells and that RV exposure delays cellular proliferation and repair. Ultimately, these findings support the hypothesis postulated and provide evidence that indeed the dysregulated epithelial functional characteristics seen in childhood mild asthma may be a critical determinant of disease progression in adults.

The early-life microbiota is important for postnatal immune maturation and implied in immune mediated diseases. The aim of this work was to study specific species of bacteria in the gut microbiota and relate them to immune function and allergic disease during childhood. In paper I we investigated gut bacteria in feces from infants included in a prospective allergy cohort. We found that children with non-allergic parents were more likely to be colonized with a group of lactobacilli. Further, lactobacilli colonization was more prevalent in children remaining non-allergic, regardless of allergic heredity. In paper II we related the infant gut bacteria to immune function at two years of age. Infant Staphylococcus (S.) aureus colonization associated with increased immune responsiveness, whereas co-colonization with S. aureus and lactobacilli associated with reduced responses. In paper III we investigated T regulatory (Treg) cell phenotype and cytokine production during childhood, and related S. aureus and lactobacilli colonization to Treg phenotype at the age of two. The Treg population matured with age, regarding phenotype and cytokine production. Furthermore, infant S. aureus colonization associated with Treg phenotype at the age of two. In paper IV we investigated the in vitro peripheral blood mononuclear cells responses to soluble factors produced by lactobacilli and S. aureus. Both T- and natural killer cells responded with cytokine production, degranulation and proliferation after S. aureus and simultaneous culture with lactobacilli could dampen the S. aureus-induced responses. Taken together this thesis shows that the gut microbiota is altered in children who develop allergies, and that early life bacteria associate with immune function. Our in vitro findings support that lactobacilli modulate immune maturation and responses, and that early lactobacilli-colonization may be important for a properly regulated maturation of the immune system.

At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 3: Manuscript. Paper 4: Manuscript.

Ce travail de thèse a porté sur l’étiologie des leucémies aigües (LA) de l’enfant, et s’est concentré sur les questions (1) du risque de LA chez les enfants conçus par assistance médicale à la procréation (AMP) ; (2) du rôle protecteur d’une supplémentation maternelle en acide folique ; (3) du rôle protecteur de l’exposition précoce à des facteurs induisant une stimulation du système immunitaire ; (4) d’un effet protecteur des antécédents d’allergie sur le risque de LA de l’enfant. Les données analysées proviennent de l’étude cas-témoins française, ESTELLE, réalisée en 2010-2011. Les cas ont été identifiés par le Registre National des Hémopathies malignes de l’Enfant et les témoins ont été recrutés en population générale par téléphone, avec une stratification sur l’âge et le sexe. L’échantillon comportait 636 cas incidents de leucémie aiguë lymphoblastique (LAL), 100 cas incidents de leucémie aiguë myéloblastique (LAM), et 1421 témoins de moins de 15 ans. Les données ont été recueillies auprès des mères à l’aide d’un questionnaire téléphonique standardisé, identique pour les cas et les témoins. Les odds ratios (OR) ont été estimés par régression logistique non conditionnelle ajustée sur l’âge, le sexe, le niveau d’éducation maternel, la catégorie socio-professionnelle du foyer, et les facteurs de confusion potentiels. Nous n’avons pas observé d’augmentation du risque de LA chez les enfants dont la conception avait été difficile (OR=0,9[0,7-1,2]), ou avait nécessité la prise d'un traitement d’infertilité (OR=0,8[0,5-1,1]). La supplémentation préconceptionnelle en acide folique était inversement associée au risque de LA (OR=0,7[0,5-1,0]), sans spécificité de sous-type. Le risque de LAL était inversement associé aux infections banales avant l’âge de 1 an (OR=0,8[0,6-1,0]), à la fréquentation d’une crèche avant 1 an (OR=0,7[0,5-1,0]), à l'allaitement maternel (OR=0,8[0,7-1,0]) , et à des contacts réguliers avec les animaux domestiques à un âge précoce (OR=0,8[0,7-1,0]). En revanche, nous n’avons pas observé d’influence du mode d’accouchement sur le risque de LA. Enfin, les LA étaient inversement associées aux antécédents de rhinite allergique, d’eczéma, de dermatite atopique, d’allergie alimentaire; et d’asthme ou bronchite asthmatiforme traité par antihistaminique. Ces résultats ne sont pas en faveur d’un risque de LA associé aux techniques d’aide médicale à la procréation. Ils renforcent l’hypothèse d’un effet protecteur de la supplémentation préconceptionnelle en acide folique pour les LA. Enfin, ils apportent des arguments supplémentaires en faveur du rôle d’une stimulation précoce du système immunitaire dans la survenue des LAL
The aim of this study was to investigate whether the following factors: 1) conception by assisted medical procreation (AMP), 2) maternal folic acid supplementation, 3) factors related to early stimulation of the immune system, and 4) the history of allergy were related to the risk of childhood acute leukemia (CL). The data were obtained from the national registry-based case-control study, Estelle, carried out in France in 2010-2011. Population controls were recruited by random digit dialing, with quotas on age and sex. The sample included 636 cases of acute lymphoblastic leukemia (ALL), 100 cases of acute myeloblastic leukemia (AML), and 1421 controls less the 15 years old and frequency matched on age and sex. The data were collected by telephone interview of the mothers, using the same standardized questionnaire for cases and controls. Odds ratios (OR) were estimated using unconditional regression models adjusted for age, sex, maternal education, parental socioeconomic status , and potential confounders. We did not observe any increase in CL risk in children who were conceived with difficulty (OR=0,9[0,7-1,2]) or with the use of any fertility treatments (OR=0,8[0,5-1,1]). Preconceptional folic acid supplementation was inversely associated with CL (OR=0,7[0,5-1,0]), without subtype-specificity. Early common infections before 1 year (OR=0,8[0,6-1,0]), attendance to day-care before 1 year (OR=0,7[0,5-1,0]), breastfeeding (OR=0,8[0,7-1,0]) and regular contact with pets in the first year (OR=0,8[0,7-1,0]) were inversely associated with ALL. However, the mode of delivery was not associated with ALL. Finally, reported history of eczema, atopic dermatitis, food allergy, allergic rhinitis, asthma or asthmatic bronchitis treated with anti-histaminic was inversely associated with CL. Our findings do not suggest that fertility treatments are risk factors for CL. They suggest that folic acid supplementation during pregnancy may reduce the risk of CL. They also support the hypothesis that some conditions promoting the maturation of the immune system may decrease the risk of ALL

