Some people remain healthier throughout life than others but the underlying reasons are poorly understood. Here we hypothesize this advantage is attributable in part to optimal immune resilience (IR), defined as the capacity to preserve and/or rapidly restore immune functions that promote disease resistance (immunocompetence) and control inflammation in infectious diseases as well as other causes of inflammatory stress. We gauge IR levels with two distinct peripheral blood metrics that quantify the balance between (i) CD8 + and CD4 + T-cell levels and (ii) gene expression signatures tracking longevity-associated immunocompetence and mortality-associated inflammation. Profiles of IR metrics in ~48,500 individuals collectively indicate that some persons resist degradation of IR both during aging and when challenged with varied inflammatory stressors. With this resistance, preservation of optimal IR tracked (i) a lower risk of HIV acquisition, AIDS development, symptomatic influenza infection, and recurrent skin cancer; (ii) survival during COVID-19 and sepsis; and (iii) longevity. IR degradation is potentially reversible by decreasing inflammatory stress. Overall, we show that optimal IR is a trait observed across the age spectrum, more common in females, and aligned with a specific immunocompetence-inflammation balance linked to favorable immunity-dependent health outcomes. IR metrics and mechanisms have utility both as biomarkers for measuring immune health and for improving health outcomes.

Introduction: Understanding factors that associate with neonatal death may lead to strategies or interventions that can aid clinicians and inform families. Objective: The aim of the study was to develop an early prediction model of neonatal death in extremely low gestational age (ELGA, <28 weeks) neonates. Methods: A predictive cohort study of ELGA neonates was derived from the Swedish Neonatal Quality Register between the years 2011 to May 2021. The goal was to use readily available clinical variables, collected within the first hour of birth, to predict in-hospital death. Data were split into a train cohort (80%) to build the model and tested in 20% of randomly selected neonates. Model performance was assessed via area under the receiver operating characteristic curve (AUC) and compared to validated mortality prediction models and an external cohort of neonates. Results: Among 3,752 live-born extremely preterm infants (46% girls), in-hospital mortality was 18% (n = 685). The median gestational age and birth weight were 25.0 weeks (interquartile range [IQR] 24.0, 27.0) and 780 g (IQR 620, 940), respectively. The proposed model consisted of three variables: birth weight (grams), Apgar score at 5 min of age, and gestational age (weeks). The BAG model had an AUC of 76.9% with a 95% confidence interval (CI) (72.6%, 81.3%), while birth weight and gestational age had an AUC of 73.1% (95% CI: 68.4%,77.9%) and 71.3% (66.3%, 76.2%). In the validation cohort, the BAG model had an AUC of 68.9%. Conclusion: The BAG model is a new mortality prediction model in ELGA neonates that was developed using readily available information.

BACKGROUND:Allergic asthma (AA) and allergic rhinoconjunctivitis (ARC) are common comorbid environmentally triggered diseases. We hypothesized that severe AA/ARC reflects a maladaptive or unrestrained response to ubiquitous aeroallergens. METHODS:We performed provocation studies wherein six separate cohorts of persons (total n = 217) with ARC, with or without AA, were challenged once or more with fixed concentrations of seasonal or perennial aeroallergens in an aeroallergen challenge chamber (ACC). RESULTS:Aeroallergen challenges elicited fully or partially restrained vs. unrestrained evoked symptom responsiveness, corresponding to the resilient and adaptive vs. maladaptive AA/ARC phenotypes, respectively. The maladaptive phenotype was evoked more commonly during challenge with a non-endemic versus endemic seasonal aeroallergen. In an AA cohort, symptom responses evoked after house dust mite (HDM) challenges vs. recorded in the natural environment were more accurate and precise predictors of asthma severity and control, lung function (FEV1), and mechanistic correlates of maladaptation. Correlates included elevated levels of peripheral blood CD4+ and CD8+ T-cells, eosinophils, and T-cell activation, as well as gene expression proxies for ineffectual epithelial injury/repair responses. Evoked symptom severity after HDM challenge appeared to be more closely related to levels of CD4+ and CD8+ T-cells than eosinophils, neutrophils, or HDM-specific IgE. CONCLUSIONS:Provocation studies support the concept that resilience, adaptation, and maladaptation to environmental disease triggers calibrate AA/ARC severity. Despite the ubiquity of aeroallergens, in response to these disease triggers in controlled settings (ie, ACC), most atopic persons manifest the resilient or adaptive phenotype. Thus, ARC/AA disease progression may reflect the failure to preserve the resilient or adaptive phenotype. The triangulation of CD8+ T-cell activation, airway epithelial injury/repair processes and maladaptation in mediating AA disease severity needs more investigation.

BACKGROUND:Signifying the 2-compartments/1-disease paradigm, allergic rhinoconjunctivitis (ARC) and asthma (AA) are prevalent, comorbid conditions triggered by environmental factors (eg, house dust mites [HDMs]). However, despite the ubiquity of triggers, progression to severe ARC/AA is infrequent, suggesting either resilience or adaptation.OBJECTIVE:We sought to determine whether ARC/AA severity relates to maladaptive responses to disease triggers.METHODS:Adults with HDM-associated ARC were challenged repetitively with HDMs in an aeroallergen challenge chamber. Mechanistic traits associated with disease severity were identified.RESULTS:HDM challenges evoked maladaptive (persistently higher ARC symptoms), adaptive (progressive symptom reduction), and resilient (resistance to symptom induction) phenotypes. Symptom severity in the natural environment was an imprecise correlate of the phenotypes. Nasal airway traits, defined by low inflammation-effectual epithelial integrity, moderate inflammation-effectual epithelial integrity, and higher inflammation-ineffectual epithelial integrity, were hallmarks of the resilient, adaptive, and maladaptive evoked phenotypes, respectively. Highlighting a crosstalk mechanism, peripheral blood inflammatory tone calibrated these traits: ineffectual epithelial integrity associated with CD8+ T cells, whereas airway inflammation associated with both CD8+ T cells and eosinophils. Hallmark peripheral blood maladaptive traits were increased natural killer and CD8+ T cells, lower CD4+ mucosal-associated invariant T cells, and deficiencies along the TLR-IRF-IFN antiviral pathway. Maladaptive traits tracking HDM-associated ARC also contributed to AA risk and severity models.CONCLUSIONS:Repetitive challenges with HDMs revealed that maladaptation to disease triggers may underpin ARC/AA disease severity. A combinatorial therapeutic approach may involve reversal of loss-of-beneficial-function traits (ineffectual epithelial integrity, TLR-IRF-IFN deficiencies), mitigation of gain-of-adverse-function traits (inflammation), and blocking of a detrimental crosstalk between the peripheral blood and airway compartments.

