An epithelial-to-mesenchymal transition induced extracellular vesicle prognostic signature in non-small cell lung cancer

Despite significant therapeutic advances, lung cancer remains the leading cause of cancer-related death worldwide¹. Non-small cell lung cancer (NSCLC) patients have a very poor overall five-year survival rate of only 10-20%. Currently, TNM staging is the gold standard for predicting overall survival and selecting optimal initial treatment options for NSCLC patients, including those with curable stages of disease. However, many patients with locoregionally-confined NSCLC relapse and die despite curative-intent interventions, indicating a need for intensified, individualised therapies. Epithelial-to-mesenchymal transition (EMT), the phenotypic depolarisation of epithelial cells to elongated, mesenchymal cells, is associated with metastatic and treatment-refractive cancer. We demonstrate here that EMT-induced protein changes in small extracellular vesicles are detectable in NSCLC patients and have prognostic significance. Overall, this work describes a novel prognostic biomarker signature that identifies potentially-curable NSCLC patients at risk of developing metastatic NSCLC, thereby enabling implementation of personalised treatment decisions.

Integrating radiomics into holomics for personalised oncology: from algorithms to bedside

Radiomics, artificial intelligence, and deep learning figure amongst recent buzzwords in current medical imaging research and technological development. Analysis of medical big data in assessment and follow-up of personalised treatments has also become a major research topic in the area of precision medicine. In this review, current research trends in radiomics are analysed, from handcrafted radiomics feature extraction and statistical analysis to deep learning. Radiomics algorithms now include genomics and immunomics data to improve patient stratification and prediction of treatment response. Several applications have already shown conclusive results demonstrating the potential of including other “omics” data to existing imaging features. We also discuss further challenges of data harmonisation and management infrastructure to shed a light on the much-needed integration of radiomics and all other “omics” into clinical workflows. In particular, we point to the emerging paradigm shift in the implementation of big data infrastructures to facilitate databanks growth, data extraction and the development of expert software tools. Secured access, sharing, and integration of all health data, called “holomics”, will accelerate the revolution of personalised medicine and oncology as well as expand the role of imaging specialists.

Spleen Volume Variation in Patients with Locally Advanced Non-Small Cell Lung Cancer Receiving Platinum-Based Chemo-Radiotherapy

There is renewed interest in the immune regulatory role of the spleen in oncology. To date, very few studies have examined macroscopic variations of splenic volume in the setting of cancer, prior to or during therapy, especially in humans. Changes in splenic volume may be associated with changes in splenic function. The purpose of this study was to investigate variations in spleen volume in NSCLC patients during chemo-radiotherapy. Sixty patients with stage I-IIIB NSCLC underwent radiotherapy (60Gy/30 fractions) for six weeks with concomitant carboplatin/paclitaxel (Ca/P; n = 32) or cisplatin/etoposide (Ci/E; n = 28). A baseline PET/CT scan was performed within 2 weeks prior to treatment and during Weeks 2 and 4 of chemo-radiotherapy. Spleen volume was measured by contouring all CT slices. Significant macroscopic changes in splenic volume occurred early after the commencement of treatment. A significant decrease in spleen volume was observed for 66% of Ca/P and 79% of Ci/E patients between baseline and Week 2. Spleen volume was decreased by 14.2% for Ca/P (p<0.001) and 19.3% for Ci/E (p<0.001) patients. By Week 4, spleen volume was still significantly decreased for Ca/P patients compared to baseline, while for Ci/E patients, spleen volume returned to above baseline levels. This is the first report demonstrating macroscopic changes in the spleen in NSCLC patients undergoing radical chemo-radiotherapy that can be visualized by non-invasive imaging.

Optimized exosome isolation protocol for cell culture supernatant and human plasma

Extracellular vesicles represent a rich source of novel biomarkers in the diagnosis and prognosis of disease. However, there is currently limited information elucidating the most efficient methods for obtaining high yields of pure exosomes, a subset of extracellular vesicles, from cell culture supernatant and complex biological fluids such as plasma. To this end, we comprehensively characterize a variety of exosome isolation protocols for their efficiency, yield and purity of isolated exosomes. Repeated ultracentrifugation steps can reduce the quality of exosome preparations leading to lower exosome yield. We show that concentration of cell culture conditioned media using ultrafiltration devices results in increased vesicle isolation when compared to traditional ultracentrifugation protocols. However, our data on using conditioned media isolated from the Non-Small-Cell Lung Cancer (NSCLC) SK-MES-1 cell line demonstrates that the choice of concentrating device can greatly impact the yield of isolated exosomes. We find that centrifuge-based concentrating methods are more appropriate than pressure-driven concentrating devices and allow the rapid isolation of exosomes from both NSCLC cell culture conditioned media and complex biological fluids. In fact to date, no protocol detailing exosome isolation utilizing current commercial methods from both cells and patient samples has been described. Utilizing tunable resistive pulse sensing and protein analysis, we provide a comparative analysis of 4 exosome isolation techniques, indicating their efficacy and preparation purity. Our results demonstrate that current precipitation protocols for the isolation of exosomes from cell culture conditioned media and plasma provide the least pure preparations of exosomes, whereas size exclusion isolation is comparable to density gradient purification of exosomes. We have identified current shortcomings in common extracellular vesicle isolation methods and provide a potential standardized method that is effective, reproducible and can be utilized for various starting materials. We believe this method will have extensive application in the growing field of extracellular vesicle research.