[ES] Antecedentes: Los patrones de colonización microbiana alterados durante la infancia pueden ser en parte responsables del aumento de enfermedades alérgicas en los países desarrollados. La microbiota intestinal difiere en composición y diversidad durante los primeros meses de vida en niños que luego desarrollan o no una enfermedad alérgica. Sin embargo, poco se sabe sobre la importancia de las respuestas inmunitarias tempranas de la mucosa a la microbiota intestinal en el desarrollo de alergias infantiles. Además, los estudios con respecto al efecto protector de la microbiota de la leche materna en el riesgo de desarrollar alergias no han sido concluyentes. Aunque la cavidad bucal es el primer lugar de encuentro entre la mayoría de los antígenos exógenos y el sistema inmunológico, no existen datos sobre la influencia de las bacterias orales en el desarrollo de alergias durante la infancia. Objetivos: El objetivo general de esta tesis fue evaluar la composición y diversidad microbiana en muestras orales, intestinales y de leche materna, junto con su interacción con IgA, para estudiar el papel de la colonización microbiana durante edades tempranas de la vida en condiciones de salud y de enfermedad alérgica. Sujetos: Los bebés y las madres incluidas en este estudio forman parte del ensayo aleatorio doble ciego más grande de Suecia, entre 2001 y 2003, donde se evaluaron los posibles efectos preventivos sobre la alergia de Lactobacillus reuteri ATCC 55730 hasta los 2 y 7 años. En esta tesis, utilizamos muestras de heces recogidas a los 1 y 12 meses, y muestras orales de bebés, obtenidas longitudinalmente a los 3, 6, 12, 24 meses y 7 años. Además, analizamos muestras de leche materna, recogidas a un mes después del parto de las madres correspondientes. Métodos: Se utilizaron tecnologías de secuenciación de segunda generación dirigidas al gen 16S rARN, en combinación con citometría de células marcadas por fluorescencia, para abordar las respuestas de IgA de la mucosa hacia las bacterias intestinales y de la leche materna. Además, se utilizó la secuenciación del gen 16S para describir la colonización oral de la microbiota, en muestras de saliva, de niños que desarrollaron alergias o de aquellos que se mantuvieron sanos. Los niveles de carga bacteriana en diferentes hábitats microbianos se obtuvieron mediante la metodología de qPCR y los niveles totales de IgA de las muestras de heces se determinaron mediante inmuno-ensayo ELISA. Resultados y conclusión: La colonización de la cavidad bucal durante la infancia temprana es progresiva, aumenta en complejidad con el tiempo, y varios factores externos parecen influir en gran medida en la maduración de la microbiota oral, ya sea con un impacto a corto o largo plazo. Los cambios tempranos en la composición microbiana oral parecen influir en la maduración inmune y el desarrollo de alergias en la infancia, y la presencia de especies bacterianas específicas puede ser importante para este proceso. Además, las respuestas de IgA alteradas hacia la microbiota intestinal durante la infancia precedieron a las manifestaciones de asma y alergia durante los primeros 7 años de vida, y el consumo de leche materna con una riqueza microbiana reducida en el primer mes de vida puede aumentar el riesgo de desarrollar alergia durante la infancia. Los hallazgos observados en la presente tesis deben confirmarse en cohortes más grandes y la importancia de los factores ambientales postnatales para el desarrollo temprano de la microbiota debe abordarse más a fondo. Las investigaciones futuras deben ir más allá de la caracterización de la composición de la comunidad bacteriana e investigar los mecanismos funcionales entre los microorganismos colonizadores tempranos, la maduración inmunitaria y la alergia, así como el desarrollo del asma durante la infancia.
[CAT] Antecedents: S'ha proposat que els patrons de colonització microbiana alterats durant la infància podrien ser en part els responsables de l'augment de malalties al·lèrgiques als països desenvolupats. La microbiota intestinal difereix en composició i diversitat durant els primers mesos de vida en els nens que després van desenvolupar una malaltia al·lèrgica. No obstant això, poc es sap sobre la importància de les respostes immunes de la mucosa a la microbiota intestinal en el desenvolupament d'al·lèrgies infantils. A més, les investigacions amb relació a l'efecte protector de la microbiota de la llet materna en el risc de desenvolupar al·lèrgies no han sigut concloents. Encara que la cavitat bucal és el primer lloc de trobada entre la majoria dels gèneres externs i el sistema immunològic, encara no s'ha descobert la influència dels bacteris en el desenvolupament d'una al·lèrgia durant la infància. Objectius: L'objectiu general d'aquesta tesi va ser avaluar la composició microbiana i la diversitat de mostres orals, fecals i llet materns, juntament amb la seva interacció amb IgA, per estudiar el paper del desenvolupament microbià durant el període de la infància primerenca a la salut i la malaltia al·lèrgica. Subjectes: Les mares i xiquets inclosos en aquest estudi formen part d'un estudi aleatori doble-cec a Suècia, entre el 2001 i el 2003, on es van avaluar els possibles efectes preventius de la suplementació amb Lactobacillus ATCC 55730 fins als 2 i 7 anys. En aquesta tesi, s'utilitzaren mostres de bebès arreplegades longitudinalment, obtinguts a 1 i 12 mesos, 3, 6, 12, 24 mesos i 7 anys, respectivament. A més, s'analitzaren les mostres de llet materna, arreplegades a un mes postpart de les corresponents mares. Mètodes: S'han utilitzat tecnologies de seqüenciació de nova generació dirigides al ARNr 16S, en combinació amb la classificació de les cèl·lules activades, per abordar les respostes de la mucosa cap als bacteris intestinals i de la llet materna. A més, s'utilitzà la seqüenciació d'Illumina MiSeq del gen 16S per descriure la colonització microbiana oral, i es van obtenir mostres longitudinals de saliva de menuts que varen desenvolupar al·lèrgies i d'alguns que es van mantenir saludables. Els nivells de càrrega bacteriana en diferents nínxols microbians s'han obtingut mitjançant la metodologia de qPCR i els nivells totals d'IgA de les mostres fecals es determinaren mitjançant l'immunoassaig ELISA. Resultats i conclusions: La colonització de la cavitat bucal durant la primera infància és transitòria, augmenta la seva complexitat amb el temps, i diversos factors externs influeixen en gran mesura el procés de maduració de la microbiota oral, amb un impacte a curt i llarg termini. Els canvis primerencs en la composició microbiana oral pareixen influir en la maduració del sistema immunològic i el desenvolupament d'al·lèrgies a la infància, així com la presència d'espècies bacterianes específiques pot ser important per a aquest progrés. A més, les respostes d'IgA alterades cap a la microbiota intestinal durant la infància precedeixen a les manifestacions relatives a la malaltia asmàtica i al·lèrgiques durant els primers 7 anys de vida. Per altra banda, el consum de llet materna amb una microbiota de riquesa reduïda al primer mes de vida podria augmentar el risc de desenvolupar al·lèrgia durant la infància. Els resultats observats en aquest estudi haurien de confirmar-se en cohorts humanes més grans i la importància dels factors ambientals post natals que influeixen en el desenvolupament de la microbiota primerenca han de ser més estudiats. Les investigacions futures deuen anar més enllà de la caracterització de la composició de la comunitat bacteriana i investigar els mecanismes funcionals entre els microorganismes colonitzadors primerencs, la maduració del sistema immunològic i el desenvolupament de l'al·lèrgia i l'asma durant la in
[EN] Background: It has been proposed that altered microbial colonization patterns during infancy may be partly responsible for the increase of allergic diseases in developed countries. The gut microbiota differs in composition and diversity during the first months of life in children who later do or do not develop allergic disease. However, little is known about the significance of early mucosal immune responses to the gut microbiota in childhood allergy development, and the findings regarding the protective effect of breastmilk microbiota in the risk of allergy development have been inconclusive. Furthermore, even though the oral cavity is the first site of encounter between a majority of foreign antigens and the immune system, the influence of oral bacteria on allergy development during childhood has not yet been reported. Objectives: The general aim of this thesis was to assess the microbial composition and diversity of oral, fecal and breastmilk samples, together with its interaction with IgA, in order to study the role of microbial development during early childhood in health and allergic disease. Subjects: The infants and mothers included in this study were part of a larger randomized double-blind trial in Sweden, between 2001 and 2003, where potential allergy preventive effects of Lactobacillus reuteri ATCC 55730 were evaluated until 2 and 7 years of age. In this thesis, we used longitudinally collected stool and oral samples from infants, obtained at 1 and 12 months and 3, 6, 12, 24 months and 7 years of age, respectively. Furthermore, we analyzed breastmilk samples, collected at one month post partum, from the corresponding mothers. Methods: Next-generation sequencing technologies targeting the 16S rRNA gene, in combination with cell activated cell sorting, were used in order to address mucosal IgA responses towards gut and breastmilk bacteria. Furthermore, sequencing of the 16S rRNA gene was used in order to describe oral microbiota colonization, in longitudinally obtained saliva samples, from children developing allergy or staying healthy. Bacterial load levels in different microbial habitats were obtained by qPCR methodology and total IgA levels of stool samples were determined by ELISA immunoassays. Results and conclusion: Colonization of the oral cavity during early childhood is transitional, increasing in complexity with time, and several external factors appear to greatly influence oral microbiota maturation, having either a short or a long-term impact. Early changes in oral microbial composition seem to influence immune maturation and allergy development in childhood, and the presence of specific bacterial species may be important for this progress. Furthermore, altered IgA responses towards the gut microbiota during infancy preceded asthma and allergy manifestations during the first 7 years of life, and consumption of breastmilk with a reduced microbial richness in the first month of life may increase the risk for allergy development during childhood. Findings observed here need to be confirmed in larger cohorts and the importance of postnatal environmental factors for early microbiota development should be addressed further. Future research should go beyond characterization of bacterial community composition and investigate the functional mechanisms between early colonizing microorganisms, immune maturation and allergy and asthma development during childhood.
Dzidic, M. (2019). Microbiota development and mucosal IgA responses during childhood in health and allergic disease [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/125479
TESIS

