Mucosal Eosinophil Count Research Articles

Six-Food Elimination Diet and Topical Steroids are Effective for Eosinophilic Esophagitis: A Meta-Regression.

Topical corticosteroids or six-food elimination diet is recommended as initial therapy for eosinophilic esophagitis (EoE). We aimed to summarize published manuscripts that report outcomes of these therapies for EoE. We performed a systematic review in MEDLINE, Web of Science, and Embase of published manuscripts describing topical fluticasone, topical budesonide, and six-food elimination diet as therapies for EoE. We conducted meta-analysis of symptom improvement and the change in peak mucosal eosinophil count, with heterogeneity between studies examined with meta-regression analysis. Systematic review yielded 51 articles that met inclusion criteria. Summary histologic response rates were 68.3% [95% prediction limits (PL) 16.2-96.0%] for fluticasone, 76.8% (95% PL 36.1-95.1%) for budesonide, and 69.0% (95% PL 31.9-91.4%) for six-food elimination diet. Corresponding decreases in eosinophil counts were 37.8 (95% PL 19.0-56.7), 62.5 (95% PL 125.6 to -0.67, and 44.6 (95% PL 26.5-62.7), respectively. Symptom response rates were 82.3% (95% PL 68.1-91.1%), 87.9% (95% PL 42.7-98.6%), and 87.3% (95% PL 64.5-96.3%), respectively. Meta-regression analyses decreased the initially large estimate of residual heterogeneity and suggested differences in histologic response rate associated with study populations' baseline eosinophil count and age. The literature describing topical corticosteroids and six-food elimination diet consists of small studies with diverse methods and population characteristics. Meta-analysis with meta-regression shows initial histologic and symptomatic response rates on the same order of magnitude for topical corticosteroids and six-food elimination diet, but heterogeneity of study designs prevents direct comparison of modalities.

Tu1093 - Improvement of Dysphagia in Patients with Fibrostenotic Eosinophilic Esophagitis Correlates Better with Fall in Intrabolus Pressure than Decrease in Mucosal Eosinophil Count

Tu1093 - Improvement of Dysphagia in Patients with Fibrostenotic Eosinophilic Esophagitis Correlates Better with Fall in Intrabolus Pressure than Decrease in Mucosal Eosinophil Count

Prognostic factors for recurrence after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps.

In this study, we aimed to clarify the prognostic factors affecting the ethmoid condition during a long-term follow-up after endoscopic sinus surgery in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). Thirty-six patients with CRSwNP underwent surgery from December 2008 to February 2012. All surgeries were performed by one surgeon, and all patients were followed up for at least 2 years postoperatively. We investigated the association of postoperative endoscopic findings with clinical parameters, mucosal eosinophil count and mRNA expression of CCL11, IL-5, and IFN-gamma in nasal polyps. Seventeen patients (47.2%) had severe mucosal edema, and the patency of each sinus was not confirmed during the >2-year follow-up. The mucosal eosinophil count and two eosinophil-associated factors, namely the CCL11 and IL-5 mRNA levels, were higher in the severe mucosal edema group than in the control group. The severe mucosal edema group was divided into two subgroups: the steroid-responsive and -resistant groups. Five patients (13.9%) had frank polyp formation because the oral steroids were less effective. The mucosal eosinophil count was significantly different among the four groups, including the control group (p=0.001); however, the CCL11, IL-5, and IFN-gamma mRNA levels were not significantly different. Although the IL-5 mRNA level was not significantly different among the four groups, it tended to increase when the sinus condition worsened. In the severe mucosal edema group, a higher IL-5 mRNA level was associated with earlier severe mucosal edema in the ethmoid cavity. The IL-5 mRNA level is associated with the time of severe edema formation in the ethmoid cavity. This finding permits early intervention on the postoperative course and would prevent polyp recurrence.

Topical Steroid Therapy for the Treatment of Eosinophilic Esophagitis (EoE): A Systematic Review and Meta-Analysis.