Optimized exosome isolation protocol for cell culture supernatant and human plasma

Extracellular vesicles represent a rich source of novel biomarkers in the diagnosis and prognosis of disease. However, there is currently limited information elucidating the most efficient methods for obtaining high yields of pure exosomes, a subset of extracellular vesicles, from cell culture supernatant and complex biological fluids such as plasma. To this end, we comprehensively characterize a variety of exosome isolation protocols for their efficiency, yield and purity of isolated exosomes. Repeated ultracentrifugation steps can reduce the quality of exosome preparations leading to lower exosome yield. We show that concentration of cell culture conditioned media using ultrafiltration devices results in increased vesicle isolation when compared to traditional ultracentrifugation protocols. However, our data on using conditioned media isolated from the Non-Small-Cell Lung Cancer (NSCLC) SK-MES-1 cell line demonstrates that the choice of concentrating device can greatly impact the yield of isolated exosomes. We find that centrifuge-based concentrating methods are more appropriate than pressure-driven concentrating devices and allow the rapid isolation of exosomes from both NSCLC cell culture conditioned media and complex biological fluids. In fact to date, no protocol detailing exosome isolation utilizing current commercial methods from both cells and patient samples has been described. Utilizing tunable resistive pulse sensing and protein analysis, we provide a comparative analysis of 4 exosome isolation techniques, indicating their efficacy and preparation purity. Our results demonstrate that current precipitation protocols for the isolation of exosomes from cell culture conditioned media and plasma provide the least pure preparations of exosomes, whereas size exclusion isolation is comparable to density gradient purification of exosomes. We have identified current shortcomings in common extracellular vesicle isolation methods and provide a potential standardized method that is effective, reproducible and can be utilized for various starting materials. We believe this method will have extensive application in the growing field of extracellular vesicle research.

Effect of Platinum-Based Chemoradiotherapy on Cellular Proliferation in Bone Marrow and Spleen, Estimated by (18)F-FLT PET/CT in Patients with Locally Advanced Non-Small Cell Lung Cancer

Historically, it has been difficult to monitor the acute impact of anticancer therapies on hematopoietic organs on a whole-body scale. Deeper understanding of the effect of treatments on bone marrow would be of great potential value in the rational design of intensive treatment regimens. 3'-deoxy-3'-(18)F-fluorothymidine ((18)F-FLT) is a functional radiotracer used to study cellular proliferation. It is trapped in cells in proportion to thymidine-kinase 1 enzyme expression, which is upregulated during DNA synthesis. This study investigates the potential of (18)F-FLT to monitor acute effects of chemotherapy on cellular proliferation and its recovery in bone marrow, spleen, and liver during treatment with 2 different chemotherapy regimens.

METHODS

Sixty patients with non-small cell lung cancer underwent concurrent radical chemoradiotherapy to 60 Gy in 6 wk with either cisplatin/etoposide (C/E, n = 28) weeks 1 and 5 or weekly carboplatin/paclitaxel (C/P, n = 32) regimens. (18)F-FLT and (18)F-FDG PET with CT were performed at baseline, week 2 (day 9 for (18)F-FLT and day 10 for (18)F-FDG PET), and week 4 (day 23 for (18)F-FLT and day 24 for (18)F-FDG PET). Visual and semiquantitative standardized uptake value (SUV) measurements were performed in bone marrow outside the radiotherapy field, liver, spleen, and small bowel. These were correlated to blood counts and smears in a subset of patients.

RESULTS

The C/E group exhibited a drop in bone marrow (18)F-FLT uptake at week 2 (median SUVmax [maximum SUV] decrease to 31%, 8.7-6.0, P < 0.001), with recovery at week 4, reflecting the absence of chemotherapy between these times. By contrast, the weekly C/P group showed gradually declining bone marrow uptake (P > 0.05). Spleen uptake in both cohorts decreased at week 2, with intense rebound activity at week 4 (SUVmax week 4 at 58% above baseline: 2.4-3.8, for C/E, respectively, 30% for C/P: 2.7-3.5, P < 0.001). Liver uptake changed little. (18)F-FLT changes preceded neutrophil count reductions. (18)F-FDG uptake in marrow liver and spleen changed much less than (18)F-FLT.

CONCLUSION

(18)F-FLT imaging may be used to quantify impairment and recovery of bone marrow by specific chemotherapy regimens and may also enable imaging of organ-specific processes such as spleen activation. (18)F-FLT is superior to (18)F-FDG for this purpose. This technology may support novel treatment planning and monitoring approaches in oncology patients.

