Ann Allergy Asthma Immunol 115 (2015) 523e535
Contents lists available at ScienceDirect
Letters
Increased basophil activation in adult patients with anaphylaxis Anaphylaxis is a severe, life-threatening allergic reaction primarily mediated through IgE antibodies that interact with basophils and mast cells to release vasoactive and proinflammatory mediators.1 Basophils comprise less than 1% of circulating leukocytes in humans; however, in recent years, it has drawn considerable attention because of involvement in various allergic diseases.2 Like mast cells, basophil activation and degranulation induced by allergens lead to a release of various mediators that can generate anaphylaxis.3 Along with release of mediators, activation of human basophils results in the expression of surface proteins and the upregulation of expressed proteins. CD203c and CD63 are surface markers of basophils that are upregulated or expressed on activated basophils.2 Basophil activation tests (BATs) using the activation markers CD203c and CD63 have been widely used to assess basophil activation status and as an important tool for checking IgE-mediated allergic reactions.4 There have been many reports regarding increased basophil activation in anaphylactic patients after allergen exposure,3 but the baseline status of these patients has not yet been studied. In the present study, we evaluated basophil activation status using CD203c and CD63 expressions in adult patients with anaphylaxis for a further understanding of pathogenic mechanisms of adultonset anaphylaxis. A total of 41 patients with various allergic diseases, including asthma and/or rhinitis, chronic urticaria, and anaphylaxis, and 23 healthy controls were recruited from Ajou University Hospital, Suwon, South Korea. Allergic patients were divided into 2 groups according to the diagnosis of adult-onset anaphylaxis to various drugs, including nonsteroidal anti-inflammatory drugs and antibiotics; foods, including wheat and seafood; and diagnostic reagents, such as radiocontrast media: the anaphylaxis (n ¼ 13) and nonanaphylaxis (n ¼ 28) groups. All participants provided written informed consent, and this study was approved by the institutional review board of Ajou Medical Center. Basophil CD203c and CD63 expressions were measured by flow cytometry. Blood samples were collected in the stable state of each patient, at least 2 months after the anaphylactic event in cases of anaphylaxis. Participants did not take any medication or stopped taking medications for at least 1 week before blood sampling. The whole blood was collected in an EDTA tube, and red blood cells were lysed with a red blood cell lysis buffer (0.154 M NH4Cl, 10 mM KHCO3, 0.1 mM EDTA, pH 7.2-7.4). Basophils were incubated with anti-IgE antibody (1 mg/mL) or calcium ionophore (1 mg/mL; Sigma-Aldrich Co, St Louis, Missouri) as Disclosures: Authors have nothing to disclose. Funding Sources: This study was supported by grant H14C2628 from the Korean Health Technology R&D Project funded by the Ministry of Health and Welfare, Republic of Korea.
positive controls or left untreated for 30 minutes. After being washed with a phosphate-buffered saline, the resuspended cells were stained with phycoerythrin-conjugated antihuman CD203c or CD63 (Beckman Coulter, Marseille, France), fluorescein isothiocyanateeconjugated antihuman CD123 (BD Pharmingen, San Jose, California), and allophycocyanin-conjugated antihuman human leukocyte antigen DR (BD Pharmingen), or isotypematched controls on ice in the dark for 30 minutes. After washing once with phosphate-buffered saline, the cells were analyzed on a FACS Canto II flow cytometer (Becton Dickinson, San Jose, California). The Mann-Whitney U test was used to compare CD203c and CD63 expression levels between the groups. Spearman correlation analysis was used for the correlation analysis. P < .05 was considered to indicate statistical significance. All statistical analyses were performed using the SPSS statistical software for Windows, version 22 (SPSS Inc, Chicago, Illinois). Mean (SD) baseline expression levels of CD203c and CD63 were significantly higher in the anaphylaxis group than in the healthy control group (30.28 [23.10] vs 13.76 [14.60], P ¼ .04; 17.67 [20.48] vs 3.31 [3.73], P ¼ .03, respectively; Fig 1) and tended to be higher in the anaphylaxis group than in the nonanaphylaxis group, although statistical significance was not reached. When the positive cutoff value for a positive BAT result was defined as the mean value plus 2 SDs of the CD203c expression levels in the healthy control group, positive BAT rates tended to be higher in the anaphylaxis group than in the nonanaphylaxis group (38.46% vs 17.85%, P ¼ .20; eFig 1), although no differences were noted in CD63 expression levels. No significant differences were found in baseline percent expressions of CD203c and CD63 or those induced by anti-IgE or calcium ionophore according to age, sex, atopic status, and total IgE level. In addition, no significant correlations were found between the expressions of CD203c and CD63 with age and total IgE (data not shown). Increased baseline expressions of CD203c and CD63 in the anaphylaxis group suggest that basophils in anaphylactic patients may be in a primed state and thus have hyperreactive responses to specific allergens. Lie et al5 found that basophils have primed phenotypes in patients with allergic asthma that cause the release of high levels of histamine when exposed to stimuli. The highaffinity IgE receptor (FcεRI) that plays an important role in basophil degranulation has been found to be upregulated on basophils in patients with chronic urticaria with CD203c and CD63 expressions compared with healthy controls.2 An in vitro study found that mast cells expressing enhanced levels of FcεRI are more sensitive to activation when stimulated with IgG anti-FcεRI.6 Therefore, basophils of anaphylactic patients may have increased FcεRI expression in the basal state that enhances its sensitivity toward specific allergens.
http://dx.doi.org/10.1016/j.anai.2015.08.014 1081-1206/Ó 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
524
Letters / Ann Allergy Asthma Immunol 115 (2015) 523e535
Figure 1. Mean percentages of basophil CD203c and CD63 expression at baseline in the anaphylaxis and nonanaphylaxis groups compared with the healthy control group. P values were determined using the Mann-Whitney U test.
Cytokines, such as interleukin (IL) 3, IL-33, and thymic stromal lymphopoietin, can activate basophils and enhance IgE-mediated degranulation.7,8 Patients with anaphylaxis have been reported to have high serum levels of IL-33 during anaphylactic shock, suggesting that IL-33 plays an important role in anaphylaxis.7 In the present study, baseline CD203c and CD63 expressions were significantly higher in the anaphylaxis group than in the nonanaphylaxis group and tended to be higher in the anaphylaxis group than in the healthy control group without statistical significance. Gernez et al9 also found an increased baseline CD203c expression in nut allergic patients compared with healthy controls. Therefore, altered cytokine milieu in the baseline condition may exist in patients with anaphylaxis that can induce basophil activation. In the present study, we used 2 surface markers of basophils to assess basophil activation. Although CD203c is thought to be the most useful marker of basophil activation because of basophilspecific and high sensitivity,10 both markers are elevated in patients with anaphylaxis. These findings suggest that implication of these 2 activation markers will be more useful for evaluating basophil activation status in patients with anaphylaxis. More studies are needed to understand why basophil activation status, even in asymptomatic patients with anaphylaxis, can be a target for new therapeutic interventions. These findings suggest that the increased basal activation status of basophils may contribute to the development of anaphylaxis in adult patients.
Supplementary Data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.anai.2015.08.014.