OBJECTIVES:Current guidelines recommend topical steroids as first-line treatment for patients with eosinophilic esophagitis (EoE). However, the evidence for this approach has been inconsistent in earlier reports. This meta-analysis aimed to clarify the efficacy of topical steroid treatment in active EoE using updated evidence.METHODS:CENTRAL, MEDLINE and EMBASE databases were searched for randomized controlled trials (RCTs) published up to May 2014 that compared topical steroids with control treatments for active EoE. Study bias was assessed using the Cochrane Collaboration Tool, and outcomes were pooled using random effects models. The primary outcome was the mean change in eosinophil counts. Secondary outcomes were symptom responses and adverse events.RESULTS:In total, seven RCTs (226 patients) were included. Topical steroids were associated with a significant reduction in esophageal mucosal eosinophil counts compared with control therapy although substantial heterogeneity between studies was observed (weighted mean difference (WMD) −27.2, 95% confidence interval (CI) −45.3 to −9.1, I2=56.2%). Subgroup analysis indicated the reduction in eosinophil counts was only present in studies where a proton pump inhibitor (PPI) trial was used to exclude other diagnoses (WMD −46.3, 95% CI −61.3 to −31.4, I2=0.0%). Subdivision of studies on the use of a PPI trial also accounted for the majority of heterogeneity among RCTs. No clear trends in symptom resolution were observed. Eleven out of 127 patients who received topical steroids developed asymptomatic esophageal candidiasis.CONCLUSIONS:These data provide updated high-quality evidence that support current guidelines for first-line EoE treatment with topical steroids after an initial PPI trial to exclude non-EoE pathologies (PROSPERO ID: CRD42014008828).

Effects of benralizumab on airway eosinophils in asthmatic patients with sputum eosinophilia

Many asthmatic patients exhibit sputum eosinophilia associated with exacerbations. Benralizumab targets eosinophils by binding IL-5 receptor α, inducing apoptosis through antibody-dependent cell-mediated cytotoxicity. We sought to evaluate the safety of benralizumab in adults with eosinophilic asthma and its effects on eosinophil counts in airway mucosal/submucosal biopsy specimens, sputum, bone marrow, and peripheral blood. In this multicenter, double-blind, placebo-controlled phase I study, 13 subjects were randomized to single-dose intravenous placebo or 1 mg/kg benralizumab (day 0; cohort 1), and 14 subjects were randomized to 3 monthly subcutaneous doses of placebo or 100 or 200 mg of benralizumab (days 0, 28, and 56; cohort 2). Cohorts 1 and 2 were consecutive. The incidence of adverse events was similar between groups. No serious adverse events related to benralizumab occurred. In cohort 1 intravenous benralizumab produced a median decrease from baseline of 61.9% in airway mucosal eosinophil counts (day 28; placebo: +19.6%; P = .28), as well as an 18.7% decrease (day 21) in sputum and a 100% decrease (day 28) in blood counts. Eosinophils were not detectable in bone marrow of benralizumab-treated subjects (day 28, n = 4). In cohort 2 subcutaneous benralizumab demonstrated a combined (100 + 200 mg) median reduction of 95.8% in airway eosinophil counts (day 84; placebo, 46.7%; P = .06), as well as an 89.9% decrease (day 28) in sputum and a 100% decrease (day 84) in blood counts. Single-dose intravenous and multiple-dose subcutaneous benralizumab reduced eosinophil counts in airway mucosa/submucosa and sputum and suppressed eosinophil counts in bone marrow and peripheral blood. The safety profile supports further development. Additional studies are needed to assess the clinical benefit in asthmatic patients.