[Interests of recombinant allergens in the practice of allergy]

Compared to total allergenic extracts, recombinant allergens available for specific IgE measurement represent an important advance in the diagnosis and treatment of IgE-mediated allergies. Recombinant allergens lead to define the sensitization profile of allergic patients, to identify markers of sensitization and to understand better polysensitivities related to cross-reactions and markers of severity of allergic reactions. They also contribute to the decision to establish tolerance induction (allergen specific immunotherapy) and the optimal selection of the allergenic composition of the vaccine.

TCRep 3D: an automated in silico approach to study the structural properties of TCR repertoires

TCRep 3D is an automated systematic approach for TCR-peptide-MHC class I structure prediction, based on homology and ab initio modeling. It has been considerably generalized from former studies to be applicable to large repertoires of TCR. First, the location of the complementary determining regions of the target sequences are automatically identified by a sequence alignment strategy against a database of TCR Vα and Vβ chains. A structure-based alignment ensures automated identification of CDR3 loops. The CDR are then modeled in the environment of the complex, in an ab initio approach based on a simulated annealing protocol. During this step, dihedral restraints are applied to drive the CDR1 and CDR2 loops towards their canonical conformations, described by Al-Lazikani et. al. We developed a new automated algorithm that determines additional restraints to iteratively converge towards TCR conformations making frequent hydrogen bonds with the pMHC. We demonstrated that our approach outperforms popular scoring methods (Anolea, Dope and Modeller) in predicting relevant CDR conformations. Finally, this modeling approach has been successfully applied to experimentally determined sequences of TCR that recognize the NY-ESO-1 cancer testis antigen. This analysis revealed a mechanism of selection of TCR through the presence of a single conserved amino acid in all CDR3β sequences. The important structural modifications predicted in silico and the associated dramatic loss of experimental binding affinity upon mutation of this amino acid show the good correspondence between the predicted structures and their biological activities. To our knowledge, this is the first systematic approach that was developed for large TCR repertoire structural modeling.

[Allergen specific immunotherapy: review of new perspectives]

Allergic diseases constitute a health problem worldwide. More than just a treatment option, the classical desensitization (SIT--Specific immunotherapy) by subcutaneous injection has profiled over time as a unique approach, able to attenuate the immune response to allergic stimuli proved. For a long time conservative, desensitization has now progressed in the knowledge of allergens, in the understanding of the mechanisms involved in immune response and in production techniques. From recombinants to alternative routes of allergen delivery, this article gives an overview of new perspectives and assesses SIT in order to provide guidance to the general physician before choosing to initiate such treatment or not in patients with respiratory allergy.

[Hymenoptera venom allergy: new diagnostic tools and management]

Anaphylactic reactions to hymenoptera venoms are common and, in our latitudes, mainly concern wasps and bees. Recently, molecular biology techniques have contributed to identifying and to sequencing the major allergens of insect venoms and led to the production of recombinant allergens. Assays for specific IgE directed against these recombinant allergens have recently been made available in clinical practice. They provide considerable assistance in identifying the insect responsible for an anaphylactic reaction, in particular when standard tests are positive for both wasp and bee. This article focuses on these new laboratory tests and also reviews the management of patients experiencing an anaphylactic reaction after hymenoptera sting.

[What to expect from allergy tests?]

Diagnosis in allergology is facing novel challenges because of the availability not only of purified or recombinant allergens, but also of multitests such as allergen micro-arrays. These new diagnostic opportunities contribute to a better understanding of crossreactivities between respiratory and food allergens. In comparison to current diagnosis based on whole allergen extracts, this novel generation of specific IgE tests is expected to provide better information on the risk of reaction to allergens as well as on its severity. However these new technologies are expensive, and will have to be carefully analyzed in terms of medical usefulness and public health costs.

[Cardiac involvement in connective tissue disease: the example of systemic lupus erythematosus]

When we think of cardiac affection in the context of systemic lupus erythematosus (SLE), we usually refer to pericarditis first. As frequent as this affection is, it is actually not the only cardio-vascular problem that occurs with this systemic inflammatory disease. Are the cardiac events--ranging from multiple heart valve involvements to increased cardiovascular risks--clinically significant? And are they involving a specific follow-up, treatment or support? We are therefore trying to evaluate these questions in order to give some recommendations to any practitioners following up a lupus patient, or a patient suffering from any other inflammatory systemic disease.

[Behçet's disease: from hippocrates to TNF-alpha-blockers]

Behçet's disease is a systemic vasculitis affecting small and large vessels (arteries, veins, veinules), characterized by recurrent oral ulcerations, genital ulcerations, inflammation of the eye and skin lesions. It can also involve articulations, central nervous system and gastro-intestinal tract. The etiology of this disease is still unknown, but the most largely discussed hypothesis is that of an important inflammatory response triggered by an infectious agent in a genetically susceptible host. The diagnostic is a based on clinical elements, because no specific diagnostic test exists. The treatment of Behçet's disease is depending on the clinical involvement and has been enlarged in recent years by TNF-alpha-blockers which constitute undoubtedly an important progress in the management of this complex disease.