Ji-Hye Kim, MD Seung-Hyun Kim, PhD Sailesh Palikhe, BS Eun-mi Yang, MS Young-Min Ye, MD, PhD Hae-Sim Park, MD, PhD Department of Allergy and Clinical Immunology Ajou University School of Medicine Suwon, South Korea [email protected]
References [1] Ye YM, Kim MK, Kang HR, et al. Predictors of the severity and serious outcomes of anaphylaxis in korean adults: a multicenter retrospective case study. Allergy Asthma Immunol Res. 2015;7:22e29. [2] Lourenco FD, Azor MH, Santos JC, et al. Activated status of basophils in chronic urticaria leads to interleukin-3 hyper-responsiveness and enhancement of histamine release induced by anti-IgE stimulus. Br J Dermatol. 2008;158: 979e986. [3] Apostolou E, Deckert K, Puy R, et al. Anaphylaxis to Gelofusine confirmed by in vitro basophil activation test: a case series. Anaesthesia. 2006;61: 264e268. [4] Hagau N, Longrois D, Petrisor C. Threshold for positivity and optimal dipyrone concentration in flow cytometry-assisted basophil activation test. Allergy Asthma Immunol Res. 2013;5:383e388. [5] Lie WJ, Knol EF, Mul FP, Jansen HM, Roos D, van der Zee JS. Basophils from patients with allergic asthma show a primed phenotype. J Allergy Clin Immunol. 1999;104:1000e1007. [6] Gomez G, Jogie-Brahim S, Shima M, Schwartz LB. Omalizumab reverses the phenotypic and functional effects of IgE-enhanced Fc epsilonRI on human skin mast cells. J Immunol. 2007;179:1353e1361. [7] Pushparaj PN, Tay HK, H’Ng SC, et al. The cytokine interleukin-33 mediates anaphylactic shock. Proc Natl Acad Sci U S A. 2009;106: 9773e9778. [8] Siracusa MC, Saenz SA, Hill DA, et al. TSLP promotes interleukin-3independent basophil haematopoiesis and type 2 inflammation. Nature. 2011;477:229e233.
Letters / Ann Allergy Asthma Immunol 115 (2015) 523e535 [9] Gernez Y, Tirouvanziam R, Yu G, et al. Basophil CD203c levels are increased at baseline and can be used to monitor omalizumab treatment in subjects with nut allergy. Int Arch Allergy Immunol. 2011;154:318e327.
525
[10] Buhring HJ, Streble A, Valent P. The basophil-specific ectoenzyme E-NPP3 (CD203c) as a marker for cell activation and allergy diagnosis. Int Arch Allergy Immunol. 2004;133:317e329.
Effect of a nasal clip on inhaling a sufficient cortico steroid powder dose We previously described a patient in whom it was difficult to control asthma symptoms because of velopharyngeal dysfunction due to submucous cleft palate.1 In patients with velopharyngeal dysfunction, inhalation is released through the nasal passage and air is also inhaled via the nose. Therefore, our patient was receiving an insufficient dose of steroid through the prescribed inhaler because the steroid became diluted with air. However, we instructed her to hold her nose when using the inhaler use trainer. She was then able to inhale a sufficient steroid dose and control her asthma symptoms even when using a nongas-type inhaler. The most common cause of velopharyngeal dysfunction is cleft palate.1e4 The symptoms of cleft palate usually affect speech, such as hypernasality,2e4 nasal emissions,2e4 and poor articulation.3,4 In general, physicians and speech therapists evaluate velopharyngeal function by objective analysis based on experience, for example, by performing nasopharyngeal fiberoscopy and/or videofluoroscopy. The subjective methods for diagnosing velopharyngeal dysfunction are listening to patients while analyzing perceptual speech and holding a mirror below the nose while a patient pronounces vowels or syllables such as /sa, shi, su, se, so/. If air escapes from the nasal passage, the mirror fogs up, indicating velopharyngeal insufficiency. Because velopharyngeal insufficiency is a potential complication occurring after surgery and in the setting of stroke, neurologic disease, and neuromuscular disease, it is necessary to instruct patients on the possibility of its development and monitor them for its signs.1 It may also be important to evaluate velopharyngeal function not only in patients with cleft palate but also in those with asthma. For these reasons, we compared the actual inspiratory and expiratory flow in healthy volunteers (without velopharyngeal insufficiency) while the nose was held with a nasal clip and without the clip both as an initial approach to assessing velopharyngeal function and to test the hypothesis that inspiratory flow is improved when holding the nose, as suggested by our experience with the previous patient.1 The study was performed at the National Hospital Organization Tokyo Medical Center and the Department of Speech Therapy of Rinshofukushi College, after approval by the National Hospital Organization Tokyo Medical Center Ethics Committee. Before participating in the study, all volunteers signed written informed consent forms. Ninety-two adult volunteers (41 men with a mean [SD] age of 32.9 [10.6] years and 51 women with a mean [SD] age of 34.2 [11.2] years) who had never been diagnosed as having a respiratory disease, such as asthma or chronic obstructive pulmonary disease, velopharyngeal dysfunction (cleft palate, neurologic movement impairment, and so on), or obstructive nasal disease (sinusitis, nasal allergy, and so on) participated in this study. We measured inspiratory (In-Check Dial, Turbohaler model; Clement Clarke Intl Ltd, Harlow, United Kingdom) (Fig 1) and expiratory (Mini-Wright Peak Flow Meter ATS Scale; Clement Disclosures: Authors have nothing to disclose. Funding Sources: This study was supported by grant 25933001 from the Japan Promotion of Science KAKENHI, Japan Society of Logpedics and Phoniatrics and Japanese National Hospital Organization.