Polyp Recurrence Rate in Chronic Rhinosinusitis Phenotypes

Objective: We proposed that chronic rhinosinusitis (CRS) is classified by 4 phenotypes in the previous study. Three phenotypes in the 4 were well classified by nasal polyps and mucosal eosinophil count. In this study we investigated the difference of recurrence rate of nasal polyps after endoscopic sinus surgery between these three phenotypes. Method: This study was a prospective collecting data and retrospective analysis. All patients were followed up for at least 180 days after endoscopic sinus surgery. We defined mucosal eosinophilia as over 80 eosinophils under high-power magnification. Disease-free survival curves were drawn using the Kaplan-Meier method and compared using log-rank test. Results: A total of 264 of the 375 patients were enrolled in the study. The mean follow-up period was 540.4 days. Polyp recurrence was significantly different between the 3 groups ( P = .016). Patients with cluster 4 (eosinophilic CRSwNP) had a higher polyp recurrence rate than cluster 2 (non-eosinophilic CRSwNP; P = .047) and cluster 1 (non-eosinophilic CRSsNP; P = .005). Cluster 1 and cluster 2 had no significant difference ( P = .362). Conclusion: We demonstrated polyp recurrence rate was different between the three phenotypes.

Identification of chronic rhinosinusitis phenotypes using cluster analysis

The pathophysiology of chronic rhinosinusitis (CRS) is not fully understood. In Europe and the United States, major subsets of CRS classification are based on the presence or absence of polyps. Although nasal polyps (NPs) are a critical factor, many other factors also contribute to the pathogenesis of CRS. The aim of this study was to investigate diverse CRS phenotypes using cluster analysis. This was a multicenter study examining clinical data from CRS patients treated at five hospitals. The study design was a retrospective analysis of prospectively collected data. Complete data were available for 425/496 patients. Data were subjected to k-means cluster analysis in an attempt to identify the different phenotypes involved in CRS. CRS was divided into four clusters. Cluster 1 (n = 180) and cluster 2 (n = 129) comprised patients with low peripheral eosinophil and mucosal eosinophil counts. However, polyp scores in cluster 2 were higher than cluster 1. Cluster 3 (n = 50) comprised patients with very high mucosal eosinophil counts but low polyp and symptom scores. Finally, subjects in cluster 4 (n = 66) showed severe polyposis. Polyp score and mucosal eosinophil count were the strongest predictors of clustering by discriminant analysis. The results of this study identified distinct clinical CRS phenotypes. CRS was classified into four phenotypes based on NPs and mucosal eosinophil counts. Cutoff points for these factors were identified by tree analysis. Additional studies are needed to establish clinical significance of the phenotypes.

Eosinophil Counts in Upper Digestive Mucosa of Western European Children: Variations With Age, Organs, Symptoms, Helicobacter pylori Status, and Pathological Findings

The aim of the study was to measure the number of eosinophils per high-power field (eos/HPF) according to age, organs, and clinical symptoms and to compare the results to histological characteristics of the upper digestive tract mucosa in children. A systematic prospective assessment of 284 esophagus, 342 antrum, 453 corpus, and 167 duodenum biopsies was carried out in 316 girls and 366 boys referred for endoscopy (median age 9 months), eos/HPF, and histological analysis. Counts (mean-max SD) were as follows: esophagus 1.73 to 50 eos/HPF (5.35), antrum 3.27 to 40 (4.7), corpus 2.11 to 38 (3.76), and duodenum 4.80 to 46 (7.7). Counts >15 eos/HPF were found in 2.8% esophagi, 3.5% corpora, 4.9% antra, and 10.7% duodena. Duodenal eos/HPF were significantly higher than those of esophageal, corporeal, and antral. Mucosal eos/HPF increased with age in esophagus and antrum. The highest esophageal eos/HPF were significantly associated with recurrent abdominal pain, and with anemia in antrum, corpus, and duodenum. Major and/or minor histological features of eosinophilic esophagitis were seen in 9 of 10 esophagi with 5 to 15 eos/HPF and 7 of 8 esophagi with >15 eos/HPF. Eosinophils per high-power field were significantly correlated with histological antral and corporeal gastric inflammation. Helicobacter pylori-positive children had higher eosinophils per high-power field than H pylori negative ones both in esophagus and in antrum. The present study shows that in a western European country mucosal hypereosinophilia is rare. Mucosal eosinophil counts increase from esophagus to duodenum, and also with age in esophagus and antrum. The highest eos/HPF in the esophagus are associated with recurrent abdominal pain and in the corpus, antrum, and duodenum with anemia. Features of eosinophilic esophagitis are rare but detectable in association with counts as low as 6 eos/HPF.