[Rare food allergies]

A limited number of foods explain the majority of food allergies. These allergies can be due to a weak allergenicity (garlic, onion, potato), or a weak (or increasing) exposure to emergent food allergens which can be imported (exotic fruits), or recently introduced (lupin, buckwheat, sesame, inulin) or modified by the industry (lysats, lecithins, traces of antibiotics, caseinates, molds, dust mite). Others are in relation with rarer cross-reactivity food allergy syndrome (Apiaceae-Compositae-mugwort syndrome, egg-bird syndrome, cat epithelium-pork meat syndrome). Others are rarely identified, because the food is masked (pepper, basilic). We illustrate rare cases of food allergy and discuss the diagnostic management which is based on a meticulous patient history.

[The multiple etiologies of angioedema]

Angioedema is a frequent disorder with multiple aetiologies. Angioedemas associated with urticaria are usually caused by histamine release and respond to anti-histamines and adrenalin. They include allergic angioedemas, anaphylactoid reactions (mostly drug-induced, e.g. NSAID), physical angioedemas and recurrent idiopathic angioedema. Bradykinin probably plays a causative role in the pathogenesis of ACE-inhibitor or angiotensin II receptor blocker related angioedemas, as well as in the pathogenesis of the rare hereditary or acquired C1-inhibitor deficiency angioedemas. Urticaria is then typically absent and anti-histamines, as well as adrenalin, are ineffective.

A novel population of human melanoma-specific CD8 T cells recognizes Melan-AMART-1 immunodominant nonapeptide but not the corresponding decapeptide

HLA-A2-restricted cytolytic T cells specific for the immunodominant human tumor Ag Melan-A(MART-1) can kill most HLA-matched melanoma cells, through recognition of two naturally occurring antigenic variants, i.e., Melan-A nonamer AAGIGILTV and decamer EAAGIGILTV peptides. Several previous studies have suggested a high degree of TCR cross-reactivity to the two peptides. In this study, we describe for the first time that some T cell clones are exclusively nonamer specific, because they are not labeled by A2/decamer-tetramers and do not recognize the decamer when presented endogenously. Functional assays with peptides gave misleading results, possibly because decamers were cleaved by exopeptidases. Interestingly, nonapeptide-specific T cell clones were rarely Valpha2.1 positive (only 1 of 19 clones), in contrast to the known strong bias for Valpha2.1-positive TCRs found in decamer-specific clones (59 of 69 clones). Molecular modeling revealed that nonapeptide-specific TCRs formed unfavorable interactions with the decapeptide, whereas decapeptide-specific TCRs productively created a hydrogen bond between CDR1alpha and glutamic acid (E) of the decapeptide. Ex vivo analysis of T cells from melanoma metastases demonstrated that both nonamer and decamer-specific T cells were enriched to substantial frequencies in vivo, and representative clones showed efficient tumor cell recognition and killing. We conclude that the two peptides should be regarded as distinct epitopes when analyzing tumor immunity and developing immunotherapy against melanoma.

[Allergic reactions to nonsteroidal anti-inflammatory drugs]

Allergy to nonsteroidal antiinflammatory drugs (NSAIDs) is a very common affliction, especially among patients with asthma and chronic urticaria. These reactions are most often of a non-immunological nature but related to pharmacologic intolerance and linked to arachidonic acid metabolism and leukotriene release. Therefore, crossed reactions implying all non-selective and semi-selective NSAIDs constitute the rule, especially during respiratory reactions to NSAIDs and for patients with chronic urticaria. In isolated acute urticaria, crossed reactions are difficult to predict so caution is necessary. Tolerance induction is possible, especially when aspirin has to be administered in small doses as antiplatelet agent. Finally, acetaminophen and selective NSAIDs as celecoxib are well tolerated by most of these patients.

[Modern nutrition and development of new allergies]

The prevalence of food allergy varies between 1 and 8% and depends on age, countries, symptoms and allergens. Main food allergens remain peanut, nuts, egg, cow milk, wheat, soybeans and fish. However, novel food industrial processes have induced new food allergies. Some are related to unusual components, like lupine seeds or flour or to modified food, like wheat or soybean isolates. Other unexpected allergies are due to residues of strong allergens--like peanut or egg--which are present in very small amounts in processed food. Swiss and european legislation have edicted lists of allergenic foods which have to be specified to the consumers. However, the legislation remains still incomplete and labelling of novel food components or modified allergens as well as as trace allergens is still far from being exhautive.

[Treatment of asthma and rhinitis during pregnancy and breast feeding]

Inhaled therapies are preferred to systemic ones during pregnancy and breast feeding. A real paradox exists however between the necessity to ensure an optimal treatment for pregnant women with asthma, in order to prevent fetal hypoxia, and the precaution linked to any drug prescription during pregnancy. Thus, the use of topical corticosteroids remains the first choice for asthma as well as rhinitis. Inhaled beta2-agonists are also recommended. Systemic corticosteroids may however be prescribed without hesitation when their use is required for asthma treatment. It is also interesting to note that oral second-generation antihistamines are currently allowed during pregnancy and breast feeding. This type of antihistamines is indeed to be preferred to first-generation ones that generate more side-effects and generally are thus not to be prescribed during breast feeding.