BACKGROUND:The risk of severe coronavirus disease 2019 (COVID-19) varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). OBJECTIVE:We sought to examine whether deficits in IR that antedate or are induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection independently predict COVID-19 mortality. METHODS:IR levels were quantified with 2 novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n = 522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n = 13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to COVID-19 outcomes. RESULTS:IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection was associated with underrepresentation of IHG-I (21%) versus overrepresentation (77%) of IHG-II or IHG-IV, especially in males versus females (P < .01). Presentation with IHG-I was associated with 88% lower mortality, after controlling for age and sex; reduced risk of hospitalization and respiratory failure; lower plasma IL-6 levels; rapid clearance of nasopharyngeal SARS-CoV-2 burden; and gene expression signatures correlating with survival that signify immunocompetence and controlled inflammation. In non-COVID-19 cohorts, IR-preserving metrics were associated with resistance to progressive influenza or HIV infection, as well as lower 9-year mortality in the Framingham Heart Study, especially in females. CONCLUSIONS:Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19.

Understanding the molecular components of insulin signaling is relevant to effectively manage insulin resistance. We investigated the phenotype of the TMEM127 tumor suppressor gene deficiency in vivo. Whole-body Tmem127 knockout mice have decreased adiposity and maintain insulin sensitivity, low hepatic fat deposition and peripheral glucose clearance after a high-fat diet. Liver-specific and adipose-specific Tmem127 deletion partially overlap global Tmem127 loss: liver Tmem127 promotes hepatic gluconeogenesis and inhibits peripheral glucose uptake, while adipose Tmem127 downregulates adipogenesis and hepatic glucose production. mTORC2 is activated in TMEM127-deficient hepatocytes suggesting that it interacts with TMEM127 to control insulin sensitivity. Murine hepatic Tmem127 expression is increased in insulin-resistant states and is reversed by diet or the insulin sensitizer pioglitazone. Importantly, human liver TMEM127 expression correlates with steatohepatitis and insulin resistance. Our results suggest that besides tumor suppression activities, TMEM127 is a nutrient-sensing component of glucose/lipid homeostasis and may be a target in insulin resistance.

Background: An emerging paradigm holds that resistance to the development of allergic diseases, including allergic rhinoconjunctivitis, relates to an intact epithelial/epidermal barrier during early childhood. Conceivably, the immunologic and genomic footprint of this resistance is preserved in nonatopic, nonallergic adults and is unmasked during exposure to an aeroallergen.Objective: The aim of this study was to obtain direct support of the epithelial/epidermal barrier model for allergic rhinoconjunctivitis.Methods: Twenty-three adults allergic to house dust mites (HDMs) (M+) and 15 nonsensitive, nonallergic (M-) participants completed 3-hour exposures to aerosolized HDM (Dermatophagoides pteronyssinus) powder on 4 consecutive days in an allergen challenge chamber. We analyzed: (1) peripheral blood leukocyte levels and immune responses; and (2) RNA sequencing-derived expression profiles of nasal cells, before and after HDM exposure.Results: On HDM challenge: (1) onlyM+ persons developed allergic rhinoconjunctivitis symptoms; and (2) peripheral blood leukocyte levels/responses and gene expression patterns in nasal cells were largely concordant between M+ and M- participants; gross differences in these parameters were not observed at baseline (pre-exposure). Two key differences were observed. First, peripheral blood CD4(+) and CD8(+) T-cell activation levels initially decreased in M- participants versus increased in M+ participants. Second, in M-compared with M+ participants, genes that promoted epidermal/epithelial barrier function (eg, filament- aggregating protein [filaggrin]) versus inflammation (eg, chemokines) and innate immunity (interferon) were upregulated versus muted, respectively.Conclusion: An imprint of resistance to HDM challenge in nonatopic, nonallergic adults was muted T-cell activation in the peripheral blood and inflammatory response in the nasal compartment, coupled with upregulation of genes that promote epidermal/epithelial cell barrier function.