Mechanical Properties of the Esophagus in Eosinophilic Esophagitis

This study aimed to analyze the mechanical properties of the esophagus in eosinophilic esophagitis (EoE) using the functional luminal imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland). Thirty-three EoE patients (22 male; age range, 23-67 years) and 15 controls (6 male; age range, 21-68 years) were included. Subjects were evaluated during endoscopy with the EndoFLIP probe, comprised of a compliant cylindrical bag (maximal diameter 25 mm) with 16 impedance planimetry segments. Stepwise bag distensions from 2 to 40 mL were conducted and the associated intrabag pressure and intraluminal geometry were analyzed. The EndoFLIP clearly displayed the tubular esophageal geometry and detected esophageal narrowing and localized strictures. Stepwise distension progressively opened the esophageal lumen until a distension plateau was reached such that the narrowest cross-sectional area (CSA) of the esophagus maximized despite further increases in intra-bag pressure. The esophageal distensibility (CSA vs pressure) was reduced in EoE patients (P = .02) with the distension plateau of EoE patients substantially lower than that of controls (median: CSA 267 mm(2) vs 438 mm(2); P < .01). Mucosal eosinophil count, age, sex, and current proton pump inhibitor treatment did not predict this limiting caliber of the esophagus (P ≥ 0.20). Esophageal distensibility, defined by the change in the narrowest measurable CSA within the distal esophagus vs intraluminal pressure was significantly reduced in EoE patients compared with controls. Measuring esophageal distensibility may be an important adjunct to the management of EoE, as it is capable of providing an objective means to measure the outcomes of medical or dilation therapy.

Ethmoid histopathology does not predict olfactory outcomes after endoscopic sinus surgery.

Histological inflammation correlates with the degree of baseline olfactory dysfunction in patients with chronic rhinosinusitis (CRS); however, factors associated with improvement in olfactory status after endoscopic sinus surgery (ESS) remain elusive. Our purpose was to compare histopathological findings in CRS patients with olfactory loss and evaluate whether inflammatory markers can predict long-term olfactory improvement after ESS. Adult (> or = 18 years) patients with CRS were prospectively enrolled after electing ESS due to failed medical management. Mucosal tissue specimens were collected at the time of surgery and underwent pathological review in a blinded fashion. Subjects completed the 40-item Smell Identification Test (SIT) preoperatively and at least 6 months postoperatively. Multivariate logistic regression was used to identify histological factors associated with postoperative improvement in SIT score. The final cohort was comprised of 101 patients with a mean follow-up of 16.7 +/- 6.0 months. Mean mucosal eosinophil count was higher in patients with hyposmia and anosmia (p < 0.001). Patients with preoperative anosmia were more likely to have greater severity of basement membrane (BM) thickening compared with subjects with hyposmia or normosmia (p = 0.021). In patients with olfactory dysfunction, 54.7% reported olfactory improvement of at least 4 points on postoperative SIT scores. After controlling for nasal polyposis, histological variables were not associated with postoperative improvement in olfaction. Patients with severe olfactory dysfunction were more likely to have mucosal eosinophilia and BM thickening on ethmoid histopathological examination compared with normosmic patients. The presence of specific histological inflammatory findings did not, however, predict olfactory improvement after surgery.

Esofagite eosinofílica: uma patologia emergente em pediatría.