Clarke) flow with and without a nasal clip to allow comparisons of the differences. Measurements of flow using each of the following procedures were obtained for each volunteer in random order: (1) use the inspiratory flow meter without a nasal clip, (2) use the inspiratory flow meter device with a nasal clip, (3) use the peak flow meter without a nasal clip, and (4) use the peak flow meter with a nasal clip. Three measurements were obtained for each of the 4 procedures in each individual, and the highest flow results for each procedure were used in the final analyses. The results were analyzed statistically with the paired t test, followed by the normality test and F test, using Microsoft Excel 2007 (Microsoft, Redmond, Washington). In the 92 volunteers, the mean (SD) inspiratory flow rate was 72.1 (13.5) L/min without the nasal clip and 75.0 (13.3) L/min with the nasal clip. A significant increase (P < .001) was therefore seen with the nasal clip. Meanwhile, the mean (SD) expiratory flow rate was 440.3 (143.7) L/min without and 439.7 (142.0) L/min with the nasal clip, which did not represent a significant difference (P ¼ .86). Our results supported the use of the traditional spirometry procedure to determine respiratory function.5 According to another
Figure 1. The inspiratory flow meter device (In-Check Dial, Turbohaler model).
525.e1
Letters / Ann Allergy Asthma Immunol 115 (2015) 523e535
eFigure 1. The prevalence of basophil activation test (BAT) positive results based on CD203 expression between the anaphylaxis and nonanaphylaxis groups. Cutoff values were calculated as mean 2 SDs.
Contents lists available at ScienceDirect
Letters
Increased basophil activation in adult patients with anaphylaxis Anaphylaxis is a severe, life-threatening allergic reaction primarily mediated through IgE antibodies that interact with basophils and mast cells to release vasoactive and proinflammatory mediators.1 Basophils comprise less than 1% of circulating leukocytes in humans; however, in recent years, it has drawn considerable attention because of involvement in various allergic diseases.2 Like mast cells, basophil activation and degranulation induced by allergens lead to a release of various mediators that can generate anaphylaxis.3 Along with release of mediators, activation of human basophils results in the expression of surface proteins and the upregulation of expressed proteins. CD203c and CD63 are surface markers of basophils that are upregulated or expressed on activated basophils.2 Basophil activation tests (BATs) using the activation markers CD203c and CD63 have been widely used to assess basophil activation status and as an important tool for checking IgE-mediated allergic reactions.4 There have been many reports regarding increased basophil activation in anaphylactic patients after allergen exposure,3 but the baseline status of these patients has not yet been studied. In the present study, we evaluated basophil activation status using CD203c and CD63 expressions in adult patients with anaphylaxis for a further understanding of pathogenic mechanisms of adultonset anaphylaxis. A total of 41 patients with various allergic diseases, including asthma and/or rhinitis, chronic urticaria, and anaphylaxis, and 23 healthy controls were recruited from Ajou University Hospital, Suwon, South Korea. Allergic patients were divided into 2 groups according to the diagnosis of adult-onset anaphylaxis to various drugs, including nonsteroidal anti-inflammatory drugs and antibiotics; foods, including wheat and seafood; and diagnostic reagents, such as radiocontrast media: the anaphylaxis (n ¼ 13) and nonanaphylaxis (n ¼ 28) groups. All participants provided written informed consent, and this study was approved by the institutional review board of Ajou Medical Center. Basophil CD203c and CD63 expressions were measured by flow cytometry. Blood samples were collected in the stable state of each patient, at least 2 months after the anaphylactic event in cases of anaphylaxis. Participants did not take any medication or stopped taking medications for at least 1 week before blood sampling. The whole blood was collected in an EDTA tube, and red blood cells were lysed with a red blood cell lysis buffer (0.154 M NH4Cl, 10 mM KHCO3, 0.1 mM EDTA, pH 7.2-7.4). Basophils were incubated with anti-IgE antibody (1 mg/mL) or calcium ionophore (1 mg/mL; Sigma-Aldrich Co, St Louis, Missouri) as Disclosures: Authors have nothing to disclose. Funding Sources: This study was supported by grant H14C2628 from the Korean Health Technology R&D Project funded by the Ministry of Health and Welfare, Republic of Korea.