[Lake Geneva Region guidelines on management of adult asthma]

Asthma is a major cause of chronic morbidity throughout the world. In Switzerland, 6.9% of the adult population is suffering from asthma. The standards of treatment are unfortunately not met in most western countries, as well as in Switzerland. We put forward a complete guideline on management of adult asthma, inspired from GINA and BTS guidelines, and adapted to the specific needs of general practitioners working in french part of Switzerland. This guideline reflects a consensus between allergy, lung and emergency specialists, working in the 2 university hospitals of the Lake Geneva Region (HUG and CHUV).

[Pathogenic mechanisms in systemic sclerosis and their therapeutical consequences. Part 1: pathogenesis]

Systemic sclerosis I(cleroderma) is a connective tissue disease caracterized by an aberrant immune activation, a vasculopathy and a fibrosis of skin and multiple internal organs (lung, kidneys, gut, among others). At present no unifying pathogenetic hypothesis exists to explain all aspects of this disease. The current hypothesis is that in patients with a favourable genetic background, certain environmental factors could produce alterations of cellular and humoral immunity and alterations of the microcirculation resulting in excessive fibrosis. A crucial component in systemic sclerosis pathogenesis is the persistent and unregulated activation of genes encoding the various extracellular matrix proteins. This is in correlation with different cytokines and growth factors produced mainly by T lymphocytes.

[Pathogenic mechanisms in systemic sclerosis and their therapeutical consequences. Part 2: treatment]

Systemic sclerosis (scleroderma) is considered as the most severe connective tissue disease. It is characterized by an abnormal immune activation, a vasculopathy and a fibrosis of the skin and of multiple internal organs. Numerous progress in the understanding of the pathogenesis with identification of key molecules have permit to introduce novel treatments that improve the management of some aspects of the disease. ACE inhibitors are effective in resolving renal crisis. Cyclophosphamide is useful for treatment of fibrosing alveolitis. Prostaglandins, endothelin receptor antagonists and phosphodiesterase type 5 inhibitors permit to improve the treatment of the vascular complications (digital ulcerations, pulmonary arterial hypertension) of scleroderma.

Perfusion and diffusion MRI of glioblastoma progression in a four-year prospective temozolomide clinical trial

PURPOSE

This study was performed to determine the impact of perfusion and diffusion magnetic resonance imaging (MRI) sequences on patients during treatment of newly diagnosed glioblastoma. Special emphasis has been given to these imaging technologies as tools to potentially anticipate disease progression, as progression-free survival is frequently used as a surrogate endpoint.

METHODS AND MATERIALS

Forty-one patients from a phase II temolozomide clinical trial were included. During follow-up, images were integrated 21 to 28 days after radiochemotherapy and every 2 months thereafter. Assessment of scans included measurement of size of lesion on T1 contrast-enhanced, T2, diffusion, and perfusion images, as well as mass effect. Classical criteria on tumor size variation and clinical parameters were used to set disease progression date.

RESULTS

A total of 311 MRI examinations were reviewed. At disease progression (32 patients), a multivariate Cox regression determined 2 significant survival parameters: T1 largest diameter (p < 0.02) and T2 size variation (p < 0.05), whereas perfusion and diffusion were not significant.

CONCLUSION

Perfusion and diffusion techniques cannot be used to anticipate tumor progression. Decision making at disease progression is critical, and classical T1 and T2 imaging remain the gold standard. Specifically, a T1 contrast enhancement over 3 cm in largest diameter together with an increased T2 hypersignal is a marker of inferior prognosis.

[Allergo-immunology]

Allergic rhinitis is a frequent illness. New therapeutic options are being developed to counteract its impact on quality of life and health costs. This article presents two of these options, laser rhinophototherapy and Butterbur Ze 339, a drug derived from petasites. The immunodepressing effect of phototherapy has been tested in nasal mucosa. This application has shown satisfactory anti-inflammatory results in nasal cleaning fluid and, consequently, has enabled to reduce allergic rhinitis. The effect of butterbur on the symptoms of allergic rhinitis has to be understood in relation with the inhibition of cysleucotrienes synthesis, as well as its action on eosinophils and mastocytes. However, long-term studies involving large cohorts of patients are needed if we want to prescribe these treatments without restrictions.

[Skin tests in allergology: really so simple?]

In allergology, skin tests (ST) are one of the main tools. Their simplicity, rapidity of the result, low cost, near absence of risk make them complements of choice to the patient history which remains the crucial step of the diagnosis. ST demonstrate in vivo the capacity of the cutaneous mast cells to potentially react to allergens. Their sensitivity is good, some precautions have to be taken into account (no antihistaminic drugs, quality of the extracts). Specificity is also good, but a positive test (which is suggestive of the presence of IgE) not always predicts clinical allergic manifestations. Knowledge of limits and pitfalls of ST is of major importance, especially when it comes to selecting extracts for specific immunotherapy and to investigate severe anaphylactic reactions to food or drugs.