The proceedings of a National Institutes of Health workshop and a meeting of an Advisory Committee of the US Food and Drug Administration,1U.S. Food and Drug Administration Center for Biologics Evaluation and Research: Allergenic Products Advisory Committee, May 12, 2011. Available at: http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/BloodVaccinesandOtherBiologics/AllergenicProductsAdvisoryCommittee/UCM258587.pdf. Accessed May 28, 2014.Google Scholar, 2Togias A. Asthma, Allergy, and Inflammation Branch, Division of Allergy, Immunology and Transplantation, NIAID/NIHEnvironmental exposure units: clinical trial design for validation. National Institute for Allergy and Infectious Diseases/National Institutes of Health, Bethesda2010: 1-12Google Scholar as well as related commentaries,3Bernstein J.A. Correlation between a pollen challenge chamber and a natural allergen exposure study design for eliciting ocular and nasal symptoms: early evidence supporting a paradigm shift in drug investigation?.J Allergy Clin Immunol. 2012; 130: 128-129Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 4Devillier P. Le Gall M. Horak F. The allergen challenge chamber: a valuable tool for optimizing the clinical development of pollen immunotherapy.Allergy. 2011; 66: 163-169Crossref PubMed Scopus (48) Google Scholar highlight the utility of an allergen challenge chamber (ACC) for conducting clinical trials for allergic rhinoconjunctivitis (AR). Mitigation of factors that might confound the design, analysis, and interpretation of these trials requires a systematic comparison of symptoms present in the natural setting versus those elicited after exposure to aeroallergens in an ACC. In prior studies we conducted out-of-season challenges with 3 separate pollens in patients with seasonal allergy.5Jacobs R.L. Harper N. He W. Andrews C.P. Rather C.G. Ramirez D.A. et al.Responses to ragweed pollen in a pollen challenge chamber versus seasonal exposure identify allergic rhinoconjunctivitis endotypes.J Allergy Clin Immunol. 2012; 130: 122-127.e8Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 6Jacobs R.L. Harper N. He W. Andrews C.P. Rather C.G. Ramirez D.A. et al.Effect of confounding cofactors on responses to pollens during natural season versus pollen challenge chamber exposure.J Allergy Clin Immunol. 2014; 133 (e1-7): 1340-1346Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Although there was high correlation in symptom scores in the natural pollination seasons and ACC, competing environmental influences (eg, mold) in the natural setting blunted the responsiveness to these pollens, whereas this confounder was not present in the ACC.5Jacobs R.L. Harper N. He W. Andrews C.P. Rather C.G. Ramirez D.A. et al.Responses to ragweed pollen in a pollen challenge chamber versus seasonal exposure identify allergic rhinoconjunctivitis endotypes.J Allergy Clin Immunol. 2012; 130: 122-127.e8Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 6Jacobs R.L. Harper N. He W. Andrews C.P. Rather C.G. Ramirez D.A. et al.Effect of confounding cofactors on responses to pollens during natural season versus pollen challenge chamber exposure.J Allergy Clin Immunol. 2014; 133 (e1-7): 1340-1346Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar However, most patients with allergy are polysensitized to outdoor (eg, pollens) and indoor (eg, house dust mite [HDM]) aeroallergens. HDM exposure is common, associated with perennial allergy, and a significant risk factor for AR and asthma. Here we compared the symptom dynamics in the natural setting versus the ACC in HDM-sensitive (M+) and nonsensitive (M−) participants meeting the inclusion/exclusion criteria shown in Table E1 in this article's Online Repository at www.jacionline.org. M− subjects lacked both a history of AR and skin prick test (SPT) wheal reactivity (≥5 mm) to 17 allergens, including HDM (see Table E2 in this article's Online Repository at www.jacionline.org). The study comprised 4 study phases: a 4-day run-in phase followed by 2 ACC exposure phases (ACC-I and ACC-II) with an intervening 38-day observation phase (Fig 1, A). This design allowed for evaluation of the reproducibility of symptom responses and factors that could potentially confound clinical trials in the ACC, including mediators of nocebo effects,7Bingel U. Avoiding nocebo effects to optimize treatment outcome.JAMA. 2014; 312: 693-694Crossref PubMed Scopus (141) Google Scholar as discussed in the Methods section in this article's Online Repository at www.jacionline.org. The study was conducted in the early fall, when only weed pollens were detected in San Antonio, Texas (Fig 1, A and B).6Jacobs R.L. Harper N. He W. Andrews C.P. Rather C.G. Ramirez D.A. et al.Effect of confounding cofactors on responses to pollens during natural season versus pollen challenge chamber exposure.J Allergy Clin Immunol. 2014; 133 (e1-7): 1340-1346Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar To mitigate this confounding factor, we selected M+ participants with negative SPT responses for weed pollens (see Table E2). All participants were allergy drug free throughout the study (see Table E3 in this article's Online Repository at www.jacionline.org). Each ACC phase comprised exposure for 3 hours on 4 consecutive days to a purified mite body powder of Dermatophagoides pteronyssinus (Fig 1, A and B, and see the Methods section in this article's Online Repository). The end point we targeted was an increase in instantaneous total symptom scores (iTSSs) of at least 6 units in 50% of participants from baseline levels. To achieve this goal, the ACC was calibrated to deliver 70 to 110 ng/m3 HDM Der p 1 antigen, as measured by means of ELISA (see Table E4 and the Methods section in this article's Online Repository at www.jacionline.org). iTSSs in the ACC and reflective total symptom scores (rTSSs) in the natural setting were recorded by using a 5-point Likert scale (see Table E5 in this article's Online Repository at www.jacionline.org). Of the 40 participants meeting inclusion criteria, 35 (21 M+ and 14 M− participants) completed all 4 study phases, and of these, 13 M+ participants and 1 M− participant had detectable (≥0.35 kU/L) serum specific IgE (ssIgE) to D pteronyssinus. This dichotomy between SPT reactivity but undetectable ssIgE has been reported for many allergens (see the Discussion section in this article's Online Repository at www.jacionline.org).8de Vos G. Skin testing versus serum-specific IgE testing: which is better for diagnosing aeroallergen sensitization and predicting clinical allergy?.Curr Allergy Asthma Rep. 2014; 14: 430Crossref PubMed Scopus (50) Google Scholar There were no differences in the key demographic characteristics between M+ and M− participants (see Table E6 in this article's Online Repository at www.jacionline.org). Five participants withdrew from the study for nonmedical reasons. M− participants had minimal symptoms in the ACC (mean iTSS, <1; Fig 1, B). In contrast, M+ participants experienced a mean increase of 3 units in the iTSS within 30 minutes of HDM challenge, and iTSSs reached a plateau after approximately 120 minutes (Fig 1, B). There was a high degree of concordance in symptom responses in M+ participants in the ACC recorded by using the Likert and visual analog scales (see Fig E1 in this article's Online Repository at www.jacionline.org). Eleven episodes of bronchospasm occurred in 5 M+ participants, a rate consistent with prior findings.9Horak F. Toth J. Marks B. Stubner U.P. Berger U.E. Jager S. et al.Efficacy and safety relative to placebo of an oral formulation of cetirizine and sustained-release pseudoephedrine in the management of nasal congestion.Allergy. 1998; 53: 849-856Crossref PubMed Scopus (43) Google Scholar These participants exhibited slightly higher total symptom scores (TSSs; see Fig E2 in this article's Online Repository at www.jacionline.org), had greater than 15% improvement in FEV1.0 after treatment with nebulized albuterol, and returned to the ACC without additional exacerbations (see the Discussion section in this article's Online Repository). These findings suggest that M+ participants with mild intermittent asthma can be safely evaluated within ACCs. The concordance in symptom responses during and between ACC-I and ACC-II was high (Fig 1, C, and see Table E7 in this article's Online Repository at www.jacionline.org). In contrast, the correlations between rTSSs recorded in the run-in versus observation phases or between rTSSs versus iTSSs were much lower (see Fig E3 in this article's Online Repository at www.jacionline.org). During ACC-I and ACC-II, an increase in iTSSs of 6 or greater from baseline (pre-exposure) was experienced in greater than 55% of participants (Fig 1, D). While less than 10% of participants had iTSSs of 15 or greater at baseline, 67% and 57% of M+ participants achieved iTSSs of 15 or greater in ACC-I and ACC-II, respectively (Fig 1, E). Substantial data indicate that ssIgE levels to allergens might serve as biomarkers for symptom severity.10Ciprandi G. Tosca M.A. Silvestri M. The practical role of serum allergen-specific IgE as potential biomarker for predicting responder to allergen immunotherapy.Expert Rev Clin Immunol. 2014; 10: 321-324Crossref PubMed Scopus (11) Google Scholar Accordingly, TSSs were greater in M+ participants with a detectable ssIgE level for D pteronyssinus in the ACC (Fig 2, A and B). The failure to detect such an association in the natural setting (Fig 2, A and B) might relate to variable HDM levels measured in dust from mattresses in the participants' homes (see Fig E4 and the Methods section in this article's Online Repository at www.jacionline.org). Pollen SPT reactivity (P+) stratified TSSs, with M+P+ participants having higher rTSSs and iTSSs when compared with those of M+P− participants (Fig 2, C). Levels of T-cell activation were greater in M+P+ participants compared with those seen in M+P− participants before and during ACCs (Fig 2, D, and see Fig E5 and the Methods section in this article's Online Repository at www.jacionline.org). Notably, T-cell activation has been associated with symptom responses during allergy.11Majori M. Piccoli M.L. Melej R. Pileggi V. Pesci A. Lymphocyte activation markers in peripheral blood before and after natural exposure to allergen in asthmatic patients.Respiration. 1997; 64: 45-49Crossref PubMed Scopus (7) Google Scholar Thus exposure to pollens in the months preceding the ACC exposures might have rendered M+P+ participants constitutively "primed," serving as a basis for the higher T-cell activation and symptoms in the natural and ACC settings (Fig 2, C and D). In the ACC phases the effects of pollen sensitization and ssIgE status were additive, with M+IgE+P+ participants manifesting maximal responsiveness after HDM exposure (Fig 2, E). The trigger for the constitutive priming could be winter and spring tree pollens because all M+P+ participants were reactive based on SPT reactivity to tree pollens (see Table E2). Moreover, the extended tree pollination season, which terminated a few months before the start of the ACC exposures, is typically associated with intense symptoms.6Jacobs R.L. Harper N. He W. Andrews C.P. Rather C.G. Ramirez D.A. et al.Effect of confounding cofactors on responses to pollens during natural season versus pollen challenge chamber exposure.J Allergy Clin Immunol. 2014; 133 (e1-7): 1340-1346Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar At the 2 transition points from the natural settings to the ACC (run-in → ACC-I and observation phase → ACC-II), there was a decrease in TSSs (Fig 1, Fig 2, A). This decrease was greater in those with more symptoms (ie, higher in M+P+ participants than in M+P− participants [Fig 2, F] and higher in M+IgE+ participants than in M+IgE− participants [data not shown]). This decrease might relate to (1) differences in how TSSs were recorded in the natural versus ACC settings (reflective vs instantaneous scoring, respectively); (2) learned responses secondary to increased emphasis/education by research staff in the ACC on how to accurately record TSSs; and (3) the controlled environment in the ACC (see the Discussion in this article's Online Repository). Inspection of the overall TSS trajectory indicated that after initiation of ACC exposures, there was a downward shift in the TSS (Fig 1, B). The baseline (pre-ACC) iTSS recorded before commencing challenge 1 was higher than the baseline iTSS recorded before challenges 2 and 3, and the baseline iTSS before challenges 4 through 8 were similar (Fig 1, B). Furthermore, the rTSS in the observation phase was lower than the rTSS in the run-in phase (Fig 1, B). This downward shift in baseline iTSS would give the mistaken impression that responsiveness was greater in challenges 2 and 3 and lower thereafter, when in fact the responsiveness in exposures 1 and 4 through 8 was similar (Fig 2, G). These downward shifts in TSSs did not differ by pollen SPT or ssIgE status (data not shown), and we surmise this might relate to a combination of factors: learned responses (secondary to education in the ACC) and partial clinical tolerance akin to what has been observed after repetitive exposure to allergens, including HDM (see the Discussion section in this article's Online Repository).12Woodfolk J.A. High-dose allergen exposure leads to tolerance.Clin Rev Allergy Immunol. 2005; 28: 43-58Crossref PubMed Google Scholar, 13Liu L.Y. Swenson C.A. Kelly E.A. Kita H. Jarjour N.N. Busse W.W. Comparison of the effects of repetitive low-dose and single-dose antigen challenge on airway inflammation.J Allergy Clin Immunol. 2003; 111: 818-825Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar In this study exposure to HDM concentrations used in the ACC was associated with reliable and reproducible elicitation of symptoms. SPT reactivity to pollen, which was associated with increased inflammatory status, and ssIgE levels to HDM were biological markers that correlated with symptom responses in the ACC. These 2 biomarkers stratified M+ participants as higher versus lower responders in the ACC, whereas this stratification is obscured in the natural settings. Therefore we suggest that out-of-pollination season challenges with HDM in the ACC might help mitigate the confounding of factors present in the natural setting: variable or low exposure to HDM, lack of association of ssIgE levels with rTSSs, and effects of competing environmental influences in a primed polysensitized subject. We also suggest that the other factors that could potentially confound clinical trials in an ACC (and natural setting) are nocebo7Bingel U. Avoiding nocebo effects to optimize treatment outcome.JAMA. 2014; 312: 693-694Crossref PubMed Scopus (141) Google Scholar and placebo14Enck P. Bingel U. Schedlowski M. Rief W. The placebo response in medicine: minimize, maximize or personalize?.Nat Rev Drug Discov. 2013; 12: 191-204Crossref PubMed Scopus (476) Google Scholar effects (expectations, learning process, and participant-physician communication). Confounding could occur by (1) misattribution of positive therapy effects to decrease symptom scores related to more precise symptom scoring (because of learned behavior) and/or partial clinical tolerance (because of repetitive exposure) and (2) imbalance in the proportion of high versus low responders in the treatment versus placebo arms. An example that highlights the potential for this imbalance is the observation that the effectiveness of anti-IgE therapy for asthma differed by the overall sensitization status of the trial participants.15Busse W.W. Morgan W.J. Gergen P.J. Mitchell H.E. Gern J.E. Liu A.H. et al.Randomized trial of omalizumab (anti-IgE) for asthma in inner-city children.N Engl J Med. 2011; 364: 1005-1015Crossref PubMed Scopus (732) Google Scholar Therapies might be more effective in patients with greater responsiveness to allergen exposure, a trait that can be readily identified in an ACC. Thus we surmise that mindfulness of the abovementioned confounders and use of an ACC might together facilitate detection of differences in the effects of placebo versus therapy in clinical trials, especially in exploratory studies with novel therapeutic agents when both the participant numbers and therapy effect sizes might be modest. Download .docx (.23 MB) Help with docx files Online Repository Data Download .pdf (.39 MB) Help with pdf files Fig E1 Download .pdf (.16 MB) Help with pdf files Fig E2 Download .pdf (.4 MB) Help with pdf files Fig E3 Download .pdf (.37 MB) Help with pdf files Fig E4 Download .pdf (.68 MB) Help with pdf files Fig E5