Eosinophilic Esophagitis has been increasingly diagnosed and results from a chronic esophagic inflammation with eosinophilic infiltrate. Evaluation of the diagnosed paediatric cases in our centre between 2004 and 2008 and revision of current literature on this subject. Four caucasian boys, aged eight to fifteen years old, were diagnosed with Eosinophilic Esophagitis. They presented with disphagia and food impaction and endoscopic findings included multiple concentric rings (pseudo-trachea pattern) and friable mucosa. All of them had mucosal eosinophil counts higher than 20 eosinophils/high-powered field and were given corticosteroids, either topic or systemic (one case) with therapeutic success. The diagnosis of Eosinophilic Esophagitis must be considered in presence of disphagia, food impaction or gastroesophageal reflux symptoms refractory to treatment. Endoscopic evaluation may be normal and the diagnosis is based on histological findings, making biopsy mandatory whenever clinically suspected. The increasing incidence of the last years associated with the high recurrence rate will lead to future prevalence increased both in child and adulthood.

The effects ofStrongylus vulgarisparasitism on eosinophil distribution and accumulation in equine large intestinal mucosa

Eosinophilic granulocytes have been associated with parasite or immune-mediated diseases, but their functions in other disease processes remain unclear. Cause and timing of eosinophil migration into the equine gastrointestinal mucosa are also unknown. To determine the effects of intestinal parasitism on eosinophils in equine large intestinal mucosa. Large intestinal mucosal samples were collected from horses and ponies (n = 16) from the general veterinary hospital population, ponies (n = 3) raised in a parasite-free environment, ponies experimentally infected with 500 infective Strongylus vulgaris larvae and treated with a proprietary anthelmintic drug (n = 14), and a similar group of ponies (n = 7) that received no anthelmintic treatment. Total eosinophil counts and eosinophil distribution in the mucosa were determined by histological examination. A mixed model analysis was performed and appropriate Bonferroni adjusted P values used for each family of comparisons. P<0.05 was considered significant. There was no difference in large intestinal mucosal eosinophil counts and eosinophil distribution between ponies infected with S. vulgaris and those raised in a parasite-free environment. Experimental infection with S. vulgaris, with or without subsequent anthelmintic treatment, did not change eosinophil counts, and counts were similar to those for horses from the general population. Migration of eosinophils to the equine large intestinal mucosa appears to be independent of exposure to parasites. Large intestinal mucosal eosinophils may have more functions in addition to their role in defence against parasites.

Chronic Rhinosinusitis: Risk Factors for the Recurrence of Chronic Rhinosinusitis Based on 5-Year Follow-Up after Endoscopic Sinus Surgery

Background: Chronic rhinosinusitis (CRS) is one of the most frequent chronic diseases in the US, and little is understood about its pathogenesis. This study was conducted to characterize, retrospectively, the clinical, objective and immunological parameters that accompany recurrence of CRS during long-term follow-up after surgery. Methods: Fifty-six patients with CRS who had undergone endoscopic sinus surgery were followed up for 5 years after the surgery. The CRS parameters chosen were as follows: history of asthma and/or allergic rhinitis, peripheral eosinophilia of at least 520 cells/µl, peripheral eosinophil count, total IgE, presence of polyps, CT score, presence of fungi (positive fungal culture or stain), mucus or mucosal eosinophilia, mucosal eosinophil count, presence of acute infection after surgery, gender and age. Individual correlations and stepwise regression were performed. Results: Patients with a total peripheral eosinophil count of 520/µl or more and those with asthma were likely to experience recurrence of CRS within 5 years after surgery. Furthermore, patients with mucus or mucosal eosinophilia who were diagnosed as having eosinophilic CRS (ECRS) showed a high incidence of recurrence within 5 years. The parameter of mucus or mucosal eosinophilia (diagnosis of ECRS) had a positive predictive value of 85.7%. Conclusions: Surgeons should always examine the inflammatory infiltrate of nasal polyps or the paranasal mucosa, and patients with ECRS require anti-inflammatory medications, such as steroids, for a long time after surgery. Long-term follow-up is also essential.