positive controls or left untreated for 30 minutes. After being washed with a phosphate-buffered saline, the resuspended cells were stained with phycoerythrin-conjugated antihuman CD203c or CD63 (Beckman Coulter, Marseille, France), fluorescein isothiocyanateeconjugated antihuman CD123 (BD Pharmingen, San Jose, California), and allophycocyanin-conjugated antihuman human leukocyte antigen DR (BD Pharmingen), or isotypematched controls on ice in the dark for 30 minutes. After washing once with phosphate-buffered saline, the cells were analyzed on a FACS Canto II flow cytometer (Becton Dickinson, San Jose, California). The Mann-Whitney U test was used to compare CD203c and CD63 expression levels between the groups. Spearman correlation analysis was used for the correlation analysis. P < .05 was considered to indicate statistical significance. All statistical analyses were performed using the SPSS statistical software for Windows, version 22 (SPSS Inc, Chicago, Illinois). Mean (SD) baseline expression levels of CD203c and CD63 were significantly higher in the anaphylaxis group than in the healthy control group (30.28 [23.10] vs 13.76 [14.60], P ¼ .04; 17.67 [20.48] vs 3.31 [3.73], P ¼ .03, respectively; Fig 1) and tended to be higher in the anaphylaxis group than in the nonanaphylaxis group, although statistical significance was not reached. When the positive cutoff value for a positive BAT result was defined as the mean value plus 2 SDs of the CD203c expression levels in the healthy control group, positive BAT rates tended to be higher in the anaphylaxis group than in the nonanaphylaxis group (38.46% vs 17.85%, P ¼ .20; eFig 1), although no differences were noted in CD63 expression levels. No significant differences were found in baseline percent expressions of CD203c and CD63 or those induced by anti-IgE or calcium ionophore according to age, sex, atopic status, and total IgE level. In addition, no significant correlations were found between the expressions of CD203c and CD63 with age and total IgE (data not shown). Increased baseline expressions of CD203c and CD63 in the anaphylaxis group suggest that basophils in anaphylactic patients may be in a primed state and thus have hyperreactive responses to specific allergens. Lie et al5 found that basophils have primed phenotypes in patients with allergic asthma that cause the release of high levels of histamine when exposed to stimuli. The highaffinity IgE receptor (FcεRI) that plays an important role in basophil degranulation has been found to be upregulated on basophils in patients with chronic urticaria with CD203c and CD63 expressions compared with healthy controls.2 An in vitro study found that mast cells expressing enhanced levels of FcεRI are more sensitive to activation when stimulated with IgG anti-FcεRI.6 Therefore, basophils of anaphylactic patients may have increased FcεRI expression in the basal state that enhances its sensitivity toward specific allergens.
http://dx.doi.org/10.1016/j.anai.2015.08.014 1081-1206/Ó 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
524
Letters / Ann Allergy Asthma Immunol 115 (2015) 523e535
Figure 1. Mean percentages of basophil CD203c and CD63 expression at baseline in the anaphylaxis and nonanaphylaxis groups compared with the healthy control group. P values were determined using the Mann-Whitney U test.