BACKGROUND:Modifiers of symptom severity in patients with allergic rhinoconjunctivitis (AR) are imprecisely characterized. The hygiene hypothesis implicates childhood microbial exposure as a protective factor. Cockroach sensitization (C+) might be a proxy for microbial exposure. OBJECTIVE:We sought to determine whether C+ assayed by means of skin prick tests influenced AR symptom severity in controlled and natural settings. METHODS:Total symptom scores (TSSs) were recorded by 21 participants with house dust mite allergy (M+) in the natural setting and during repeated exposures of 3 hours per day to house dust mite allergen in an allergen challenge chamber (ACC). In M+ participants the peripheral blood and nasal cells were assayed for T-cell activation and transcriptomic profiles (by using RNA sequencing), respectively. Participants allergic to mountain cedar (n = 21), oak (n = 34), and ragweed (n = 23) recorded TSSs during separate out-of-season exposures to these pollens (any pollen sensitization [P+]) in the ACC; a subset recorded TSSs in the pollination seasons. RESULTS:The hierarchy of TSSs (highest to lowest) among M+ participants tracked the following skin prick test sensitization statuses: M+P+C- > M+P+C+ > M+P-C- > M+P-C+. In nasal cells and peripheral blood the immune/inflammatory responses were rapidly resolved in M+P+C+ compared with M+P+C- participants. Among those allergic to pollen, C+ was associated with a lower TSS during pollen challenges and the pollination season. After aggregated analysis of all 4 ACC studies, C+ status was associated with a 2.8-fold greater likelihood of a lower TSS compared with C- status (odds ratio, 2.78; 95% CI, 1.18-6.67; P = .02). CONCLUSIONS:C+ status is associated with mitigation of AR symptom severity in adults with AR.