Eosinophilic Esophagitis: A Prevalent Disease in the United States That Affects All Age Groups

Most reports on eosinophilic esophagitis (EE) are limited to small series from single institutions. This study describes features of EE in a broader population. A national pathology database (Caris Diagnostics, Irving, TX) was used to identify EE cases from a cohort of upper endoscopies. Slides from potential cases were reviewed by pathologists. Study inclusion required a mean of (1) 20 eosinophils or more in 5 high-power fields, or (2) 30 eosinophils in 2-4 high-power fields. Endoscopists provided demographic and clinical information. There were 363 cases identified from 74,162 patients and 26 states. EE had a male predominance (odds ratio, 3.0; 95% confidence interval, 2.4-3.8). Ages ranged from 1 to 98 years, including 42 children and 321 adults. The most common endoscopy indications in adults were dysphagia (70.1%) and gastroesophageal reflux disease (GERD)/heartburn (27.1%). Children most frequently reported GERD/heartburn (38.1%) and abdominal pain/dyspepsia (31.0%). A total of 25.1% of cases had a peak mucosal eosinophil count of 20-59, 29.2% had a peak mucosal eosinophil count of 60-100, and 45.7% had a peak mucosal eosinophil count of more than 100. There was no difference in the peak counts between age groups or sexes, but patients with dysphagia had higher counts (P < .001). The prevalence of EE increased during the study period (P < .001). EE is a national disease found in all age groups, more frequently in males. Dysphagia and GERD symptoms are common indications for endoscopy. The degree of eosinophilic infiltration is high throughout all ages and may be related to patients' symptoms. Our series highlights important elements of this disease, the prevalence and/or recognition of which is increasing.

Intermittent Dysphagia for Solids Associated with a Multiringed Esophagus: Clinical Features and Response to Dilatation

The entity of the multiringed esophagus, generally presenting in adults as intermittent dysphagia for solids, is relatively uncommon and its pathogenesis is unknown. The goal of this study was to describe the demographic, clinical, and endoscopic features of patients presenting with this condition, their response to esophageal dilatation, and the relationship of multiple esophageal rings to eosinophilic esophagitis. Between 1989 and June 2004, 32 patients at this adult hospital fulfilled the following inclusion criteria: (1) intermittent dysphagia for solids, (2) multiple esophageal rings at endoscopy, and (3) esophageal dilatation(s) performed. Response to esophageal dilatation was measured by need for subsequent dilatations. Seventy-five percent of the patients were male. Median age at onset of dysphagia was 21 years and at presentation 36.5 years. All had multiple rings in the proximal or midesophagus on endoscopy and had undergone a total of 73 esophageal dilatations with no esophageal perforations. Median maximal dilator size was 15 mm; however, 16% developed significant esophageal mucosal tears even with 11-mm dilators. Sixty-six percent required repeat dilatation, with the median time interval before recurrence being 8 months. Eosinophilic esophagitis (mucosal eosinophil count > 20/HPF) was present in 50% of this cohort. From this study we conclude that a multiringed esophagus causing intermittent dysphagia occurs predominantly in young males, responds well to dilatation, but repeated dilatations are often necessary. Dilatation can lead to extensive mucosal tears and should be performed with caution. Eosinophilic esophagitis is commonly but not invariably associated with this entity. Frequent relapse of dysphagia highlights the need for effective pharmacotherapy.

