[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.] / S2k-Leitlinie zur fachärztlichen Diagnostik und Therapie von Asthma 2023.

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

Molecular sensitization patterns in animal allergy: Relationship with clinical relevance and pet ownership.

BACKGROUND: In vitro diagnosis using single molecules is increasingly complementing conventional extract-based diagnosis. We explored in routine patients with animal allergy to what extent molecules can explain polysensitization and identify primary sensitizers and how individual IgE patterns correlate with previous pet ownership and clinical relevance. METHODS: Serum samples from 294 children and adults with suspect allergic rhino-conjunctivitis or asthma and a positive skin prick test to cat, dog and/or horse were tested by ImmunoCAP for IgE antibodies against eleven different allergens from cat (Fel d 1,2,4,7), dog (Can f 1,2,3,4,5,6) and horse (Equ c 1). RESULTS: Patients monosensitized to cat (40.8%) or dog (6.1%) showed simple IgE patterns dominated by Fel d 1 (93%) and Can f 5 (67%), respectively. Double-sensitization to cat+dog (25.9%), cat+horse (5.4%) and polysensitization (20.7%) was associated with an increasing prevalence of the cross-reactive lipocalins Fel d 4/Can f 6/Equ c 1 and Fel d 7/Can f 1. While these lipocalins were not reliable markers for genuine sensitization per se, comparison of sIgE levels may give a clue on the primary sensitizer. Sensitizations to dog appeared to result from cross-reactivity with cat in 48%, with half of these sensitizations lacking clinical relevance. Individual sensitization patterns strongly mirrored current or previous pet ownership with the exception of Fel d 1 which regularly caused sensitization also in non-owners. CONCLUSIONS: Allergen components can reasonably illuminate the molecular basis of animal (poly)sensitization in the majority of patients and are helpful in distinguishing between primary sensitization and sometimes less relevant cross-reactivity.

Drug-specific history, skin and in vitro tests can reduce the need for drug provocation tests in betalactam-hypersensitivity.

BACKGROUND: Many patients report questionable drug hypersensitivity reactions (DHR) to betalactam antibiotics. A workup is required for objectivation. Direct drug provocation tests (DPTs) omitting a prior allergy workup are increasingly recommended as the primary diagnostic approach. However, apart from the risk of severe side effects, DPTs often are a scarce resource in overloaded healthcare-systems. We investigated how many cases can be solved by drug-specific history, drug-specific IgE, and skin tests obviating the need for DPT. METHODS: We conducted a chart review in a retrospective cohort of 932 patients in an allergy outpatient centre from 2016 to 2017. Patients had been submitted to drug-specific history and specific IgE-, skin prick-, intradermal- and patch-tests with early and late readings with a series of penicillins and cephalosporins but DPTs were no option. RESULTS: Overall, positive in vitro and/or skin tests were found in 96/932 (10.3%) patients. Drug-specific IgE was detected in 40/932 (4.3%) patients, 61/787 (7.8%) patients had positive skin tests. In vitro tests to Pencillin V showed the highest rate of positivity 24/479 (5.0%) and early readings of ampicillin the highest amongst the skin tests (3/49, 6.1%). Immediate skin tests were more often positive than delayed ones (75:45). The combination of all parameters including drug-specific history solved 346/932 (37.1%) cases while 586/932 (62.9%) remained unresolved. Self-reported DHR could be less often confirmed in females and young children (p < 0.05). CONCLUSIONS: Testing with betalactams applying simple, cheap, and safe skin and blood tests can solve a third of DHR-cases on a high throughput scale.

ImmunoCAP cellulose displays cross-reactive carbohydrate determinant (CCD) epitopes and can cause false-positive test results in patients with high anti-CCD IgE antibody levels.