Cytokines, such as interleukin (IL) 3, IL-33, and thymic stromal lymphopoietin, can activate basophils and enhance IgE-mediated degranulation.7,8 Patients with anaphylaxis have been reported to have high serum levels of IL-33 during anaphylactic shock, suggesting that IL-33 plays an important role in anaphylaxis.7 In the present study, baseline CD203c and CD63 expressions were significantly higher in the anaphylaxis group than in the nonanaphylaxis group and tended to be higher in the anaphylaxis group than in the healthy control group without statistical significance. Gernez et al9 also found an increased baseline CD203c expression in nut allergic patients compared with healthy controls. Therefore, altered cytokine milieu in the baseline condition may exist in patients with anaphylaxis that can induce basophil activation. In the present study, we used 2 surface markers of basophils to assess basophil activation. Although CD203c is thought to be the most useful marker of basophil activation because of basophilspecific and high sensitivity,10 both markers are elevated in patients with anaphylaxis. These findings suggest that implication of these 2 activation markers will be more useful for evaluating basophil activation status in patients with anaphylaxis. More studies are needed to understand why basophil activation status, even in asymptomatic patients with anaphylaxis, can be a target for new therapeutic interventions. These findings suggest that the increased basal activation status of basophils may contribute to the development of anaphylaxis in adult patients.
Supplementary Data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.anai.2015.08.014.
Ji-Hye Kim, MD Seung-Hyun Kim, PhD Sailesh Palikhe, BS Eun-mi Yang, MS Young-Min Ye, MD, PhD Hae-Sim Park, MD, PhD Department of Allergy and Clinical Immunology Ajou University School of Medicine Suwon, South Korea [email protected]
References [1] Ye YM, Kim MK, Kang HR, et al. Predictors of the severity and serious outcomes of anaphylaxis in korean adults: a multicenter retrospective case study. Allergy Asthma Immunol Res. 2015;7:22e29. [2] Lourenco FD, Azor MH, Santos JC, et al. Activated status of basophils in chronic urticaria leads to interleukin-3 hyper-responsiveness and enhancement of histamine release induced by anti-IgE stimulus. Br J Dermatol. 2008;158: 979e986. [3] Apostolou E, Deckert K, Puy R, et al. Anaphylaxis to Gelofusine confirmed by in vitro basophil activation test: a case series. Anaesthesia. 2006;61: 264e268. [4] Hagau N, Longrois D, Petrisor C. Threshold for positivity and optimal dipyrone concentration in flow cytometry-assisted basophil activation test. Allergy Asthma Immunol Res. 2013;5:383e388. [5] Lie WJ, Knol EF, Mul FP, Jansen HM, Roos D, van der Zee JS. Basophils from patients with allergic asthma show a primed phenotype. J Allergy Clin Immunol. 1999;104:1000e1007. [6] Gomez G, Jogie-Brahim S, Shima M, Schwartz LB. Omalizumab reverses the phenotypic and functional effects of IgE-enhanced Fc epsilonRI on human skin mast cells. J Immunol. 2007;179:1353e1361. [7] Pushparaj PN, Tay HK, H’Ng SC, et al. The cytokine interleukin-33 mediates anaphylactic shock. Proc Natl Acad Sci U S A. 2009;106: 9773e9778. [8] Siracusa MC, Saenz SA, Hill DA, et al. TSLP promotes interleukin-3independent basophil haematopoiesis and type 2 inflammation. Nature. 2011;477:229e233.
Letters / Ann Allergy Asthma Immunol 115 (2015) 523e535 [9] Gernez Y, Tirouvanziam R, Yu G, et al. Basophil CD203c levels are increased at baseline and can be used to monitor omalizumab treatment in subjects with nut allergy. Int Arch Allergy Immunol. 2011;154:318e327.
525
[10] Buhring HJ, Streble A, Valent P. The basophil-specific ectoenzyme E-NPP3 (CD203c) as a marker for cell activation and allergy diagnosis. Int Arch Allergy Immunol. 2004;133:317e329.