[Sarcoidosis: new therapeutic and pathogenic aspects for an "old" disease]

Sarcoidosis is a multisystemic disorder of unknown etiology characterized by non-caseating epithelioid granuloma. Clinical features are protean and the lack of a specific diagnostic test can make diagnosis difficult. The cause of this disease is still unknown but the diverse manifestations of this disorder help fuel the prevailing hypothesis that sarcoidosis has more than one cause each of which may promote a different pattern of illness. Recent progress, especially in immunology and molecular biology, has advanced our understanding of the pathogenesis of the disease and improved our ability to diagnose and treat this complex condition. This article gives an overview about current concepts in sarcoidosis and focus on immunopathogenic and therapeutic aspects.

[Oral allergy syndrome and food allergy]

To obtain a precise diagnosis of food allergy, it is essential to take a careful and detailed clinical history. This allows for directing further investigations and the patient should receive adequate information. In a research setting, recombinant allergens obtained by biotechnologies permit to reach a precise identification of allergenic proteins, with the hope of treating patients exclusively with the proteins to which they are allergic. In case of light reactions, a strict allergen avoidance is not required, but it is preferable to avoid the consumption of potentially dangerous food in isolated sites and before or during physical effort. In case of severe anaphylactic reactions with potent allergens like hazelnuts, peanuts and sea food, strict information about allergen avoidance and prescription of an emergency kit will be given.

Intravenous immunoglobulin replacement prevents severe and lower respiratory tract infections, but not upper respiratory tract and non-respiratory infections in common variable immune deficiency

BACKGROUND

Although the dose of 400 mg/kg body weight intravenous immunoglobulins (IVIG) every 3-4 weeks is now standard for treating patients with common variable immune deficiency, studies demonstrating its long-term benefits over low 200 mg/kg dose and its effects on infectious subsets (upper vs lower respiratory vs non-respiratory infections) are rare.

METHODS

All patients from a single center with the diagnosis of common variable immune deficiency and whose clinical chart was available during three successive therapeutic periods [a pre-IVIG replacement period, a low-dose (200 mg/kg every 3 weeks) and a standard-dose replacement period (400 mg/kg every 3 weeks)] were screened retrospectively.

RESULTS

Seven patients followed up for a total of 116 patient-years over the three defined periods of observation were recruited. When compared with low-dose therapy, standard-dose intravenous immunoglobulin therapy raised trough IgG levels from 4.3 to 6.5 g/l and significantly decreased the overall frequency of infections, with marked effects on lower respiratory tract and severe infection number. In contrast, non-respiratory and upper respiratory infections were, in comparison, resistant to therapy.

CONCLUSIONS

Overall, these data support the use of standard-dose 400 mg/kg intravenous immunoglobulin therapy, despite the high cost, to raise trough IgG levels to 5-7 g/l, but underlines that some categories of infectious events (non-respiratory, upper respiratory) may need parallel surgical or pharmacological approaches to be optimally prevented or treated.

[Widal triad (Asthma-Nasal polyposis-aspirin intolerance): an inflammatory metabolism abnormality]

Widal disease is characterized by symptomatic triad of aspirin intolerance, nasal polyposis and asthma. This disease is closely linked to abnormalities of the arachidonic acid metabolism. Partly of genetic origin, these anomalies are also related to the immune system function and probably to age. These factors induce an increase of cysleukotriene synthetase enzyme, and consequently an overproduction of cysleukotrienes that have both proinflammatory and bronchoconstrictive effects. In recent years, encouraging results were obtained with anti-leukotrienes, especially when they are associated with topic corticosteroids. Finally, numerous research that attempt to reach a better understanding of arachidonic acid metabolism are underway, which enables us to hope for future therapeutic advances.

Idiotypic vaccination with a murine anti-dsDNA antibody: phase I study in patients with nonactive systemic lupus erythematosus with nephritis

OBJECTIVE

To determine the safety and immunogenicity of an idiotypic anti-dsDNA vaccine in patients with nonactive systemic lupus erythematosus (SLE) and stable lupus nephritis.

METHODS

Patients with SLE with a history of nephritis were randomized for vaccination with the murine anti-dsDNA monoclonal antibody (Mab) 3E10 in a dose ranging, double blind, placebo controlled study (phase I).

RESULTS

Of the 9 patients injected with Mab 3E10, 5 showed a human anti-mouse antibody (HAMA) response, in large part antiidiotypic, which developed within the first 3 months in 3 strong HAMA responders, and more than one year after immunization in an initially weak HAMA responder. All but one nonresponder were receiving low dose prednisone. No adverse events, in particular no evidence of lupus flares, and no untoward laboratory findings were reported over a followup of 2 years.

CONCLUSION

In patients with stable lupus nephritis, immunization with Mab 3E10 appears safe and can generate a significant antiidiotypic response. Idiotypic vaccination may be an approach to specific immunotherapy of autoimmune lupus nephritis.

Evaluation of acoustic rhinometry in a nasal provocation test with allergen

BACKGROUND

The objective was to validate acoustic rhinometry (AR) in a nasal challenge with allergen.