BACKGROUND: Cross-reactive carbohydrate determinants (CCDs) in plants and insect venoms are a common cause of irrelevant positive test results during in vitro allergy diagnosis. We observed that some CCD-positive sera show nonspecific IgE binding even with CCD-free recombinant allergens when using the Phadia ImmunoCAP platform. OBJECTIVE: We investigated whether cellulose used as an allergen carrier in ImmunoCAP harbors residual N-glycans, causing nonspecific background binding in CCD-positive sera. METHODS: IgE binding to 6 samples of blank ImmunoCAPs coupled to either streptavidin (SA-CAP-1 or 2) or nonallergenic maltose-binding protein (MBP; MBP-CAP-1 to 4) and binding to a panel of 4 recombinant allergens were compared in CCD-positive sera before and after inhibition with a CCD inhibitor (MUXF3-human serum albumin). RESULTS: Of 52 CCD-positive sera (bromelain, 1.01-59.6 kilounits of antigen per liter [kUA/L]) tested on SA-CAP-1, 35 (67%) showed IgE binding of greater than 0.35 kUA/L (0.41-4.22 kUA/L). Among those with anti-CCD IgE levels of greater than 7.0 kUA/L, 90% (26/29) were positive. IgE binding to SA-CAP-1 correlated with IgE binding to bromelain (r = 0.68) and was completely abolished by serum preincubation with the CCD inhibitor (n = 15). Binding scores with SA-CAP-2 and MBP-CAP-1 to MBP-CAP-4 were generally lower but strongly correlated with those of SA-CAP-1 and bromelain. IgE reactivity of 10 CCD-positive sera (14.0-52.5 kUA/L) with the recombinant allergens rPhl p 12, rFel d 1, rAra h 2, and rPru p 3 was positive to at least 1 allergen in 8 of 10 (0.36-1.63 kUA/L) and borderline in 2 of 10 (0.21-0.25 kUA/L). Binding correlated with antibody binding to bromelain (r = 0.61) and to all blank ImmunoCAPs (r > 0.90) and could be completely blocked by the CCD inhibitor. Overall, mean background binding to cellulose CCDs corresponded to 2% to 3% of the reactivity seen with bromelain. CONCLUSIONS: Cellulose used as a solid-phase allergen carrier can contain varying amounts of CCDs sufficient to cause false-positive test results up to 2 kUA/L with nonglycosylated recombinant allergens in patients with high levels of anti-CCD IgE antibodies.

Allergy screening with extract-based skin prick tests demonstrates higher sensitivity over in vitro molecular allergy testing.

BACKGROUND: As extract-based skin testing as well as in vitro tests for major allergens have their own advantages, both procedures are usually performed in routine settings. In times of shortages in medical staff and supplies, we asked ourselves, how many patients would be underdiagnosed, if only one test could be used. METHODS: In a retrospective analysis, we investigated a cohort of 2646 patients seen by a single physician in a large Austrian outpatient allergy clinic in 2018. Only patients with an allergen source-specific history and pairs of extract-based skin prick (SPT) and in vitro molecular allergy tests to major allergens were included. RESULTS: For all tested allergen sources, sensitivity was higher for SPT than for sIgE-based molecular allergy testing. Concerning 1006 birch pollen-allergic patients, 791 (78.6%) had positive results with both tests, while 153 (15.2%) only with the SPT and 62 (6.2%) only with the sIgE to Bet v1. The other allergen sources showed similar results: For house dust mite 816/1120 (72.9%), grass pollen 1077/1416 (76.1%) and cat 433/622 (69.6%) remained test-positive with both procedures, whereas in 276 (24.6%), 224 (15.8%) and 173 (27.8%) times only the SPT and 28 (2.5%), 115 (8.1%) and 16 (2.6%) times only the sIgE to Der p1/2/23, Phl p1/5 and Fel d1 showed a positive result. Each comparison was statistically significant (each p < 0.0001, Chi-squared test). CONCLUSIONS: Screening for allergy with major molecular allergens has lower sensitivity when compared with extract-based skin tests. A combination of both is required for an optimal sensitivity.

[Abdominal spasms, meteorism, diarrhea: fructose intolerance, lactose intolerance or IBS?]. / Bauchschmerzen, Blähbauch, Diarrhoe: Fruktosemalabsorption, Laktoseintoleranz oder Reizdarmsyndrom?

Meteorism, abdominal spasms, diarrhea, casually obstipation, flatulence and nausea are symptoms of fructose malabsorption (FIT) and/or lactose intolerance (LIT), but are also symptoms of irritable bowel syndrome (IBS). Therefore these diseases should be considered primarily in patients with digestive complaints. For diagnosis an H(2)-breath test is used.In 1,935 patients (526 m, 1,409 f) a fructose intolerance test and in 1,739 patients (518 m,1,221 f) a lactose intolerance test was done.FIT is found more frequently than LIT (57 versus 52 % in adults (p < 0,02) and in children 90 versus 62 % (p < 0,001)) and is in polyintolerances most frequently correlated to histamine intolerance (HIT). Headache (ca. 10 %), fatigue (ca. 5 %) and dizziness (ca. 3 %) may occur after the test, irrespective whether the test was positive or negative.In more than 2/3 of patients a diet reduced in fructose or lactose may lead to improvement or remission of these metabolic disorders. IBS, which is often correlated with FIT (183/221 patients = 83 %), can be improved by relevant but also not relevant diets indicating that irritable bowel disease seems to be caused primarily by psychological disorders.