RationaleThe relationship between factors that influence symptomatology following exposure to a perennial allergen such as house dust mite in the environment versus ACC is unknown.Methods23 mite-sensitive participants underwent 4 consecutive 3 hour exposures in an ACC to milled, purified mite body preparation of D. pteronyssinus. The outcome was the maximum Total Symptom Score (maxTSS) recorded in the ACC and average TSS recorded for 4 days preceding and the morning of the ACC exposures (run-in period). Predictors were age, gender, ethnicity, skin test size for D. pteronyssinus, number of positive skin test out of 18 aeroallergens tested, specific IgE to Der p1 (sIgE), and %peripheral eosinophils.ResultsAverage run-in TSS, TSS prior to entry into the ACC and maxTSS were 13.9, 9.2 and 18.2, respectively. Run-in TSS explained 40% of the variability in maxTSS in the ACC. Male gender, skin test size for D. pteronyssinus, number of positive skin tests, and sIgE respectively explained 16%, 22%, 21%, and 22% of the variability in maxTSS in the ACC. Only sIgE predicted the degree of change in TSS in the ACC (r2=0.19). Male gender and %eosinophils respectively explained 15% and 24% of the variability in the run-in TSS.ConclusionsCo-factors in the environment unrelated to dust mite lead to high run-in TSS values, accounting for their modest capacity in predicting TSS specific to dust mite exposure in the ACC. Accordingly, baseline predictors of TSS during the run-in and ACC were only partly overlapping. Thus, the ACC has high value for evaluating dust mite-specific therapies. RationaleThe relationship between factors that influence symptomatology following exposure to a perennial allergen such as house dust mite in the environment versus ACC is unknown. The relationship between factors that influence symptomatology following exposure to a perennial allergen such as house dust mite in the environment versus ACC is unknown. Methods23 mite-sensitive participants underwent 4 consecutive 3 hour exposures in an ACC to milled, purified mite body preparation of D. pteronyssinus. The outcome was the maximum Total Symptom Score (maxTSS) recorded in the ACC and average TSS recorded for 4 days preceding and the morning of the ACC exposures (run-in period). Predictors were age, gender, ethnicity, skin test size for D. pteronyssinus, number of positive skin test out of 18 aeroallergens tested, specific IgE to Der p1 (sIgE), and %peripheral eosinophils. 23 mite-sensitive participants underwent 4 consecutive 3 hour exposures in an ACC to milled, purified mite body preparation of D. pteronyssinus. The outcome was the maximum Total Symptom Score (maxTSS) recorded in the ACC and average TSS recorded for 4 days preceding and the morning of the ACC exposures (run-in period). Predictors were age, gender, ethnicity, skin test size for D. pteronyssinus, number of positive skin test out of 18 aeroallergens tested, specific IgE to Der p1 (sIgE), and %peripheral eosinophils. ResultsAverage run-in TSS, TSS prior to entry into the ACC and maxTSS were 13.9, 9.2 and 18.2, respectively. Run-in TSS explained 40% of the variability in maxTSS in the ACC. Male gender, skin test size for D. pteronyssinus, number of positive skin tests, and sIgE respectively explained 16%, 22%, 21%, and 22% of the variability in maxTSS in the ACC. Only sIgE predicted the degree of change in TSS in the ACC (r2=0.19). Male gender and %eosinophils respectively explained 15% and 24% of the variability in the run-in TSS. Average run-in TSS, TSS prior to entry into the ACC and maxTSS were 13.9, 9.2 and 18.2, respectively. Run-in TSS explained 40% of the variability in maxTSS in the ACC. Male gender, skin test size for D. pteronyssinus, number of positive skin tests, and sIgE respectively explained 16%, 22%, 21%, and 22% of the variability in maxTSS in the ACC. Only sIgE predicted the degree of change in TSS in the ACC (r2=0.19). Male gender and %eosinophils respectively explained 15% and 24% of the variability in the run-in TSS. ConclusionsCo-factors in the environment unrelated to dust mite lead to high run-in TSS values, accounting for their modest capacity in predicting TSS specific to dust mite exposure in the ACC. Accordingly, baseline predictors of TSS during the run-in and ACC were only partly overlapping. Thus, the ACC has high value for evaluating dust mite-specific therapies. Co-factors in the environment unrelated to dust mite lead to high run-in TSS values, accounting for their modest capacity in predicting TSS specific to dust mite exposure in the ACC. Accordingly, baseline predictors of TSS during the run-in and ACC were only partly overlapping. Thus, the ACC has high value for evaluating dust mite-specific therapies.

While inter-subject differences in the responsiveness to seasonal allergens in an ACC have been demonstrated much less is known about heterogeneity in responses to perennial allergens such as house dust mite. Twenty-three dust mite sensitive and 15 normal controls were enrolled to undergo 3 hour chamber exposures on 4 consecutive days to a milled, purified mite body preparation of Dermatophagoides pteronyssinus. Total symptom scores (TSS) were monitored at baseline and 30 minute intervals. Complete blood cell counts (CBC) were measured immediately prior to and immediately after the exposures on the first and fourth day. 65% of the atopics develop TSS ≥ 15 (out of 28) while the majority of the non-atopics had TSS ≤ 4. The increases in lymphocyte, monocyte and eosinophil cell counts were concordant between atopics and non-atopics, but eosinophilia was greater in the atopics compared with non-atopics. Hierarchical clustering of TSS identified five clinical endophenotypes in the atopics: 4 differed primarily with respect to severity of TSS, with one group remaining non-responsive; the fifth endophenotype was characterized by a progressive decrease in TSS with each ACC exposure and a distinct CBC signature. While atopics exhibit wide heterogeneity in severity of symptom responses following dust mite exposure in an ACC, non-atopics are non-responsive. Despite this, non-atopics and atopics share a partly concordant leukocyte response. Identifying the basis for non-responsiveness despite leukocyte responses following exposure to dust mites in an ACC could potentially uncover the basis for resistance to dust mite allergy.