METHODS

Nasal response to allergen provocation was based on clinical and symptom scores, cross-sectional changes of the nasal mucosa as measured by AR with the Rhinoklack system, and peak nasal inspiratory flow (PNIF), in atopic and nonatopic volunteers.

RESULTS

After allergen challenge, mean variation in minimal cross-sectional area (deltaMCA), as measured by AR, or in peak nasal inspiratory flow (deltaPNIF) in nonatopic volunteers, was -0.4+/-14.3% and 5.2+/-15.7%, respectively, compared to baseline. This allowed the determination of a reaction threshold of -29% for deltaMCA and of -26% for deltaPNIF. All but one of the 30 atopic patients reached the AR reaction threshold, whereas all patients reached the PNIF reaction threshold. AR and PNIF closely correlated with clinical and symptom scores for nasal congestion, since there was no significant difference at reaction threshold between both methods.

CONCLUSIONS

In an allergen provocation test, AR appears to be as specific and sensitive as peak nasal inspiratory flow, with the advantage of being independent of the patient's active cooperation. Discrepancies between both methods emphasize the role of nasal cavity anatomy in measuring nasal congestion by AR.

The potential of bronchoalveolar lavage in the prognosis and treatment of connective-vascular diseases

Interstitial lung disease (ILD) has a poor prognosis in a significant number of patients with connective vascular disease (CVD). By bronchoalveolar lavage fluid (BALF) analysis, ILD may be demonstrated in nearly half of patients with CVD prior to any alteration in lung function or chest radiograph. High neutrophil and eosinophil counts are usually associated with a high risk of functional deterioration, whereas the presence of increased lymphocytes correlates with a better outcome. Furthermore, initiation of therapy (steroids and/or cytotoxic agents) early in the course of disease is predictive of a better response. Cell differentials in bronchoalveolar lavage (BAL), together with measurements of cell by-products and techniques such as high resolution computed tomography, may contribute in the near future to help characterize those patients with the highest risks of evolution to pulmonary fibrosis, and to determine the most favorable time in the course of the disease for the initiation of therapy.

Referral pattern to the allergist for hay fever in a health-care system with open access to specialists

Little is known about referral patterns to the allergist for hay fever. In a system with open access to the specialist, we investigated the reasons for consulting an allergist in 126 patients who completed a questionnaire on their first visit. Both sexes were equally represented, the median age was 29 years, the duration of the disease and the duration of seasonal symptoms were 9 years and 10 weeks (median), respectively, and 54% of patients reported a history suggestive of asthma. The symptoms were highly variable; on average, 5.6 on a 10-cm visual analog scale. Most of the patients (94%) had been treated for hay fever before. Only 30% were referred by another physician, the rest being self-referred. The reasons for referral were investigated. The overall motivation to consult was related to symptom severity in 63% of the patients; 37% consulted for other reasons, including an expectation of greater "know-how" on the part of the allergist concerning specific diagnosis, treatment, and advice or counseling. The stimulus triggering the consultation was clearly not related to symptoms or disease in 25% of the cases. We conclude from these data that many patients are clearly interested in benefiting from the professional skill of a fully trained allergist.

Comparison of two in vitro assays, RAST and CAP, when applied to the diagnosis of anaphylactic reactions to honeybee or yellow jacket venoms. Correlation with history and skin tests

We compared the results obtained with a new specific IgE assay (Pharmacia CAP system) to those of RAST and intradermal skin tests (ST) performed in 87 patients with a history of generalized reaction to honeybee or yellow jacket venom. When CAP and RAST were compared with positive ST performed with honeybee venom, CAP sensitivity was not significantly higher (98%) than that of RAST (95%). When yellow jacket venom was tested, CAP sensitivity (93%) was clearly superior to that of RAST (40%). When we compared the specificities of RAST and CAP to bee venom, RAST was positive in 21% of the 24 subjects with negative ST, and CAP in 42%. Among the 29 patients with negative ST to yellow jacket venom, RAST was positive in 17% and CAP in 28%. These results do not reflect a lower specificity of CAP, because CAP positivities could be inhibited in vitro, and because, in three patients with a history of anaphylactic reaction (one to honeybee, two to yellow jacket), CAP was the only positive test confirming the clinical observation. Among the 53 patients who were able to identify the offending insect (honeybee, 31; yellow jacket, 22), the cause of the anaphylactic reaction was usually confirmed by ST and CAP: honeybee venom 97% for both ST and CAP; yellow jacket venom 82% for ST, 86% for CAP. This was not the case for RAST, which confirmed honeybee venom hypersensitivity in 87% and yellow jacket venom hypersensitivity in only 41%. Thus, CAP is both more sensitive and more rapid than RAST, without losing specificity.