The positive effect of spermidine in older adults suffering from dementia : First results of a 3-month trial.

The worldwide prevalence of dementia is estimated at 35.6 million and will rise to 115 million by 2050. There is therefore an urgent need for well-founded dementia diagnostics and well-researched therapeutic options. Previous studies have highlighted that spermidine has the ability to trigger the important process of dissolving amyloid-beta plaques by autophagy. They also confirmed that nutritional intervention with the natural polyamine spermidine can prevent memory loss in aging model organisms. This multicentric double-blind preliminary study focused on the effect of oral spermidine supplementation on older adults' cognitive performance. Memory tests were carried out on 85 subjects aged between 60 and 96 years in 6 nursing homes in Styria. Blood samples were taken for the determination of spermidine concentration and measurement of metabolic parameters. The results demonstrated a clear correlation between the intake of spermidine and the improvement in cognitive performance in subjects with mild and moderate dementia in the group treated with the higher spermidine dosage. The most substantial improvement in test performance was found in the group of subjects with mild dementia with an increase of 2.23 points (p = 0.026) in the mini mental state examination (MMSE) and 1.99 (p = 0.47) in phonematic fluidity. By comparison, the group which had a lower spermidine intake showed consistent or declining cognitive performance.

Signal recognition particle (SRP) positive myositis in a patient with cryptogenic organizing pneumonia (COP).

We report of a 46-year-old female patient with cryptogen organizing pneumonia preceding the rare SRP positive necrotising myositis without cardiac involvement and no sign of dysphagia. Myositis showed full regression without oral immune suppression but with extracorporeal treatment, performed as a combined therapy of plasmaexchange and immunoadsorption. After 33-month of treatment, anti-SRP antibodies were not detectable any more.

Insect hypersensitivity beyond bee and wasp venom allergy.

The bites of blood-feeding insects regularly induce sensitization to salivary proteins and cause local hypersensitivity reactions in over 90% of the population, representing either an IgE-mediated immediate wheal and flare reaction or a T cell-driven delayed papule. Long-lasting large local reactions and bullous reactions may cause significant discomfort and reduction in quality-of-life. Anaphylaxis is rarely reported though proven for several insects, above all mosquitoes, horse flies, and kissing bugs. Recently, salivary gland proteins have been thoroughly studied in some blood-feeding insect species, and several allergens have been identified. Interestingly, many of them belong to the same protein families as the well-known honeybee and wasp venom allergens (phospholipases, hyaluronidases, antigens 5, serine proteases) though sequence identities are mostly low. There is still insufficient evidence for the proposed cross-reactivity between salivary proteins from blood-feeding insects and Hymenoptera venom allergens.

Spermidine in dementia : Relation to age and memory performance.

Previous studies have highlighted that spermidine has the ability to trigger the important process of dissolving amyloid-beta plaques by autophagy. This manuscript focuses on the correlation of serum spermidine levels between age and between performance in mini-mental state examinations. It will serve as a premise for an ongoing multicentric placebo-controlled study, which focuses on the effect of oral spermidine supplementation on memory performance. Memory tests were carried out on 80 subjects aged 60-96 years old in 6 nursing homes in Styria. Blood samples were taken for the determination of spermidine concentration. The results showed a significant correlation between the spermidine concentration and the mini-mental state examination score (p = 0.025). On the basis of the dependence demonstrated it can be concluded that spermidine might be suitable as a biomarker for the diagnosis of neurocognitive changes (senile dementia or Alzheimer's disease).

[Masterplan 2025 of the Austrian Society of Pneumology (ASP)-the expected burden and management of respiratory diseases in Austria]. / Masterplan 2025 der Österreichischen Gesellschaft für Pneumologie (ÖGP) ­ die erwartete Entwicklung und Versorgung respiratorischer Erkrankungen in Österreich.