Background: The severity of allergic rhinoconjunctivitis (AR) symptomatology elicited after exposure to pollen in the absence versus the presence of confounding cofactors, such as in a pollen challenge chamber (PCC) and the natural pollinating season, respectively, might differ.Objective: We sought to determine the correlation of AR severity in the natural season versus out-of-season PCC exposures.Methods: Twenty-four Virginia live oak (VLO)-positive, 14 VLO-negative, 16 mountain cedar (MC) 2 positive, 8 MCnegative, and 26 ragweed-positive participants recorded AR symptoms (total symptom score [TSS]) during the VLO, MC, and ragweed pollinating seasons and during 2 consecutive PCC exposures of 3 hours each to these pollens separately.Results: The TSSs recorded before the natural season were higher than the pre-PCC values. This prepriming was greater among VLO 1 than MC 1 participants, and it blunted further increases in TSSs during the VLO natural season. Nonatopic participants were nonreactive in the PCC. There was wide variation in the level of AR symptomatology after exposure to VLO, MC, or ragweed pollen in the PCC. Prepriming formed the basis for higher AR responses observed in the natural season than in the PCC, resulting in the identification of distinct PCC/natural season endophenotypes and a partial correlation between the TSSs recorded in the natural season versus those recorded in the PCC (r = 5 0.34, 0.54, and 0.65 for VLO+, MC+, and ragweed-positive participants, respectively).Conclusions: Prepriming in the natural pollinating season might obscure the true correlation between AR severity in the natural season versus the PCC. By mitigating confounding cofactors, PCC exposures have utility for evaluation of novel AR therapeutics.

RationaleThe effect of exposure to Mt. Cedar pollen in a pollen challenge chamber (PCC) on white blood cell (WBC) counts and cytokines is unknown.MethodsTwenty-two Mt. Cedar positive subjects (MCPS) and 11 Mt. Cedar negative subjects (MCNS) were challenged for Mt. Cedar in a PCC for 3 hours per day for 2 days. With exposure, total symptom scores (TSS) were calculated. Blood pre-challenge and following the second challenge was analyzed.ResultsIn MCPS, there was an increase in neutrophils, lymphocytes, monocytes, and eosinophils with exposure (P = 0.004, 1.50x10-11, 3.59x10-11, 1.04x10‑7). In MCNS, lymphocytes and eosinophils increased upon exposure (P = 2.05x10-6, 0.012). Comparing MCPS to MCNS, the changes in MCPS for both monocytes and eosinophils were significantly larger (P = 0.048, 0.022). After exposure,13 out of the 38 cytokines analyzed (IFNa2, BAC1, MCP4, I.309, CTACK, IFNg, IL10, IL-12p70, IL-1b, IL-2, IL-4, IL-5, IL-7) had significant increases in MCPS while only 3 (IL-10, Eotaxin-2, TRAIL) had significant decreases. In MCPS, the fold change of eosinophils, Eotaxin, MDC, and TRAIL after exposure were significantly associated with TSS (r2 = 0.29, 0.34, 0.39, 0.34). Although none of the cytokines had a significant change in MCNS, 32 had a concordant direction of change with MCPS after pollen exposure.ConclusionsChanges in both cell counts and cytokine levels characteristic of a Th2 response were observed in MCPS. MCNS had minimal symptoms, but also experienced concordant changes in cell counts and cytokine levels, although at lower levels than MCPS. RationaleThe effect of exposure to Mt. Cedar pollen in a pollen challenge chamber (PCC) on white blood cell (WBC) counts and cytokines is unknown. The effect of exposure to Mt. Cedar pollen in a pollen challenge chamber (PCC) on white blood cell (WBC) counts and cytokines is unknown. MethodsTwenty-two Mt. Cedar positive subjects (MCPS) and 11 Mt. Cedar negative subjects (MCNS) were challenged for Mt. Cedar in a PCC for 3 hours per day for 2 days. With exposure, total symptom scores (TSS) were calculated. Blood pre-challenge and following the second challenge was analyzed. Twenty-two Mt. Cedar positive subjects (MCPS) and 11 Mt. Cedar negative subjects (MCNS) were challenged for Mt. Cedar in a PCC for 3 hours per day for 2 days. With exposure, total symptom scores (TSS) were calculated. Blood pre-challenge and following the second challenge was analyzed. ResultsIn MCPS, there was an increase in neutrophils, lymphocytes, monocytes, and eosinophils with exposure (P = 0.004, 1.50x10-11, 3.59x10-11, 1.04x10‑7). In MCNS, lymphocytes and eosinophils increased upon exposure (P = 2.05x10-6, 0.012). Comparing MCPS to MCNS, the changes in MCPS for both monocytes and eosinophils were significantly larger (P = 0.048, 0.022). After exposure,13 out of the 38 cytokines analyzed (IFNa2, BAC1, MCP4, I.309, CTACK, IFNg, IL10, IL-12p70, IL-1b, IL-2, IL-4, IL-5, IL-7) had significant increases in MCPS while only 3 (IL-10, Eotaxin-2, TRAIL) had significant decreases. In MCPS, the fold change of eosinophils, Eotaxin, MDC, and TRAIL after exposure were significantly associated with TSS (r2 = 0.29, 0.34, 0.39, 0.34). Although none of the cytokines had a significant change in MCNS, 32 had a concordant direction of change with MCPS after pollen exposure. In MCPS, there was an increase in neutrophils, lymphocytes, monocytes, and eosinophils with exposure (P = 0.004, 1.50x10-11, 3.59x10-11, 1.04x10‑7). In MCNS, lymphocytes and eosinophils increased upon exposure (P = 2.05x10-6, 0.012). Comparing MCPS to MCNS, the changes in MCPS for both monocytes and eosinophils were significantly larger (P = 0.048, 0.022). After exposure,13 out of the 38 cytokines analyzed (IFNa2, BAC1, MCP4, I.309, CTACK, IFNg, IL10, IL-12p70, IL-1b, IL-2, IL-4, IL-5, IL-7) had significant increases in MCPS while only 3 (IL-10, Eotaxin-2, TRAIL) had significant decreases. In MCPS, the fold change of eosinophils, Eotaxin, MDC, and TRAIL after exposure were significantly associated with TSS (r2 = 0.29, 0.34, 0.39, 0.34). Although none of the cytokines had a significant change in MCNS, 32 had a concordant direction of change with MCPS after pollen exposure. ConclusionsChanges in both cell counts and cytokine levels characteristic of a Th2 response were observed in MCPS. MCNS had minimal symptoms, but also experienced concordant changes in cell counts and cytokine levels, although at lower levels than MCPS. Changes in both cell counts and cytokine levels characteristic of a Th2 response were observed in MCPS. MCNS had minimal symptoms, but also experienced concordant changes in cell counts and cytokine levels, although at lower levels than MCPS.