Atopic asthma is characterized by excessive T helper 2 (Th2)-like immunity to allergens in the bronchial mucosa. The Th2-cytokine interleukin (IL)-4 induces IgE production, while the Th2-cytokine IL-5 promotes eosinophilic inflammation in the airways of asthmatics. Most asthmatics are atopic, but a subgroup is non-atopic. We hypothesize that allergen-induced Th2, particularly IL-5, responses can be observed in peripheral blood in both atopic and non-atopic asthmatic children but not in healthy control children. The aim of the present study was to determine IL-4, IL-5, IL-9, IL-10, IL-13 and IFN-γ secretion induced from peripheral blood mononuclear cells (PBMC) by a broad panel of inhalant allergens (timothy, cat, birch, dog and house dust mite) in asthmatic children with and without sensitization. The study included 13 atopic asthmatic, 5 non-atopic asthmatic, and 12 non-atopic non-asthmatic children. PBMC were stimulated with allergens and cytokine production was measured with enzyme-linked immunosorbent assay (ELISA). Higher levels of cat and dog antigen-induced IL-5 release were more commonly observed in both atopic and non-atopic asthmatics than in controls. Children with atopic, but not non-atopic, asthma produced higher levels of allergen-induced IL-4 and IL-9 than controls. Non-atopic asthmatics produced more IL-10 than atopic asthmatics after cat stimulation. High levels of eosinophilia-associated IL-5 responses are induced by cat and dog allergen in both atopic and non-atopic asthmatic children. The Th2 cytokines IL-4 and IL-9 were associated only with atopic asthma, probably due to their IgE-inducing properties.

Background: Allergic sensitization is the most important risk factor for asthma and rhinitis among children, adolescents and young adults. Less is known about the incidence and remission of allergic sensitization, particularly in older adults. Furthermore, it is not clear if the earlier documented increase in prevalence of allergic sensitization continues. This thesis is focused on prevalence, incidence and remission of allergic sensitization to airborne allergens among adolescents and adults as well as on time trends in prevalence among adults. Furthermore, associated risk factors and the relation of allergic sensitization to asthma and rhinitis were assessed. Methods: In the study of children and adolescents, incidence, remission and prevalence of allergic sensitization were assessed in a cohort study of schoolchildren, aged 7-8 years (y) at baseline. In the studies of adults, incidence and remission of allergic sensitization were assessed in a randomly selected adult population sample in 1994 (n=664) aged 20-69 y, which was followed up in 2004 (n=555). Trends in prevalence of allergic sensitization were assessed by comparing two cross-sectional studies; the cohort from 1994 and another randomly selsected population sample examined in 2009 (n=737). The relation of allergic sensitization to asthma and rhinitis was determined in the adult cohort in 2009. Allergic sensitization was assessed by skin prick test (SPT) with ten common airborne allergens at ages 7-8, 11-12 and 19 y in the cohort of children and in the participants ≤ 60 y in the adult cohorts. Specific IgE to nine airborne allergens was analyzed in the adult cohorts in 2004 and 2009. Risk factors for allergic sensitization and variables defining respiratory disease and symptoms were assessed by questionnaires in the cohort of children and by structured interviews in the adult cohorts. Results: The 10-year cumulative incidence of allergic sensitization among the adults from 1994 to 2004 was 5%, while remission was 32%. In both adult cohorts, the prevalence of allergic sensitization was highest among young adults, aged 20-29 y, 55% and 61% and decreased significantly with increasing age. Among children and adolescents, both incidence and persistence of allergic sensitization were high, and the prevalence of allergic sensitization increased by age from 21% at age 7-8 y to 42% at age 19 y. Multisensitization at age 19 y was strongly associated with early onset of sensitization. The prevalence of sensitization to the major specific allergens birch, timothy, cat and dog as well as multisensitization (from 40% in 1994 to 56% in 2009, p=0.002) increased significantly from 1994 to 2009 among the adults. Sensitization to any allergen increased from 35% to 39%, however not significantly (p=0.13). A family history of allergic rhinitis was strongly and consistently associated with allergic sensitization in all ages. Male sex and urban living were significantly positively and birth order and furry animals at home in childhood were negatively associated with onset of sensitization before the age of 7-8 y, but not with onset of sensitization from 11-12y to 19 y. Young adult age and urban living were significant factors associated with allergic sensitization in adult age. Sensitization to any animal was significantly positively associated with current asthma (OR4.80 (95% CI 2.68-8.60)), whereas both sensitization to any pollen (OR 4.25 (2.55-7.06)) and any animal (OR 3.90 (95% CI 2.31-6.58)) were associated with current allergic rhinitis. The association between allergic sensitization and allergic rhinitis was strongest in young adult age and decreased with increasing age, while asthma was similarly associated with sensitization to any animal across all adult ages. Among asthmatics, the prevalence of allergic sensitization decreased with increasing age of asthma onset. Conclusion: Both incidence and persistence of allergic sensitization were high among children and adolescents explaining the increase in prevalence by increasing age. An inverse pattern with low incidence and high remission of allergic sensitization was seen among adults. The decrease in prevalence of allergic sensitization by increasing adult age might at least partly be explained by normal ageing and not only by an effect of year of birth (cohort effect). The significant increase in prevalence of sensitization to the specific allergens explained the significant increase in multisensitization over 15 years. A family history of allergy was the strongest and the only consistent risk factor for allergic sensitization in all ages. The prevalence of allergic sensitization decreased with increasing age of asthma onset among adult asthmatics.

This study showed a strong association between asthma, hay fever, and eczema in the same child. The presence of pets outdoors but not indoors appeared to be associated with an increased incidence of wheezing in children. Use of the traditional Gulf incense also appeared to be a precipitating factor for asthma in this study. There were also statistically significant relationships between asthma and exposure to dust at home from air conditioner blasts, which is consistent with studies elsewhere. Moreover, in this study, passive exposure to tobacco smoking at home did not appear to have any significant relationship with asthma. There was, however, a statistically significant relationship between asthma and exposure to pollen from indoor plants, which is also consistent with studies elsewhere. Parental asthma but not parental atopy was a significant risk factor for asthma in offspring, a finding which agrees with other studies that have shown that parental atopy may enhance the likelihood of the expression of asthma, but does not, on its own, impact as a risk factor in the same way as parental asthma. There was a statistically significant difference in the prevalence of asthma and the symptoms of asthma between different areas across the United Arab Emirates, but not for eczema or hay fever. This is most likely attributable to the impact of radically different environmental conditions on the development of allergies in two genetically homogenous populations of United Arab Emirates nationals. Asthma, wheeze, dyspnoea and nocturnal cough were more prevalent in coastal humid Dubai, compared to dry inland Al-Ain. However, there was no statistically significant difference in the prevalence of eczema and hay fever between coastal and inland areas in the United Arab Emirates. An environmental survey carried out in Dubai and Al-Ain to study the effect of air pollution among asthmatic children showed that overall air quality in both Dubai and in Al-Ain is good, except during adverse weather conditions, strong winds and dust storms, in summer time, where the level of Respirable Particulates (PM10) is occasionally high in Dubai. However, a previous study of seasonal trends in hospital admissions for asthmatic children in Dubai showed that the highest numbers of admissions for asthmatic children occurred between the months of October and February. These are the coldest months of the year in the United Arab Emirates. Therefore air pollution from dust storms was not the cause of the high prevalence of asthma in Dubai. Although the prevalence of asthma and wheezing was lower in the United Arab Emirates than in some developed countries, it was still higher than other chronic diseases. This study demonstrated that symptoms suggestive of asthma are quite common and constitute a major health problem in the United Arab Emirates. High rates of consanguineous marriage, a buoyant economy, rapid industrialization, development of the agricultural sector, an increase in the domestication of animals and dairy farms, combined with an emphasis on 'greening' the environment, may have resulted in an increase of the prevalence of asthma. World-wide trends have been in this direction. Therefore, a concentrated effort should be made to implement therapeutic and non-therapeutic programmes for the management of asthma by parents, teachers and physicians.