Airway inflammation assessed by invasive and noninvasive means in severe asthma: Eosinophilic and noneosinophilic phenotypes

Airway inflammation assessed by bronchial biopsies demonstrates distinct eosinophilic and noneosinophilic phenotypes in severe asthma, but their relationship to other biomarkers of disease (induced sputum and nitric oxide [NO]) is not clear. We sought to compare airway inflammation using noninvasive (induced sputum, exhaled NO), and invasive (bronchial biopsies) methods in moderate and severe asthma and to assess whether induced sputum and exhaled NO would allow the identification of eosinophilic and noneosinophilic phenotypes in severe asthma. We performed a cross-sectional study of 32 subjects with severe asthma and 35 subjects with moderate asthma, from whom we obtained bronchial biopsies, induced sputum, and exhaled NO measurements. Among subjects with severe asthma, we identified eosinophilic and noneosinophilic phenotypes using both bronchial biopsies and sputum cell counts. However, the vast majority of subjects with high sputum eosinophil counts did not have high mucosal eosinophil counts. Exhaled NO was increased in the eosinophilic phenotype as judged from bronchial biopsy findings, but not on the basis of induced sputum. Subjects with high sputum eosinophil counts experienced more asthma exacerbations than the subjects with low sputum eosinophil counts. In contrast, we did not find any differences in the clinical characteristics between eosinophilic and noneosinophilic phenotypes that were identified by bronchial biopsies. The use of sputum cell counts allowed the identification of a subgroup of subjects with severe asthma who were at risk of more frequent asthma exacerbations. Monitoring sputum eosinophil counts in subjects with severe asthma may allow identifying the subjects with the greatest disease activity.

Effect of Six-Food Elimination Diet on Clinical and Histologic Outcomes in Eosinophilic Esophagitis

In children, eosinophilic esophagitis (EE) is predominantly, but not exclusively, a food-hypersensitivity disorder. A crystalline amino acid-based elemental diet (ELED) formula currently remains the most effective nutritional treatment in inducing clinical and histologic remission. However, compliance with an exclusive, poor-tasting liquid formulation is difficult. This retrospective observational study assessed the short-term clinical and histologic responses of 2 cohorts of children with EE evaluated during 2 different time periods: one was treated with the standard 6-food elimination diet (SFED) and the other was treated with ELED. Of the 60 children who met the inclusion criteria and were compliant with the dietary protocol, 35 were treated with a diet excluding cow-milk protein, soy, wheat, egg, peanut, and seafood while allowing all other table foods and 25 were treated exclusively with ELED. Repeat esophageal biopsy specimens were obtained at least 6 weeks later. Twenty-six of 35 (74%) in the SFED group and 22 of 25 (88%) in the ELED group achieved significant improvement of esophageal inflammation (</=10 eosinophils/high-power field). The pretreatment and posttreatment peak eosinophil counts for the SFED were 80.2 +/- 44.0 and 13.6 +/- 23.8 (P < .0001) and 58.8 +/- 31.9 and 3.7 +/- 6.5 (P < .001) for the ELED group, respectively. SFED treatment was associated with clinical and histologic improvement in EE in an observational study. It offers advantages of better acceptance, cost, and compliance than ELED and should be considered as an option in the initial management of children with EE.

Rapid improvement of immunity to Teladorsagia circumcincta is achieved through a reduction in the demand for protein in lactating ewes

Protein supplementation can improve the resistance to parasites of periparturient ewes, as indicated by reduced nematode egg excretion and worm burdens. However, the rate at which this improvement can occur is largely unknown. We investigated the rate of improvement by assessing temporal changes in faecal egg counts after we experimentally reduced nutrient demand. Three groups of nine pregnant ewes each were trickle infected with Teladorsagia circumcincta from day −70 to day 16 (parturition is day 0). Two groups of twin-rearing ewes were fed at 0.8 (L22) or 1.2 (H22) times their assumed metabolizable protein requirements, and a third group was fed the same daily food allowances as L22 ewes, but one of their lambs was removed on day 10 (L21). Ewes were slaughtered on day 21 to assess worm burdens, in vitro larval establishment on abomasal explants, and mucosal inflammatory cells. Faecal egg counts of L22 ewes were higher than H22 ewes throughout lactation. After the removal of one lamb, faecal egg counts of L21 ewes decreased within 5 days to levels similar to H22 ewes. Relative to L22 ewes, L21 and H22 ewes had lower worm burdens, parasite per capita fecundity and in vitro establishment rates of both T. circumcincta and Haemonchus contortus. Mucosal mast cell and eosinophil counts were similar for all ewes, but H22 ewes had higher globule leukocyte counts than L22 and L21 ewes. The data suggest that a reduction in protein demand can rapidly improve periparturient immunity to T. circumcincta. This may be associated with increased parasite expulsion, reduced fecundity and non-parasite specific reduction of in vitro larval establishment.