RationaleThe level of concordance between allergic symptoms induced on exposure to pollen in a pollen challenge chamber (PCC) versus the natural season has not been well studied.MethodsSeventeen Mt. Cedar-positive participants and 7 Mt. Cedar-negative participants were challenged to Mt. Cedar pollen in a PCC for 3 hours per day for 2 days as well as recorded symptoms for 30 days during the natural Mt. Cedar season. A similar study was conducted using Virginia Live Oak (VLO) pollen for 24 VLO-positive and 14 VLO-negative participants in the PCC for 3 hours per day for 2 days and recorded symptoms for 51 days during the nature VLO season.ResultsThe correlation between the maximum total symptom scores (maxTSSs) recorded in the natural season and PCC was very high (overall r2 for Mt. Cedar and VLO were 0.67 and 0.61, respectively). 87.5% and 12.5% of the Mt. Cedar-positive participants (87.5%) had concordant vs. discordant maxTSSs in the natural season and PCC. A similar results was found for the VLO study with the corresponding percentages being 89.5% and 11.5%, respectively, although there was a trend of having higher maxTSS in the chamber when compared to maxTSS in the PCC (P=0.114).ConclusionsOur findings suggest individuals react similarly to either Mt. Cedar or VLO pollen in a PCC as they do in the natural season and highlight the utility of the PCC as a model to explore mechanisms underpinning allergic rhinoconjunctivitis as well as for evaluating efficacy of therapeutic agents. RationaleThe level of concordance between allergic symptoms induced on exposure to pollen in a pollen challenge chamber (PCC) versus the natural season has not been well studied. The level of concordance between allergic symptoms induced on exposure to pollen in a pollen challenge chamber (PCC) versus the natural season has not been well studied. MethodsSeventeen Mt. Cedar-positive participants and 7 Mt. Cedar-negative participants were challenged to Mt. Cedar pollen in a PCC for 3 hours per day for 2 days as well as recorded symptoms for 30 days during the natural Mt. Cedar season. A similar study was conducted using Virginia Live Oak (VLO) pollen for 24 VLO-positive and 14 VLO-negative participants in the PCC for 3 hours per day for 2 days and recorded symptoms for 51 days during the nature VLO season. Seventeen Mt. Cedar-positive participants and 7 Mt. Cedar-negative participants were challenged to Mt. Cedar pollen in a PCC for 3 hours per day for 2 days as well as recorded symptoms for 30 days during the natural Mt. Cedar season. A similar study was conducted using Virginia Live Oak (VLO) pollen for 24 VLO-positive and 14 VLO-negative participants in the PCC for 3 hours per day for 2 days and recorded symptoms for 51 days during the nature VLO season. ResultsThe correlation between the maximum total symptom scores (maxTSSs) recorded in the natural season and PCC was very high (overall r2 for Mt. Cedar and VLO were 0.67 and 0.61, respectively). 87.5% and 12.5% of the Mt. Cedar-positive participants (87.5%) had concordant vs. discordant maxTSSs in the natural season and PCC. A similar results was found for the VLO study with the corresponding percentages being 89.5% and 11.5%, respectively, although there was a trend of having higher maxTSS in the chamber when compared to maxTSS in the PCC (P=0.114). The correlation between the maximum total symptom scores (maxTSSs) recorded in the natural season and PCC was very high (overall r2 for Mt. Cedar and VLO were 0.67 and 0.61, respectively). 87.5% and 12.5% of the Mt. Cedar-positive participants (87.5%) had concordant vs. discordant maxTSSs in the natural season and PCC. A similar results was found for the VLO study with the corresponding percentages being 89.5% and 11.5%, respectively, although there was a trend of having higher maxTSS in the chamber when compared to maxTSS in the PCC (P=0.114). ConclusionsOur findings suggest individuals react similarly to either Mt. Cedar or VLO pollen in a PCC as they do in the natural season and highlight the utility of the PCC as a model to explore mechanisms underpinning allergic rhinoconjunctivitis as well as for evaluating efficacy of therapeutic agents. Our findings suggest individuals react similarly to either Mt. Cedar or VLO pollen in a PCC as they do in the natural season and highlight the utility of the PCC as a model to explore mechanisms underpinning allergic rhinoconjunctivitis as well as for evaluating efficacy of therapeutic agents.

Background Up to 90% HIV-1 positive intravenous drug users (IDUs) are co-infected with HCV. Although best recognized for its function as a major co-receptor for cell entry of HIV, CC chemokine receptor 5 (CCR5) has also been implicated in the pathogenesis of HCV infection. Here, we investigated whether CCR5 haplotypes influence HIV-1 and HCV seropositivity among 373 Caucasian IDUs from Estonia. Methods Of these IDUs, 56% and 44% were HIV and HCV seropositive, respectively, and 47% were coinfected. 500 blood donors seronegative for HIV and HCV were also evaluated. CCR5 haplotypes (HHA to HHG*2) were derived after genotyping nine CCR2–CCR5 polymorphisms. The association between CCR5 haplotypes with HIV and/or HCV seropositivity was determined using logistic regression analysis. Co-variates included in the models were length of intravenous drug use, HBV serostatus and copy number of CCL3L1, the gene encoding the most potent HIV-suppressive chemokine and ligand for CCR5. Results Compared to IDUs seronegative for both HCV and HIV (HCV−/HIV-), IDUs who were HCV+/HIV- and HCV+/HIV+were 92% and 82%, respectively, less likely to possess the CCR5-HHG*1 haplotype, after controlling for co-variates (Padjusted = 1.89×10−4 and 0.003, respectively). This association was mostly due to subjects bearing the CCR5 HHE and HHG*1 haplotype pairs. Approximately 25% and<10% of HCV−/HIV- IDUs and HCV−/HIV- blood donors, respectively, possessed the HHE/HHG*1 genotype. Conclusions Our findings suggest that HHG*1-bearing CCR5 genotypes influence HCV seropositivity in a group of Caucasian IDUs.