Background A significant proportion of children are exposed to environmental tobacco smoke (ETS) throughout the world. This is mainly because of exposure to parental smoking. It is unknown to what extent the negative effects of ETS on respiratory symptoms track from childhood into adulthood. Methods TESAOD (Tucson Epidemiologic Study of Airway Obstructive Disease) is a large population-based prospective study that was initiated in 1972. Participants were followed prospectively with questionnaires and pulmonary function tests (PFTs) completed about every two years in 12 follow-up surveys up to 1996. Skin prick tests and blood samples for IgE measurements were collected at surveys 1, 6, and 11. We identified subjects who entered the study as children (<15 years old) and were followed to adulthood (>18 years) during the study follow-up. Based on questionnaire data, active asthma, wheeze, cough, and chronic cough (cough for three consecutive months) were coded as never (never reported in childhood or adulthood), incident (never reported in childhood, but ≥ one positive report in adulthood), remittent (≥ one positive report in childhood, but not in adulthood), and persistent (≥ one positive report both in childhood and adulthood). PFTs measurements included forced expiratory volume in 1 second, forced vital capacity, and forced expiratory flow at 25-75%. Parent information on smoking status was collected simultaneously at child visits. ETS exposure status was assessed as “ever” or “never” between birth and 15 years. Results Information on parental ETS exposure in childhood and outcomes in adulthood was available for 444 non-Hispanic white participants (51.4% male) with mean age at initial survey of 7.7 years. Total mean follow-up time was 19.0 years (8.8 years in adulthood). Between birth and 15 years, 53.4% of children were exposed to ETS. After adjusting for sex, age at enrollment, years of follow-up, and personal smoking status (assessed at age 15 and above), combined parental ETS exposure in childhood was significantly associated with persistent wheeze (RR(adj) 1.9, p=0.026), persistent cough (RR(adj) 5.9, p<0.001), and persistent (RR(adj) 3.7, p=0.030) and incident chronic cough (RR(adj) 2.3, p=0.040). Paternal ETS exposure in childhood was associated with persistent wheeze (RR(adj) 2.3, p=0.002), persistent cough (RR(adj) 3.9, p<0.001), persistent (RR(adj) 4.8, p=0.004) and incident chronic cough (RR(adj) 2.2, p=0.031), and persistent asthma (RR(adj) 2.3, p=0.016). Maternal ETS exposure was associated with persistent (RR(adj) 1.9, p=0.029) and incident cough (RR(adj) 2.5, p=0.006). Maternal ETS exposure was associated with an increased percent predicted FVC in adulthood (coefficient, 3.75; p=0.019). No other effects on lung function were seen. There were no effects of ETS exposure on total serum IgE or allergic sensitization. ETS exposure was associated with respiratory symptoms in adulthood among both never and current smokers. Conclusions ETS exposure in childhood has long term health effects on lung function and respiratory symptoms. These effects do not appear to be IgE-mediated. ETS exposure, especially paternal ETS exposure, seems to influence the persistence of respiratory symptoms from childhood to adulthood and to affect women more than men. These effects are independent of personal smoking and also seen in never smokers. Both smoking mothers and fathers should be targeted when attempting to reduce ETS exposure among children.

Summary: Allergic diseases have exponentially increased during the last decades. The complexity of its aetiology is due to multifaceted interactions between genetic and environmental factors on the development of the immune system. While advances of technology have identified allergy susceptibility genes, functional assays are needed to better understand the underlying mechanisms. Epidemiological studies have consistently shown that rural/farm environments are protective for the development of allergic diseases, including asthma and atopic sensitization. Importantly, prenatal and early life exposures have been shown to confer the strongest protection effects. The mechanisms of how farming modulates the immune system are still not disentangled in detail but include regulation of innate receptors and Regulatory T cells. In the herewith presented thesis, the following main findings were achieved in the context of genetic and immunological influences on development of allergic disease in two different birth cohort studies: First, 200 neonates were assessed for genetic influence of polymorphisms on neonatal immune responses and development of allergic diseases in childhood. The present study suggested a role for polymorphisms in the Th2-pathway, particularly for STAT6 rs324011, on immune regulation at an early stage of immune maturation, namely significantly lower Treg-associated gene expression and Th1-polarization. Polymorphisms in the Th1-pathway, namely the transcription factors TBX21 and HLX1, were shown to be relevant in shaping early immune responses and mainly Th2 cytokines at birth. Th1 and Th2 genotype-related immune responses at birth were partially associated with development of allergic diseases and/or protection during early life. These children are currently followed until the age of 6 years to further investigate allergic and respiratory disease during age-related immune maturation. Secondly, almost 150 children were investigated at the age of 6 years to assess the role of regulatory T cells in relation to farm exposures and clinical outcomes of allergic diseases. Our data indicated an inverse association of farm exposures and the prevalence of asthma during childhood. Children exposed to hay, stable and farm milk had a lower prevalence of asthma. Regarding underlying immune mechanisms, we have detected that children with contact to hay have increased levels of Treg cells and that farm milk intake earlier during childhood can still be partially reflected on Treg cells levels at age 6 years. Assessing Treg functional mechanisms, changes in cytokine secretion were observed depending on the farming and asthmatic status of the children, however confirmation in a larger number of children is required In summary the present work indicated that Th1 and Th2 polymorphisms were associated with modulated immune responses already at birth and influenced allergic disease development during the first three years of life. Furthermore, farm exposures were associated with a lower prevalence of asthma and associated with modulation of regulatory T cell frequency in German children at age 6 years.

Most analyses of International Study of Asthma and Allergies in Childhood (ISAAC) data in developing countries have suggested an increase over time in 12-month prevalence of rhinitis and eczema symptoms amongst adolescents. The objective of this study is to measure the sociodemographic, dietary and environmental risk factors of allergic rhinitis and atopic eczema symptoms amongst adolescents of the Cape Town centre of the ISAAC Phase Three study.

碩士
國立成功大學
環境醫學研究所
88
Previous studies have suggested an increasing prevalence of allergic diseases in developing countries, and the similar trend has been observed in Taiwan. Allergy is known as a multi-factorial disease, including genetic and environmental factors. Among those risk factors such as family history and environmental allergens, the effect of maternal dietary manipulation and the feeding regimen during infancy to the childhood allergy is still unclear. Several studies have indicated that a fetus can be sensitized in utero, thus precautions should be taken as early as possible. In the prevention of allergic disease, environmental control is proved to be effective, but the dietary control during pregnancy and infancy is yet to be confirmed. The objective of the study is to evaluate the effect of maternal diet during pregnancy, maternal environmental allergen exposure, feeding regimen during infancy, and other relative factors on the development of allergy. A retrospective study was conducted. The outpatients from the Division of Pediatric Allergy & Immunology were included as case group. The control group was randomly selected from general population aged from 3 to 6 years old in Tainan city of southern Taiwan. All subjects were investigated by a structured questionnaire through telephone interviews. Information on family history, maternal diet during pregnancy and lactation, feeding regimen during infancy and allergic status were collected. Data were analyzed by Chi-square and multiple logistic regression. The results showed that there is no association between maternal dietary manipulation during pregnancy and the subsequent development of childhood allergic diseases. The use of hypoallergenic formula can effectively reduce the risk to the development of asthma (OR=2.42, 95%CI: 1.00~5.92), this effect is much more significant in high risk children (OR=3.79, 95%CI: 1.39~ 10.31). No association was found between environmental allergen exposure, indoor air pollution and childhood allergy assessed by questionnaire. Future efforts are essential to complete more subjects and include population outside of clinical setting to finalize associations found in these preliminary analyses.