Is There a Seasonal Variation in the Incidence and Severity of Allergic Eosinophilic Esophagitis?

Introduction: Allergic eosinophilic esophagitis (AEE) is thought to be an allergic reaction characterized by dense eosinophilic inflammation (>15 eosinophils per high power field) of the esophageal epithelium. We examined the seasonal distribution of newly diagnosed AEE patients in order to establish variations with seasons associated with increased atopy. Methods: Retrospective analysis of all newly-diagnosed children with AEE over a five-year period (December 1998 to November 2003) at our institution. Results: A total of 194 children (mean age 8.2 years, median age 8.0 years, age range 0.42 - 20 years) were diagnosed with AEE during the study period. A higher number of patients were newly-diagnosed, and had denser esophageal mucosal eosinophil counts in the spring/fall seasons combined, compared to the summer/winter seasons combined (p= 0.031 and 0.016 respectively). On comparing the seasons individually, significantly fewer patients were newly-diagnosed during winter compared to either spring or fall, but similar to summer. The severity of inflammation was higher in fall compared to winter or summer, but similar to that in spring. Conclusions: The higher number of newly-diagnosed patients and the increased esophageal eosinophilic inflammation during seasons of increased aeroallergen concentrations and atopy (i.e spring/fall), further support an allergic basis to AEE and suggest a role for aeroallergens in the pathogenesis of AEE. Consideration should be given to testing AEE patients for aeroallergens.

Effects of protein supply and reproductive status on local and systemic immune responses to Teladorsagia circumcincta in sheep

The effects of protein supply and reproductive status on circulating antibody responses and local inflammatory cell counts were investigated in parasitized sheep, with local immune responses assessed through a recently refined abomasal cannulation methodology. We hypothesized that if breakdown of immunity has a nutritional basis, then protein scarcity would result in a breakdown of immunity to Teladorsagia circumcincta in both periparturient and non-reproducing (barren) ewes. Twin-bearing and barren, abomasally cannulated ewes were fed at either 0.8 or 1.3 times protein requirements from 3 weeks before until 6 weeks after parturition ( n = 6). All sheep were trickle infected at a rate of 10,000 infective larvae (L 3) per day, for 3 days per week throughout the experiment. Faecal egg counts remained virtually zero in all barren ewes, whilst protein supplementation reduced faecal egg counts in the periparturient ewes during most of the periparturient period. Final worm burdens, taken at 6 weeks into lactation, were lower for the barren ewes than for the lactating ewes, whilst protein supplementation reduced worm burdens in the latter. Protein supply did not affect mucosal mast cell counts, which were consistently higher for the barren ewes than the periparturient ewes, but were temporarily decreased around parturition. Barren ewes and protein supplemented lactating ewes had higher globule leukocyte counts than the unsupplemented lactating ewes. Protein supplementation increased eosinophil counts in the lactating ewes though only during the later part of the lactation period. Plasma IgA anti-L 3 antibody was similar for all ewes, but IgE anti-L 3 antibody was higher for the protein supplemented periparturient ewes compared to the unsupplemented periparturient ewes and all barren ewes. It is likely that the combination of low protein requirements and large body protein reserves did not result in breakdown of immunity to T. circumcincta for the barren ewes. These results suggest that changes in mucosal mast cell and eosinophil counts are not necessarily associated with changes in host resistance to T. circumcincta. However, the data support the view that increased globule leukocyte counts and plasma IgE anti-L 3 antibody may be associated with nutritionally improved expression of immunity in periparturient ewes.