RationaleThe pathogenesis of allergic rhinoconjunctivitis has not been well studied.MethodsTwenty-two Mt. Cedar positive subjects (MCPS) and 11 Mt. Cedar negative subjects (MCNS) were challenged for Mt. Cedar in a Pollen Challenge Chamber (PCC) for 3 hours per day for 2 days. Blood samples were taken prior to and immediately following the 2 days of pollen challenge. RNA-seq on whole blood-derived RNA was conducted using Illumina HiSeq-2000. Differential expression (DE) was determined in the following groups: (i) between MPCS participants post- vs. pre-exposure; and (ii) post exposure between MCPS and MCNS. The DE genes (FDR<0.05 and FC>1.5) and the associated fold change were then analyzed Ingenuity Pathway Analysis™ (IPA™) for pathway analysis.ResultsBoth comparisons had the same top five canonical pathways: EIF2 Signaling, Regulation of eIF4 & p70S6K Signaling, Oxidative Phosphorylation, mTOR Signaling, and Mitochondrial Dysfunction. IPA™ also predicted that NFKBIA and IRF4 are up regulated post-exposure in MCPS when compared to both pre-exposure PCPS and post-exposure MCNS, while MYC and MYCN was predicted to be down regulated.ConclusionsOur data suggests that pathways involved in protein synthesis and energy consumption plays a role in allergy rhinoconjunctivitis pathogenesis and that NFKBIA, IRF4, mTOR, MYC, and MYCN may act as important regulators for allergy rhinoconjunctivitis pathogenesis. Notably, IRF4 has been shown to play a critical role in the induction of Th2 responses, and mTOR has been implicated in asthma pathogenesis, validating the utility of RNA-seq-derived whole genome transcriptomics to uncover key pathways underpinning allergic rhinoconjunctivitis in humans. RationaleThe pathogenesis of allergic rhinoconjunctivitis has not been well studied. The pathogenesis of allergic rhinoconjunctivitis has not been well studied. MethodsTwenty-two Mt. Cedar positive subjects (MCPS) and 11 Mt. Cedar negative subjects (MCNS) were challenged for Mt. Cedar in a Pollen Challenge Chamber (PCC) for 3 hours per day for 2 days. Blood samples were taken prior to and immediately following the 2 days of pollen challenge. RNA-seq on whole blood-derived RNA was conducted using Illumina HiSeq-2000. Differential expression (DE) was determined in the following groups: (i) between MPCS participants post- vs. pre-exposure; and (ii) post exposure between MCPS and MCNS. The DE genes (FDR<0.05 and FC>1.5) and the associated fold change were then analyzed Ingenuity Pathway Analysis™ (IPA™) for pathway analysis. Twenty-two Mt. Cedar positive subjects (MCPS) and 11 Mt. Cedar negative subjects (MCNS) were challenged for Mt. Cedar in a Pollen Challenge Chamber (PCC) for 3 hours per day for 2 days. Blood samples were taken prior to and immediately following the 2 days of pollen challenge. RNA-seq on whole blood-derived RNA was conducted using Illumina HiSeq-2000. Differential expression (DE) was determined in the following groups: (i) between MPCS participants post- vs. pre-exposure; and (ii) post exposure between MCPS and MCNS. The DE genes (FDR<0.05 and FC>1.5) and the associated fold change were then analyzed Ingenuity Pathway Analysis™ (IPA™) for pathway analysis. ResultsBoth comparisons had the same top five canonical pathways: EIF2 Signaling, Regulation of eIF4 & p70S6K Signaling, Oxidative Phosphorylation, mTOR Signaling, and Mitochondrial Dysfunction. IPA™ also predicted that NFKBIA and IRF4 are up regulated post-exposure in MCPS when compared to both pre-exposure PCPS and post-exposure MCNS, while MYC and MYCN was predicted to be down regulated. Both comparisons had the same top five canonical pathways: EIF2 Signaling, Regulation of eIF4 & p70S6K Signaling, Oxidative Phosphorylation, mTOR Signaling, and Mitochondrial Dysfunction. IPA™ also predicted that NFKBIA and IRF4 are up regulated post-exposure in MCPS when compared to both pre-exposure PCPS and post-exposure MCNS, while MYC and MYCN was predicted to be down regulated. ConclusionsOur data suggests that pathways involved in protein synthesis and energy consumption plays a role in allergy rhinoconjunctivitis pathogenesis and that NFKBIA, IRF4, mTOR, MYC, and MYCN may act as important regulators for allergy rhinoconjunctivitis pathogenesis. Notably, IRF4 has been shown to play a critical role in the induction of Th2 responses, and mTOR has been implicated in asthma pathogenesis, validating the utility of RNA-seq-derived whole genome transcriptomics to uncover key pathways underpinning allergic rhinoconjunctivitis in humans. Our data suggests that pathways involved in protein synthesis and energy consumption plays a role in allergy rhinoconjunctivitis pathogenesis and that NFKBIA, IRF4, mTOR, MYC, and MYCN may act as important regulators for allergy rhinoconjunctivitis pathogenesis. Notably, IRF4 has been shown to play a critical role in the induction of Th2 responses, and mTOR has been implicated in asthma pathogenesis, validating the utility of RNA-seq-derived whole genome transcriptomics to uncover key pathways underpinning allergic rhinoconjunctivitis in humans.

The relationship between allergic symptoms induced upon exposure to Virginia Live oak (VLO) pollen and co-factors in the natural season is unknown. We sought to determine the role of co-factors in causing heightened allergic rhinitis symptoms during the natural VLO season compared with out-of-season Pollen Challenge Chamber (PCC) exposure. VLO pollen sensitive participants recorded symptoms throughout the VLO pollinating season and during out-of-season challenge to VLO pollen in a PCC. Natural season pollen counts were obtained from the NAB Pollen and Mold Report. Twenty-four sensitive participants completed both phases of the study, and total symptom scores (TSS) were higher in the natural season compared with PCC. All participants were also reactive to multiple pollen, mold spores, mites, and animal dander. Pollen from other plants overlapped with the VLO season. High-level symptoms were present at onset of VLO pollination and sustained for 1 month beyond the VLO pollinating season. Mean TSS at onset of the VLO season and pre-PCC exposure were 12.5 and 1.54, respectively. During the out-of season PCC exposure, no significant pollen was present in the environment, however, exposure to perennial allergens continued. Priming co-factors in the natural season were exposures to other pollen which overlap with the VLO season leading to high TSSs at the onset of and the extension of high symptoms beyond the VLO pollinating season. Potential perennial co-factors remained but did not cause significant baseline symptoms prior to the PCC exposures and, therefore, had little effect on priming during the natural VLO season.