It is postulated that maternal n-3 (omega 3) long chain polyunsaturated fatty acids (LCPUFA) supplementation may modulate a range of inflammatory and immune pathways involved in the development of allergic diseases in early childhood, potentially leading to a reduction of allergic diseases in children. Thus the focus of this thesis was to determine whether maternal n-3 LCPUFA supplementation during pregnancy or lactation could prevent allergies in children. Two nested follow-up studies from two randomised controlled trials (RCTs) were performed, as well as a Cochrane systematic review to address this question. Of the two nested follow-up studies, one was a prenatal n-3 LCPUFA supplementation and the other a postnatal n-3 LCPUFA supplementation study. Parental reports of allergy outcomes were evaluated in children between birth to three years of age and birth to seven years of age in these studies. The Cochrane systematic review and meta-analysis was used to determine overall effects of maternal n-3 LCPUFA supplementation on allergy outcomes of the children involved. All relevant RCTs to date and the data from my two follow-up studies were included in the systematic review. Eight trials involving 3366 women and their 3175 children were included and in these trials, women were supplemented with n-3 LCPUFA during pregnancy (five trials), lactation (two trials) or both pregnancy and lactation (one trial). All trials randomly allocated women to either a n-3 LCPUFA supplement or a control group. The risk of bias varied across the eight included trials in this review with only two trials with a low risk of selection, performance and attrition bias. Overall, there is limited evidence to support maternal n-3 LCPUFA supplementation during pregnancy and/or lactation for reducing allergic disease in children. Few differences in childhood allergic disease were seen between women who were supplemented with n-3 LCPUFA and those who were not. N-3 LCPUFA supplementation showed a clear reduction in the primary outcome of any allergy (medically diagnosed IgE mediated) in children aged 12 to 36 months (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.44 to 0.98; two RCTs; 823 children), but not beyond 36 months (RR 0.86, 95% CI 0.61 to 1.20; one RCT, 706 children). For any allergy (medically diagnosed IgE mediated and/or parental report), no clear differences were seen in children either at 12 to 36 months (RR 0.89, 95% CI 0.71 to 1.11; two RCTs, 823 children) or beyond 36 months of age (RR 0.96, 95% CI 0.84 to 1.09; three RCTs, 1765 children). For the secondary outcomes of specific allergies there were no clear differences for food allergies at 12 to 36 months and beyond 36 months, but a clear reduction was seen for children in their first 12 months with n-3 LCPUFA (both for medically diagnosed IgE mediated and medically diagnosed IgE mediated and/or parental report). There was a clear reduction in medically diagnosed IgE mediated eczema with n-3 LCPUFA for children 12 to 36 months of age, but not at any other time point for both medically diagnosed IgE mediated and medically diagnosed IgE mediated and/or parental report. No clear differences for allergic rhinitis or asthma/wheeze were seen at any time point for both medically diagnosed IgE mediated, and medically diagnosed IgE mediated and/or parental report. There was a clear reduction in children's sensitisation to egg and sensitisation to at least one allergen between 12 to 36 months of age when mothers were supplemented with n-3 LCPUFA. In terms of safety for the mother and child, n-3 LCPUFA supplementation during pregnancy did not show increased risk of postpartum haemorrhage or early childhood infections. The data obtained in one of the nested follow-up studies in this thesis was used to compare the validity of parental reports of allergy outcome measures against medical diagnosis of allergies. This revealed that parental reports of doctor diagnosed eczema were the most reliable for the diagnosis of eczema in infants, but further studies are needed to validate other allergy outcomes before parent reports of allergy symptoms can be considered as a useful tool to evaluate early childhood allergies in large scale research.
Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2015.

Allergic disease has risen to epidemic proportions during recent years. Evidence shows that prenatal events play a critical role in determining disease susceptibility via environmental influences on placental function and fetal programming. We hypothesised that childhood susceptibility to allergy is increased through significant alterations in placental gene expression involved in regulating immune system development. Furthermore, we hypothesised that products of altered placental genes are indirect measures of altered protein concentrations in the saliva of children with allergies. The aim of this PhD thesis was to identify proteins associated with childhood allergy using two sources of biological tissue: placental tissue and child saliva. The long term objectives were to identify proteins that could be measures of allergic risk in placenta and saliva, develop an assay for detection of allergic risk in newborns and target proteins for interventions that prevent allergy onset. Placental tissue and child saliva samples were examined using a proteomic approach involving quantitative label-free comparative mass spectrometry. Data analysis were performed using Mascot database and MaxLFQ software. Placental tissue and saliva from children with no allergy were compared with children with allergic diseases (placenta, n= 16; saliva, n= 18). Using placental samples, 1223 proteins were identified from MaxLFQ analysis. Nineteen proteins were significantly altered in allergic male placentae and 21 proteins were altered in allergic female placentae, relative to non-allergic children. Of these proteins, five candidate placental proteins associated with allergic diseases were validated with Western blot (n=68), which include chloride intracellular channel protein 3, peroxiredoxin-2, haptoglobin and complement C3. Moreover, 14-3-3 protein had very high expression in allergic children and very low expression in the non-allergic group. Using child saliva samples, 177 proteins were identified from MaxLFQ analysis. Of these proteins, six candidate proteins with significant ratio in specific allergic phenotypes were validated with Western blot (n=62). These proteins include salivary 14-3-3, cornulin, involucrin, transferrin, haptoglobin and desmoglein 1. Based on Western blot findings, 14-3-3, cornulin and involucrin proteins were further validated using the Blitz system that uses crude saliva sample for rapid identification and quantitation as a potential non-invasive bedside allergy biomarker screening (n=126). Blitz results demonstrated that these proteins were significantly altered in allergic children with asthmatic mother (high risk of allergy), as compared to non-allergic children with asthmatic mother. Only salivary cornulin was significantly altered in allergic children as compared to non-allergic children regardless of maternal asthma status. Findings revealed that in both placental and saliva samples, 14-3-3 proteins were significantly altered in female allergic children as compared with female non-allergic children. Interestingly, altered expression of some proteins varies in a sex-specific manner, such as observed in haptoglobin and involucrin, and in relation to presence or absence of maternal asthma. In conclusion, our findings indicate that protein expression can be altered in-utero in children who subsequently develop an allergy and altered expression of these proteins is detectable in saliva in early life.
Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 2018

Research Doctorate - Immunology/Microbiology
Asthma is a chronic inflammatory disease of the airways that is characterised by activation of CD4+ T-helper 2 type (Th) cells and eosinophils. The cause of this aberrant Th2 response is unknown but lack of early life infection is thought to play a significant role. The timing of infection and the type of pathogen may be critical to programming the immune response to a protective Th1, or destructive Th2, phenotype. The immune responses to infection with Salmonella typhimurium and Mycobacterium bovis Bacille Calmette Guerin (BCG) have been identified as targets for reprogramming or preventing the development of asthma. However, the role of these infections in contributing to a Th2-Th1switch or suppression of this response remains limited. In this investigation ovalbumin (OVA) T-cell receptor (TCR) transgenic (Tg) mice in combination with these bacterial strains expressing OVA have been used to specifically track the affects of each infection as well as OVA exposure on the T-cell response and the development of allergic airways disease (AAD) in the mouse model. BCG infection as an adult and a neonate prior to OVA challenge induced significant reductions in eosinophils in broncho-alveolar lavage fluid (BALF) and lung tissue compared to sham-infected mice that received OVA challenge. However, high levels of both Th1 (interferon gamma (IFN-γ)) and Th2 (interleukin (IL)-4, IL-5, IL-13) cytokines from supernatants of cultured peri-bronchial lymph node (PBLN) cells and splenocytes were found in all groups examined. Further studies tracking the development of the immune system after BCG infection at birth without OVA exposure revealed significant decreases in lung tissue eosinophils and decreased immunoglobulin (Ig) G1, IgG2a and IgE levels from serum compared to sham-infected controls. This coincided with decreased numbers of CD4+ and CD8+ T-cells in the spleens and PBLN cells. Levels of cytokines in splenocytes and PBLN cell cultures failed to show significant trends toward either a polarised Th1 or Th2, leaving a mixed Th1/Th2 phenotype. Infection with S.typhimurium lowered eosinophil levels in BALF, and mucous secreting cell (MSC) and eosinophil number in lung tissue after challenge with 23 OVA, compared to sham-infected mice challenged with OVA. In mice infected as neonates and adults prior to OVA challenge increased levels of IFN-γ from splenocyte culture supernatants were found, compared to sham-infected OVA challenged controls. Decreased levels of IL-5 from splenocyte culture supernatants was found in neonates but not adult mice infected with S.typhimurium prior to OVA challenged compared to sham-infected OVA challenged controls. High levels of both Th1 and Th2 cytokines were present in splenocyte and PBLN culture supernatants from all groups tested, indicating a mixed Th1/Th2 phenotype rather than a profound switch to Th1 immune response. Further studies showed that infection with S.typhimurium at birth without OVA exposure causes changes to the development of the neonatal immune system resulting in decreased eosinophil numbers in BALF and lung tissue, decreased levels of serum IgG1 and IgG2a, and a shift from Th2 to a mixed Th1/Th2 cytokine profile. These changes were found in samples examined up to 9-weeks post infection. This investigation demonstrates that infection with BCG or S.typhimurium can alter the immune system resulting in attenuation of various immunological and patho-physiological features of asthma. Infection with BCG or S.typhimurium as a neonate appears to produce the most pronounced modification in the subsequent immune responses to OVA. These findings provide important insights into possible modified vaccination regimes at birth and during childhood, which may have the potential to prevent the development of asthma and allergic inflammatory disorders in adulthood.