Scientific Members of the Austrian Society of Pneumology describe the expected development in respiratory health and provide guidance towards patient-oriented and cost-efficient respiratory care in Austria.Methods: In November 2017, respiratory care providers (physicians, nurses, physiotherapists) together with patient's advocacy groups and experts in health development, collaborated in workshops on: respiratory health and the environment, bronchial asthma and allergy, COPD, pediatric respiratory disease, respiratory infections, sleep disorders, interventional pneumology, thoracic oncology and orphan diseases.Results: Respiratory disease is extremely prevalent and driven by ill-health behavior, i.e. cigarette smoking, over-eating and physical inactivity. For the majority of respiratory diseases increased prevalence, but decreased hospitalizations are expected.The following measures should be implemented to deal with future challenges:1. Screening and case-finding should be implemented for lung cancer and COPD.2. E-health solutions (telemedicine, personal apps) should be used to facilitate patient management.3. Regional differences in respiratory care should be reduced through E­health and harmonization of health insurance benefits across Austria.4. Patient education and awareness, to reduce respiratory health illiteracy should be increased, which is essential for sleep disorders but relevant also for other respiratory diseases.5. Respiratory care should be inter-professional, provided via disease-specific boards beyond lung cancer (for ILDs, sleep, allergy)6. Programs for outpatient's pulmonary rehabilitation can have a major impact on respiratory health.7. Increased understanding of molecular pathways will drive personalized medicine, targeted therapy (for asthma, lung cancer) and subsequently health care costs.

Diagnosis and management of asthma - Statement on the 2015 GINA Guidelines.

This statement was written by a group of pulmonologists and pediatric pulmonologists belonging to the corresponding professional associations ÖGP (Austrian Society for Pulmonology) and ÖGKJ (Austrian Society for pediatric and adolescent medicine) to provide a concise overview of the latest updates in the 2015 GINA Guidelines and to include aspects that are specific to Austria.

The Rare Case of a Probably True IgE-Mediated Allergy to Local Anaesthetics.

The majority of immediate type adverse reactions to local anaesthetics seem to be non-IgE-mediated. We report a case of a 31-year-old woman, who developed conjunctivitis and conjunctival erythema immediately after intrauterine application of a local anaesthetic. Skin prick testing and intradermal testing were done with lidocaine, mepivacaine, and procaine. Intradermal testing showed positive reactions to mepivacaine (1 : 10), undiluted lidocaine, and procaine (1 : 10 and undiluted). Specific IgE could be detected against mepivacaine, but not against latex. Serum tryptase was in the normal range. In order to rule out the exceptional case of a true IgE-mediated reaction, allergy testing with local anaesthetics is still required in the workup of patients.

[Alpha1-antitrypsin deficiency in Austria: analysis of the Austrian Alpha1-international-registry database]. / Alpha1-Antitrypsin-Mangel in Osterreich: Auswertung der österreichischen Datenbank des internationalen Alpha1-Antitrypsin Registers.

OBJECTIVE: Alpha1-antitrypsin deficiency is a rare hereditary disorder. Deficient patients are at a higher risk to develop lung emphysema at an early age. The alpha1-antitrypsin registry was founded on 1996 to get new insights into the pathogenesis of the disease and to develop new therapeutic strategies. In this study the epidemiological and clinical findings of the Austrian alpha1-antitrypsin deficient patients are presented. MATERIAL AND METHODS: A total of 139 patients with severe alpha1-antitrypsin deficiency, identified by phenol- and genotyping, were evaluated retrospectively by their physicians with the help of a questionnaire. RESULTS: Most patients were smokers or ex-smokers (71.9%) who developed symptoms in their fourth decade. The mean duration between the onset of symptoms and the final diagnosis was 6.5 years. About 25% of the evaluated patients were unable to practice their profession because of their illness. CONCLUSION: Alpha1-antitrypsin deficiency is a rare condition with delayed diagnosis. Because of the benefit of an early diagnosis further effort should be put towards early detection.

[Allergic rhinitis and its impact on asthma (ARIA update 2008). The Austrian perspective]. / Die Auswirkungen von allergischer Rhinitis auf Asthma (ARIA-Aktualisierung 2008). Die österreichische Perspektive.

In 1999, during the ARIA (Allergic Rhinitis and its Impact on Asthma) WHO workshop, an evidence-based document was produced using an extensive review of the literature available up to December of the same year. An update of the ARIA guidelines was soon needed and started in 2004. Thereafter, there was the need for an even more global document, which would highlight the interactions between the upper and the lower airways including diagnosis, epidemiology, common risk factors, management and prevention, and comprise the allergy perspective also for developing countries. This goal was achieved with the most recently published ARIA update 2008. The present article is the result of consecutive efforts of the authors of the ARIA update 2008 to accomplish the nationwide comprehensive distribution of information by publication in important national journals, like the WMW.