Effect of a nasal clip on inhaling a sufficient cortico steroid powder dose We previously described a patient in whom it was difficult to control asthma symptoms because of velopharyngeal dysfunction due to submucous cleft palate.1 In patients with velopharyngeal dysfunction, inhalation is released through the nasal passage and air is also inhaled via the nose. Therefore, our patient was receiving an insufficient dose of steroid through the prescribed inhaler because the steroid became diluted with air. However, we instructed her to hold her nose when using the inhaler use trainer. She was then able to inhale a sufficient steroid dose and control her asthma symptoms even when using a nongas-type inhaler. The most common cause of velopharyngeal dysfunction is cleft palate.1e4 The symptoms of cleft palate usually affect speech, such as hypernasality,2e4 nasal emissions,2e4 and poor articulation.3,4 In general, physicians and speech therapists evaluate velopharyngeal function by objective analysis based on experience, for example, by performing nasopharyngeal fiberoscopy and/or videofluoroscopy. The subjective methods for diagnosing velopharyngeal dysfunction are listening to patients while analyzing perceptual speech and holding a mirror below the nose while a patient pronounces vowels or syllables such as /sa, shi, su, se, so/. If air escapes from the nasal passage, the mirror fogs up, indicating velopharyngeal insufficiency. Because velopharyngeal insufficiency is a potential complication occurring after surgery and in the setting of stroke, neurologic disease, and neuromuscular disease, it is necessary to instruct patients on the possibility of its development and monitor them for its signs.1 It may also be important to evaluate velopharyngeal function not only in patients with cleft palate but also in those with asthma. For these reasons, we compared the actual inspiratory and expiratory flow in healthy volunteers (without velopharyngeal insufficiency) while the nose was held with a nasal clip and without the clip both as an initial approach to assessing velopharyngeal function and to test the hypothesis that inspiratory flow is improved when holding the nose, as suggested by our experience with the previous patient.1 The study was performed at the National Hospital Organization Tokyo Medical Center and the Department of Speech Therapy of Rinshofukushi College, after approval by the National Hospital Organization Tokyo Medical Center Ethics Committee. Before participating in the study, all volunteers signed written informed consent forms. Ninety-two adult volunteers (41 men with a mean [SD] age of 32.9 [10.6] years and 51 women with a mean [SD] age of 34.2 [11.2] years) who had never been diagnosed as having a respiratory disease, such as asthma or chronic obstructive pulmonary disease, velopharyngeal dysfunction (cleft palate, neurologic movement impairment, and so on), or obstructive nasal disease (sinusitis, nasal allergy, and so on) participated in this study. We measured inspiratory (In-Check Dial, Turbohaler model; Clement Clarke Intl Ltd, Harlow, United Kingdom) (Fig 1) and expiratory (Mini-Wright Peak Flow Meter ATS Scale; Clement Disclosures: Authors have nothing to disclose. Funding Sources: This study was supported by grant 25933001 from the Japan Promotion of Science KAKENHI, Japan Society of Logpedics and Phoniatrics and Japanese National Hospital Organization.
Clarke) flow with and without a nasal clip to allow comparisons of the differences. Measurements of flow using each of the following procedures were obtained for each volunteer in random order: (1) use the inspiratory flow meter without a nasal clip, (2) use the inspiratory flow meter device with a nasal clip, (3) use the peak flow meter without a nasal clip, and (4) use the peak flow meter with a nasal clip. Three measurements were obtained for each of the 4 procedures in each individual, and the highest flow results for each procedure were used in the final analyses. The results were analyzed statistically with the paired t test, followed by the normality test and F test, using Microsoft Excel 2007 (Microsoft, Redmond, Washington). In the 92 volunteers, the mean (SD) inspiratory flow rate was 72.1 (13.5) L/min without the nasal clip and 75.0 (13.3) L/min with the nasal clip. A significant increase (P < .001) was therefore seen with the nasal clip. Meanwhile, the mean (SD) expiratory flow rate was 440.3 (143.7) L/min without and 439.7 (142.0) L/min with the nasal clip, which did not represent a significant difference (P ¼ .86). Our results supported the use of the traditional spirometry procedure to determine respiratory function.5 According to another
Figure 1. The inspiratory flow meter device (In-Check Dial, Turbohaler model).
525.e1
Letters / Ann Allergy Asthma Immunol 115 (2015) 523e535
eFigure 1. The prevalence of basophil activation test (BAT) positive results based on CD203 expression between the anaphylaxis and nonanaphylaxis groups. Cutoff values were calculated as mean 2 SDs.