碩士
中山醫學大學
醫學研究所
103
Background: Sensitisation to allergen has long been known to relate to childhood allergic disease. In general, food allergens are associated with atopic dermatitis and inhalant allergens are associated with allergic rhinitis and/or asthma. Several studies revealed that polysensitised individuals have more severe atopic disease, whereas individuals with cosensitized to food and inhalant allergen were under-researched. Objective: To realize the relationship between sensitization to food allergen and childhood allergic rhinitis and asthma. Design: This was a prospective case-controlled study. Methods: We included 138 participants with sensitized to allergen as assessed by serum-specific IgE. 87 of 138 participants had allergic rhinitis and 51 participants with both allergic rhinitis and asthma. All participants underwent a physical examination, measurement serum total IgE values and requested to complete the Pediatric Rhinoconjunctivitis Quality of Life Questionnaires (PRQLQ). Besides, nasal peak expiratory flow rate (nPEFR) was performed by allergic rhinitis participants, lung function test and asthma control test (ACT) were performed by both asthma and allergic rhinitis participants. Results: 48 of 87 allergic rhinitis participants with sensitized to food and inhalant allergens (AR food group), 39 of 87 allergic rhinitis participants with sensitized to inhalant allergen alone (AR inhalant group). AR food group significantly lower nPEFR values and higher total IgE values (p<0.05) compared with the other group. 24 of 51 both asthma and allergic rhinitis participants with sensitized to food and inhalant allergens (asthma and AR food group), 27 of 51 both asthma and allergic rhinitis participants with sensitized to inhalant allergen alone (asthma and AR inhalant group). Asthma and AR food group significantly higher total IgE values (p<0.05) compared with the other group and it was higher than the AR food group. Asthma and AR food group also had higher lung function test values and asthma control test (ACT) scores than the other group. Conclusion: This study evidences that children with sensitized to both food and inhalant allergens have more severe clinical symptoms and abnormal laboratory findings. Sensitisation to food allergen was more related to pediatric allergic rhinitis. We may need larger, longer and extended study to assess the conclusion.

Σύμφωνα με τα ευρήματα τεσσάρων καταγραφών που έγιναν στην Πάτρα κατά την περίοδο 1978-2003, ο επιπολασμός του πρόσφατου (διαγνωσμένου στα 2 τελευταία χρόνια) και του οποτεδήποτε διαγνωσμένου κατά τη διάρκεια της ζωής συριγμού/άσθματος παιδιών σχολικής ηλικίας έχει αυξηθεί, αν και με επιβραδυνόμενο ρυθμό. Ανάλογη αύξηση παρατηρήθηκε και στον επιπολασμό της ρινοεπιπεφυκίτιδας και του εκζέματος όπως καταγράφηκε σε τρεις αποτυπώσεις στο διάστημα 1991-2003. Σκοπός: Διερευνήθηκε ο επιπολασμός του συριγμού/άσθματος, της ρινοεπιπεφυκίτιδας και του εκζέματος στο ίδιο αστικό περιβάλλον το 2008. Μέθοδος: Χρησιμοποιώντας πανομοιότυπη μεθοδολογία με τις προηγούμενες συγχρονικές αποτυπώσεις, μοιράσθηκε γραπτό ερωτηματολόγιο που απευθυνόταν στους γονείς παιδιών Τρίτης και Τετάρτης τάξης Δημοτικού Σχολείου (8-9 ετών) το 2008 και υπολογίσθηκε ο πρόσφατος και ο οποτεδήποτε διαγνωσμένος κατά τη διάρκεια της ζωής επιπολασμός των τριών νοσημάτων. Τα ευρήματα συγκρίθηκαν με εκείνα των προηγούμενων καταγραφών (1978: N=3003, 1991: N=2417, 1998: N=3076 και 2003: N=2725). Αποτελέσματα: Ο επιπολασμός του πρόσφατου άσθματος κατά τα έτη 1978, 1991, 1998, 2003 και 2008 (Ν=2688) ήταν 1.5%, 4.6%, 6.0%, 6.9% και 6.9% αντίστοιχα (p τάσης διακύμανσης διορθωμένο ως προς το φύλο <0.001). Οι αντίστοιχες τιμές για συριγμό/άσθμα οποτεδήποτε κατά τη διάρκεια της ζωής στις καταγραφές της περιόδου 1991-2008 ήταν 8.0%, 9.6%, 12.4% και 12.6% (p τάσης διακύμανσης διορθωμένο ως προς το φύλο <0.001). Ανεξαρτήτως φύλου, το διαγνωσμένο άσθμα ελαττώθηκε στα παιδιά με πρόσφατο συριγμό/άσθμα κατά 17% (p <0.001) την περίοδο 2003-2008, όμως δε συνέβη το ίδιο σε εκείνα με αποδραμόντα συριγμό/άσθμα (6.6%, p=0.16). Ο επιπολασμός της ρινοεπιπεφυκίτιδας οποτεδήποτε κατά τη διάρκεια της ζωής τα έτη 1991, 1998, 2003 και 2008 ήταν 2.1%, 3.4%, 4.6% και 5.1% αντίστοιχα (p τάσης διακύμανσης διορθωμένο ως προς το φύλο <0,001). Οι αντίστοιχες τιμές για έκζεμα οποτεδήποτε κατά τη διάρκεια της ζωής ήταν 4.5%, 6.3%, 9.5% και 10.8% (p τάσης διακύμανσης διορθωμένο ως προς το φύλο <0.001). Η αναλογία αγόρια:κορίτσια του πρόσφατου και οποτεδήποτε κατά τη διάρκεια της ζωής συριγμού/άσθματος, ρινοεπιπεφυκίτιδας και εκζέματος αυξήθηκε κατά τη διάρκεια των 30 ετών παρακολούθησης του άσθματος και των 17 ετών παρακολούθησης της αλλεργίας (p τάσης διακύμανσης <0.001). Επίσης παρατηρήθηκε αύξηση της ρινοεπιπεφυκίτιδας και του εκζέματος στα παιδιά με πρόσφατο συριγμό/άσθμα (p τάσης διακύμανσης διορθωμένο ως προς το φύλο <0.001) κατά την περίοδο 1991-2008. Το ποσοστό του συριγμού/άσθματος που μπορεί να αποδοθεί στην αλλεργία (πρόσφατος συριγμός/άσθμα με ρινοεπιπεφυκίτιδα ή/και έκζεμα οποτεδήποτε στη διάρκεια της ζωής) αυξήθηκε περαιτέρω κατά την περίοδο 2003-2008 (p <0.05, p τάσης διακύμανσης <0.001 για την περίοδο 1991-2008). Συμπεράσματα: Ο επιπολασμός του συριγμού και του άσθματος κορυφώθηκε κατά την περίοδο 2003-2008 στην Πάτρα, ενώ η αναλογία αγόρια:κορίτσια αυξήθηκε. Αντίθετα, παρατηρήθηκε συνεχής αύξηση του επιπολασμού των αλλεργικών εκδηλώσεων –ρινοεπιπεφυκίτιδα και έκζεμα– στο διάστημα 1991-2008. Η συχνότητα του συριγμού/άσθματος που μπορεί να αποδοθεί στην αλλεργία, μετά από μια απότομη κλιμάκωση κατά την περίοδο 1991-2003, συνέχισε να αυξάνεται στο διάστημα 2003-2008, αλλά με βραδύτερο ρυθμό, παρά τη διατήρηση του επιπολασμού του συριγμού/άσθματος σταθερού στη διάρκεια αυτής της πενταετίας.
According to four surveys conducted in the city of Patras, Greece, during 1978-2003, the prevalence of current (diagnosed in the last 2 years) and lifetime wheeze/asthma at schoolage has risen, albeit at a decelerating rate. A similar increase occurred in the prevalence of lifetime rhinoconjunctivitis and eczema in the three more recent surveys during 1991-2003. Aim: We examined the prevalence of wheeze/asthma, rhinoconjunctivitis and eczema in the same urban environment in 2008. Methods: Using identical methodology with the previously conducted cross-sectional surveys, a parental written questionnaire was distributed in 2008 to Third and Fourth grade schoolchildren (8-9 year-old) and the current and lifetime sex-specific prevalence of the three diseases was calculated and compared with the findings of the previous surveys (1978: N=3003; 1991: N=2417; 1998: N=3076; and 2003: N=2725). Results: The prevalence rates of current wheeze/asthma in 1978, 1991, 1998, 2003 and 2008 (N=2688) were 1.5%, 4.6%, 6.0%, 6.9% and 6.9%, respectively (sex-adjusted p for trend <0.001). Respective values for lifetime (ever had) wheeze/asthma in the 1991-2008 surveys were 8.0%, 9.6%, 12.4% and 12.6% (sex-adjusted p for trend <0.001). Irrespective of sex, diagnosed asthma declined during 2003-2008 among current wheezers by 17% (p<0.001); however, this was not the case among non-current wheezers (6.7%, p=0.16). The prevalence rates of lifetime rhinoconjunctivitis in 1991, 1998, 2003 and 2008 were 2.1%, 3.4%, 4.6% and 5.1%, respectively (sex-adjusted p for trend <0.001). The respective values for lifetime eczema were 4.5%, 6.3%, 9.5% and 10.8% (sex-adjusted p for trend <0.001). The male:female ratio of current and lifetime wheeze/asthma, rhinoconjunctivitis and eczema increased during the 30-year surveillance period of wheeze/asthma and the 17-year surveillance period for allergic disease (p for trend <0.001). Among current wheezers/asthmatics there was an increase in lifetime rhinoconjunctivitis and lifetime eczema (sex-adjusted p for tend <0.001) over the period 1991-2008. The proportion of wheeze/asthma attributable to allergy (current wheeze/asthma with lifetime rhinoconjunctivitis and/or eczema) increased further during 2003-2008 (p <0.05, p for trend during 1991-2008 <0.001). Conclusions: Childhood wheeze and asthma have reached plateau during the 2003-2008 period in Patras, Greece. The diagnosis of asthma declined among schoolage but not preschool wheezers during the same period, while the male:female ratio increased. On the other hand, there was a continuous increase in the prevalence of allergic manifestations, i.e. rhinoconjunctivitis and eczema, during 1991-2008. The frequency of wheeze/asthma attributable to allergy, after a steep rise in 1991-2003, continued to increase during 2003-2008 –albeit at a decelerating rate–despite the wheeze/asthma plateau which occurred over this 5-year period.