Hereditary angioedema: uncomplicated maxillofacial surgery using short-term C1 inhibitor replacement therapy

We report on the successful use of a pasteurized C1 inhibitor (C1-INH) concentrate during dental surgery of a patient affected by hereditary angioedema. The patient recovered fully without complications or side effects. Within 30 min, the first 1,000 U of C1-INH concentrate raised C1-INH concentration from 19 to 55% and function from 40 to 90% of the normal mean. When measured 4 h after the second injection, a further increase of the C1-INH concentration to 86% and a function of 106% relative to the normal mean was observed. Within 2 weeks C1-INH concentration returned to pretreatment level, while the function remained above this value. Serum liver enzyme values did not change and no anti-C1-INH alloantibodies were detected 10 months post-replacement therapy. We conclude that in patients affected by C1-INH deficiency, dental surgery and likely other traumatic procedures can be safely performed in conjunction with C1-INH replacement therapy even without preliminary treatment.

Clinical evaluation of a new in-vitro assay for specific IgE, the immuno CAP system

The Pharmacia CAP system is a new assay for specific IgE characterized by a new solid phase (hydrophilic polymer encased in a capsule). The CAP results were compared to those of the Phadebas IgE RAST and skin-prick tests (SPT) performed in 145 subjects suffering from rhinitis and/or asthma with eight common inhalant allergens (total number of tests = 1160). Concording CAP/RAST results were found in 91% of the tests. The CAP was positive in 78% and the RAST in 65% of the positive SPT. Conversely, the CAP was negative in 90.6% and the RAST in 96.4% of the negative SPT. A pattern negative SPT, negative RAST and positive CAP' was found in 56 tests (40 subjects): in four such subjects, the CAP positivity was confirmed by a positive IgE crossed radioimmunoelectrophoresis. Three borderline positive results were found among 240 negative controls (serum from cord blood or non-atopics). These data indicate that compared with SPT the CAP system is (a) more sensitive than the Pharmacia RAST and (b) does not seem less specific.

[Multifocal pulmonary bilharzioma due to Schistosoma mansoni]

A case of mixed schistosomiasis in an African female immigrant from Cameroon is reported. Schistosoma mansoni was found in a symptomatic double abscess of the lower lobe of the left lung (1981). S. haematobium was present in the stool and the rectal mucosa but the patient had no symptoms. In Africa the patient had been treated for urinary and intestinal bilharziosis with niridazole in 1979, at which time she did not present pulmonary symptoms. After her arrival to Switzerland (1980) she complained of thoracic pain and bloody purulent sputum. A solitary pulmonary infiltration in the left lower lobe and eosinophilia were noted. Tuberculosis was suspected and, despite negative bacillary findings, trial treatment with tuberculostatics was started. As a smaller infiltration appeared beside the first, left lower lobectomy was performed followed by niridazole treatment. The exceptional diagnosis of pulmonary bilharzioma should be considered in patients with a solitary pulmonary infiltration who come from an area endemic for bilharziosis or who show clinical or laboratory signs of a present or past bilharzial infection.

Effect of one gold salt, of betamethasone, and of aspirin on the chemotaxis of human neutrophils measured in vitro

The effects of 1 gold salt, of betamethasone, and of acetylsalicylate on the chemotaxis of human neutrophils were compared in normal volunteers by means of a modified Boyden chamber. The gold salt inhibited chemotaxis by reducing both cell migration capacity and the capacity of plasma to attract the cell. Betamethasone reduced cell migration capacity, but not the chemoattractant capacity of plasma. Acetylsalicylate had no effect on these functions.

[Chemotaxis of human granulocytes "in vitro". Study of inflammatory rheumatic diseases]

68 mesures of chemiotaxis of the blood granulocytes carried out in 42 patients suffering from systemic lupus erythematosus (SLE-17 cases), rheumatoid polyarthritis (RP-15 cases) and sclerodermia (SD-10 cases) showed a deficit in 15 cases. The deficit seen is cellular or plasmatic in the former two conditions (SLE & RP) but purely cellular in the sclerodermia. In SLE there is a relationship between the chemiotaxic deficit and a renal attack or a reduction in complement. In RP a relationship was established between chemiotaxis and a marked rise in VS (?) (synovial volume ?) and the rheumatoid factor titre. A relationship with a visceral attack was seen in SD. Contrary to other studies reporting a constant chemiotaxic deficit in these conditions, the present work shows that the deficit : 1. exists in only a minority of patients ; 2. is transitory ; 3. is not associated solely with granulocytes but may also be related to plasmatic factors. The diminution of chemiotaxis which is always seen in the acute phase of the illness may result from the reduction on the quantities of less reactive granulocytes in the peripheral blood ; the most reactive pass out through the walls of the vessels and move towards the foci of inflammation.

[Chemotaxis of human polymorphonuclear cells in vitro. Study of inflammatory rheumatic diseases]

Sixty-eight determinations of leukocyte chemotaxis were performed in 42 patients suffering from systemic lupus erythematodes (17 cases), rheumatoid arthritis (15 cases) and scleroderma (10 cases). In contrast to the results of others, this study showed a deficiency in only 15 of 42 cases (35.7%). Impairment of chemotaxis was always transitory and demonstrable only during acute phases of disease. Intrinsic deficiency of PMN leukocytes as well as deficiency of plasma factors were related to the clinical and biological course of the disease and to the treatment.