碩士
中國醫藥大學
臨床醫學研究所碩士班
95
Background: Although there is evidence of a positive association between leptin and asthma in adults and children, very little is known about the role of adiponectin and leptin in children with allergic rhinitis (AR). Objectives: The aims of this study were to evaluate serum leptin and adiponectin levels in a group of children with allergic rhinitis before the initiation of therapy and to examine the relationship between leptin and adiponectin and allergic inflammatory markers in AR children. Methods: Body mass index (BMI) and serum leptin and adiponectin levels were measured in 51 (18 female, 33 male; mean age, 7.3 ± 2.08 years) allergic rhinitis children and 47 (15 female, 32 male; mean age, 6.43 ± 2.59 years) healthy children. Total serum IgE and mite-specific IgE and serum eosinophil cationic protein (ECP) levels were also measured. Results: A significant difference was observed in serum leptin and adiponectin levels between AR and healthy children. Median (interquartile range) levels of leptin were 4.60 (2.16-14.82) ng/ml and 3.31 (1.08-7.10) ng/ml, respectively (P = 0.041). Median (interquartile range) levels of adiponectin were 30.36 (21.08-41.85) μg/ml and 39.07 (30.83-45.46) μg/ml, respectively (P = 0.005). Further analysis revealed that these differences in leptin and adiponetin levels appeared to be far more significant in boys than girls. By logistic regression analysis, only leptin and adiponectin were predictive factors for having allergic rhinitis with their odds ratios being 27.06 (95% confidence interval (CI), 1.01-1209) and 13.14 (95% CI, 1.84-115.1), respectively. In the multiple regression analysis, only BMI and AR were significantly associated with leptin levels and BMI, age and AR correlated with adiponectin levels. A significantly negative but weak correlation was observed between log adiponectin and log ECP levels among children with AR (r = -0.29; P = 0.036). There was no relation between adipokines levels and total IgE or mite-specific IgE levels. Conclusion: Patients with allergic rhinitis have a marked increase in serum levels of leptin but a marked decrease in adiponectin levels. These data confirm a relevant role for adipokines in the pathogenesis of allergic rhinitis and suggest important therapeutic implications that need further exploration.

碩士
國立臺灣大學
社會學研究所
103
Childhood allergic diseases are currently a crucial health concern in Taiwan. According to the biomedical model of allergic diseases, these diseases have several risk factors such as heredity, immune conditions, air pollution, and allergen exposure. This study examined the risk governance of childhood allergies. I argue that risk governance is dynamic and includes several actors. This study involved determining how, during different historical periods, experts, the government, and industries in Taiwan have recognized these risk factors; examining the management practices that they have recommended; and investigating the effects of these management practices on parents. In addition, this study examined the knowledge and practices of parents, and describing their gender, generation and structural difference. The data used in this study include information obtained from archives, interviews, and participant observation. The five major findings of this study are described as follows: 1) During the process of governance, knowledge producers, health promoters, and parents participate in preventing and reducing the risks of childhood allergies. Moreover, a non-human actor, the dust mite, plays a critical role in connection with other participants. 2) However, not every risk factor has a corresponding strategy for reducing or preventing risks. Therefore, a gap exists between risk assessment and management. Because of governance policies, environmental risks associated with childhood allergies are restricted to specific “environments” on the micro level, especially the maternal environment and household environment. Many strategies have been created for reducing and preventing these environmental risks. The environmental controlling strategies involve knowledge, strategies, and commodities. 3) The limited environmental risks reinforce the moral responsibility of parents regarding the health of their children. This study follows the concept “intensive parenthood” to describe the role of parenting in preventing and reducing the risks of allergies. Parenting is financially expensive, knowledge-rich, labor-intensive, and emotionally absorbing. Parents usually perform more tasks than experts have suggested. Younger parents collect information from both the expert-guided biomedicine paradigm and situated knowledge provided by lay’s experience. By contrast, older parents rediscover their parenting methods of the past 20 years based on their knowledge of the risks of allergies. Governing the risk of allergies affects both the current practices of parents and interpretation of older parents’ previous parenting methods. 4) Risk governance became increasingly market driven in approximately 2000. Commercial corporations have played a dominant role in governing the risk of allergies. Corporations that are related to preventing and reducing the risks of allergies have shifted from traditional medical industries to industries that manufacture household electronic appliances and cleaning products. When household appliance and cleaning product corporations promote health, these promotions are focused on dust mites and identify product consumption as the primary solution. Taiwanese parents mostly receive health information related to allergies from commercial advertisements rather than from physicians or the government. 5) In 2013, there has been a controversy regarding anti-dust-mite products in Taiwan. The Homemaker United Foundation discovered that anti-dust-mite laundry detergent has the same ingredient as pesticides do, Permethrin. The anti-dust-mite laundry detergent was disputed by parents, industries, NGOs, governmental agencies, chemical experts, dust-mite experts, and physicians. The deficit in Taiwanese regulations was discovered because of public concerns. Chemicals were regulated through numerous regulations and directives before the emergence of the controversy. In conclusion, regarding the multiple risks associated with allergies, the current solutions are often reduced to a specific range of “environmental” controls, which are combined with individualized behavior management. Through household environmental controls, commercial corporations play an essential role in governing the risk of childhood allergies. However, the anti-dust-mite product unintentionally causes new risks on the ecological environment, parenting, and regulatory policies. The intensive parenting on children’s allergies is intertwined with risk management, individual moral responsibility, and healthy lifestyle consumption.

碩士
國立成功大學
環境醫學研究所
97
Literatures have consistently demonstrated associations between exposures to microbial agents in built environments with increasing risk of reporting respiratory diseases, mostly based on measurements of single or selected microbial agents. However, in reality, environmental microbes (e.g. fungi and bacteria and other allergens) are co-existed in any environments at all times. Therefore, study including concurrent assessment of related bioaerosols becomes essential to elucidate their individual or synergistic roles deriving at corresponding health outcomes of concerns. The aims of this study with children aged 6 to 8 is to investigate the individual and combined effects of concurrent exposures to various microbial agents, such as airborne fungal spores, viable fungi, viable bacteria, house dust associated fungal (1→3)-β-D-glucan and bacterial endotoxin, as well as house dust mite allergens, on reporting respiratory or allergic symptoms and diseases. Home characteristics are also analyzed for associations with quantitative microbial levels when appropriate to examine the potential and effective surrogates reflecting microbial exposures for prevention. Results indicate that fungal spores and Der p1 are the significant major microbial agents related to the studied health outcomes. Moreover, the moisture content of building materials (>100%), indoor and outdoor 24-hrs average temperature (<27.13℃ and <27.58℃, respectively), indoor 24-hrs average relative humidity (>63.65%), presence of irritant smells as well as higher human density can be considered as alternative or surrogate environmental indicators without actual maneuver of real sampling and analytical activity for environmental microbes. Preventive measures and priority of remedial actions can therefore be planned accordingly.

碩士
中山醫學院
毒理學研究所
89
Allergic diseases, such as asthma, rhinitis and food allergics, are reaching epidemic proportions in both developed and developing world. The mechanism of allergy is a polarization of T-lymphocyte responses, and enchanced secretion of cytokines involved in regulation of immunoglobulin E, mast cells, basophils and eosinophiles, leading to inflammation and diseases. Although many factors are important to the development of atopy, the environmental and hereditary factors are the strong ones, especially some genes and chromosomal regions were reported been linked to allergy. To determine the polymorphism of interleukin-4（IL-4） and interleukin-13（IL-13） for the development of atopy, asthma, and allergic rhinitis, 514 subjects were identified, to whom 120 were controls, 394 were allergy patients divided to three groups - 90 subjects were asthma cases, 119 subjects were allergic rhinitis and 185 were both asthma and allergic rhinitis. Compared with controls, the serum total IgE and eosinophil counts were increased in allergic patients, but the forced expiratory volumn in the first second（FEV1）, did not decreased. The enzyme-linked immunosorbent assay（ELISA） showed the IL-4 and IL-13 concentration were increased in allergic patients, asthma patients, allergic rhinitis patients and both asthma and allergic rhinitis patients. All the subjects were analyzed polymorphism by polymerase chain reaction（PCR）and restriction fragment length polymorphism（RFLP）. The statistical data showed the polymorphism of IL-4 ligand（C589T、C33T）, IL-4 receptor（R576Q）, IL-13 ligand（Q110R、C1055T）in Taiwanese children did not correlate to allergic disease, asthma , allergic rhinitis and patients who had asthma and allergic rhinitis. The polymorphism of IL-4 receptor（Q551R）was correlate to asthma（p = 0.0113）, and I50V was associated with patients who had asthma and allergic rhinitis（p = 0.0338）. Besides, IL-13 receptor（A1398G）was associated with allergic rhinitis. Combined with polymorphism and biochemical data, total IgE, eosinophil counts and serum IL-4 concentration were increased in allergic patients, asthma, allergic rhinitis and patients who had asthma and allergic rhinitis. The concentration of serum IL-13 were increased in asthma patients, but FEV1 did not decreased in the study.

碩士
中山醫學院
毒理學研究所
88
Atopic disorder（including asthma and allergic rhinitis）is one of the worldwide chronic diseases, has been seen an exponential increase in childhood. The raised prevalence of the atopic disorder may be dued to the strong environmental factor, but hereditary factor is also the important factor. To identify genetic factors for susceptibility to atopy asthma and allergic diseases in childhood, 258 subjects were identified, mainly from Taichung in Taiwan, of whom 41 were unrelated controls, 41 were asthma cases, 31 were allergic rhinitis cases, 92 were both asthma and allergic rhinitis cases, and 53 other allergic disease cases. All the subjects were characterized for lung function（FEV1, forced expiratory volume in the first second）, eosinophil counts , total serum IgE and specific IgE reactivity to common aeroallergens. Asthma or allergic disease was defined as FEV1 ＜85% and/or increased IgE levels. Several candidate genes was investigated, and genome-wide linkage analysis was been initiated. Increased total serum IgE levels, reduced FEV1 and eosinophil counts have been detected in both control and allergic disorders. The regions of interest were amplified from genomic DNA using polymerase chain reaction（PCR）, while restriction enzyme digestion was used for genotyping individuals for the candidate gene polymorphisms. An analysis was then performed on 41 unrelated controls, 41 asthmatic , 31 allergic rhinitis , 92 both asthmatic and allergic rhinitis , and 53 other allergic disease children for each polymorphism. The LT-α, IL-4Rα（R576）and FcεRⅠ（intron 2、exon 7）polymorphisms were not associated with allergic diseases, but the TNF-α and FcεRⅠ（E237G）polymorphisms were associated with allergic rhinitis. The increased total serum IgE levels was found to be linked to each polymorphism. FcεRⅠ（exon 7）positive subjects had a significantly elevated eosinophil counts to both asthma and allergic rhinitis. TNF-α、LT-α、IL-4Rα（R576）及FcεRⅠ（intron 2）positive subjects had a significantly elevated eosinophil counts to both asthma and allergic rhinitis, and other allergic diseases. FcεRⅠ（E237G）positive subjects had a significantly elevated eosinophil counts to asthma, both asthma and allergic rhinitis, and other allergic diseases. Among the six polymorphisms, TNF-α, LT-α, IL-4Rα（R576）and FcεRⅠ（intron 2）demonstrated an association with a significantly reduced FEV1 to both asthma and allergic rhinitis, and other allergic disease. FcεRⅠ（E237G）positive subjects had a significantly reduced FEV1 to both asthma and allergic rhinitis. FcεRⅠ（exon 7）showed no association with reduced FEV1 to atopic disorder. We also examined the relative contributions of four environmental factors to the development of atopic disorders. Smoking and incensing in house were associated with allergic rhinitis, both asthma and allergic rhinitis, and other allergic disease. These results suggest that the TNF-α, LT-α, IL-4Rα（R576）and FcεRⅠ（E237G, intron 2 and exon 7）polymorphisms were not associated with asthma and the other allergic diseases, but TNF-αand FcεRⅠ（E237G）polymorphisms were associated with allergic rhinitis.

The major goal of my study is to understand how the nervous system regulates lung function and disease pathophysiology. Asthma, which is a chronic allergic disease in the lung, has been associated with deregulated airway innervation. The two cell types in the lung that are innervated are airway smooth muscle cells and pulmonary neuroendocrine cells (PNECs). Given that asthma often starts in early childhood, prior research established a neonatal mouse model of allergen exposure to facilitate functional studies of nerves in the development of asthma. Our previous findings showed that allergen exposure to developing, postnatal lungs upregulated levels of neurotrophin 4 (NT4), and caused airway hyperinnervation associated with persistent mucus overproduction. In this work, I describe a novel role of the pulmonary neuroendocrine system in promoting mucus overproduction in early life through deregulated GABAergic signaling. PNECs are the only innervated epithelial cells and express a variety of neuropeptides and bioactive amines. However, how neural innervation affects PNEC secretion and function in disease is not known. Here, I demonstrated that PNECs were the only source of gamma-Aminobutyric acid (GABA) in airways and that GABA hypersecretion from PNECs was required for mucus overproduction following early life allergen exposure. Further, mice lacking NT4 were protected from allergen-induced PNEC hyperinnervation, GABA hypersecretion, and thus mucus overproduction, all which could be rescued with addition of GABA. These findings link PNECs and allergen-induced mucus overproduction through NT4-dependent innervation. Notably, like mice, infant nonhuman primates exhibit PNEC hyperinnervation following early life exposure to ozone and allergens. In addition, I demonstrate that GABA acts in concert with interleukin-13 to induce the proliferation of mucus-producing goblet cells in human airway epithelium cell cultures. Lastly, building upon our previous observations that mast cells contributed to the elevated NT4 levels after allergen exposure, I initiated a research project that investigates the function of a discrete, resident mast cell in: NT4 expression, PNEC innervation, and mucus overproduction. Together, my findings address a novel fundamental role of the neuroendocrine system biology in animal models of asthma. Targeting the nerve–PNEC axis may be a valid treatment strategy for mucus overproduction in asthma.
2020-06-12T00:00:00Z