Pre-asthma: a useful concept for prevention and disease-modification? A EUFOREA paper. Part 1-allergic asthma

Asthma, which affects some 300 million people worldwide and caused 455,000 deaths in 2019, is a significant burden to suffers and to society. It is the most common chronic disease in children and represents one of the major causes for years lived with disability. Significant efforts are made by organizations such as WHO in improving the diagnosis, treatment and monitoring of asthma. However asthma prevention has been less studied. Currently there is a concept of pre- diabetes which allows a reduction in full blown diabetes if diet and exercise are undertaken. Similar predictive states are found in Alzheimer's and Parkinson's diseases. In this paper we explore the possibilities for asthma prevention, both at population level and also investigate the possibility of defining a state of pre-asthma, in which intensive treatment could reduce progression to asthma. Since asthma is a heterogeneous condition, this paper is concerned with allergic asthma. A subsequent one will deal with late onset eosinophilic asthma.

EUFOREA summit in Brussels 2023: inspiring the future of allergy & respiratory care

In March 2023, the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) organized its bi-annual Summit in Brussels with expert panel members of EUFOREA, representatives of the EUFOREA patient advisory board, and the EUFOREA board and management teams. Its aim was to define the research, educational and advocacy initiatives to be developed by EUFOREA over the next 2 years until the 10th anniversary in 2025. EUFOREA is an international non-for-profit organization forming an alliance of all stakeholders dedicated to reducing the prevalence and burden of chronic allergic and respiratory diseases via research, education, and advocacy. Based on its medical scientific core competency, EUFOREA offers an evidence-supported platform to introduce innovation and education in healthcare leading to optimal patient care, bridging the gap between latest scientific evidence and daily practice. Aligned with the mission of improving health care, the expert panels of asthma, allergic rhinitis (AR), chronic rhinosinusitis (CRS) & European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), allergen immunotherapy (AIT) and paediatrics have proposed and elaborated a variety of activities that correspond to major unmet needs in the allergy and respiratory field. The current report provides a concise overview of the achievements, ambitions, and action plan of EUFOREA for the future, allowing all stakeholders in the allergy and respiratory field to be up-dated and inspired to join forces in Europe and beyond.

Enhanced recovery after surgery in patients with normal pressure hydrocephalus undergoing ventriculoperitoneal shunting procedures

OBJECTIVE

Patients with idiopathic normal pressure hydrocephalus (iNPH) who undergo ventriculoperitoneal shunt (VPS) placement often belong to an older demographic, putting them at increased risk of postoperative delirium and related complications. Recent literature documenting the use of Enhanced Recovery After Surgery (ERAS) protocols in various disciplines of surgery has shown improved clinical outcomes, faster discharge, and lower readmission rates. Early return to a familiar environment (i.e., discharged home) is a well-known predictor of reduced postoperative delirium. However, ERAS protocols are uncommon in neurosurgery, especially intracranial procedures. We developed a novel ERAS protocol for patients with iNPH undergoing VPS placement to gain further insight regarding postoperative complications, specifically delirium.

METHODS

We studied 40 patients with iNPH with indications for VPS. Seventeen patients were selected at random to undergo the ERAS protocol, and twenty-three patients underwent the standard VPS protocol. The ERAS protocol consisted of measures to reduce infection, manage pain, minimize invasiveness, confirm procedural success with imaging, and shorten the length of stay. Pre-operative American Society of Anesthesiologists (ASA) grade was collected for each patient to indicate baseline risk. Rates of readmission and postoperative complications, including delirium and infection, were collected at 48 h, 2 weeks, and 4 weeks postoperatively.

RESULTS

There were no perioperative complications among the 40 patients. There was no postoperative delirium in any of the ERAS patients. Postoperative delirium was observed in 10 of 23 non-ERAS patients. There was no statistically significant difference between the ASA grade between the ERAS and non-ERAS groups.

CONCLUSIONS

We described a novel ERAS protocol for patients with iNPH receiving VPS focusing on an early discharge. Our data suggest that ERAS protocols in VPS patients might reduce the incidence of delirium without increasing the risk of infection or other postoperative complications.

Surgical Treatment of Dural Arteriovenous Fistula: A Case Report and Literature Review

Dural arteriovenous fistulas (dAVF) are rare, acquired intracranial arteriovenous malformations consisting of a pathological shunt located within the intracranial dura matter. The etiology of dAVFs remains unclear, but current thought suggests that these lesions are associated with thrombosis of the dural sinuses and other intracranial veins. dAVF’s with severe symptomatology or high-risk angioarchitecture should be treated without delay, and endovascular repair is generally accepted as the first-line treatment. Both transarterial and transvenous approaches can be used to cure dAVFs. Surgery and stereotactic radiosurgery may also be used when endovascular approaches are unsuccessful or not feasible. Some studies, however, have shown that surgery for dAVFs in the anterior cranial fossa is preferred over the endovascular approach. Due to the proximity of some dAVFs to the orbit, endovascular embolization of the dAVF carries a higher risk of complications, primarily due to the formation of dangerous extracranial or intracranial anastomoses. We present the case of a 64-year-old male with an incidentally discovered Borden type III dAVF arising from the anterior branches of the middle meningeal artery and draining into the middle cerebral vein. Due to the location of his dAVF, craniotomy was selected for ligation of the fistula. The procedure went without complication. A catheter angiogram of the brain one month after surgery showed an absence of flow through the arteriovenous fistula and a middle meningeal artery that had returned to its normal caliber.

Modified automatic R-peak detection algorithm for patients with epilepsy using a portable electrocardiogram recorder

Earlier studies have shown that short term heart rate variability (HRV) analysis of ECG seems promising for detection of epileptic seizures. A precise and accurate automatic R-peak detection algorithm is a necessity in a real-time, continuous measurement of HRV, in a portable ECG device. We used the portable CE marked ePatch® heart monitor to record the ECG of 14 patients, who were enrolled in the videoEEG long term monitoring unit for clinical workup of epilepsy. Recordings of the first 7 patients were used as training set of data for the R-peak detection algorithm and the recordings of the last 7 patients (467.6 recording hours) were used to test the performance of the algorithm. We aimed to modify an existing QRS-detection algorithm to a more precise R-peak detection algorithm to avoid the possible jitter Qand S-peaks can create in the tachogram, which causes error in short-term HRVanalysis. The proposed R-peak detection algorithm showed a high sensitivity (Se = 99.979%) and positive predictive value (P+ = 99.976%), which was comparable with a previously published QRS-detection algorithm for the ePatch® ECG device, when testing the same dataset. The novel R-peak detection algorithm designed to avoid jitter has very high sensitivity and specificity and thus is a suitable tool for a robust, fast, real-time HRV-analysis in patients with epilepsy, creating the possibility for real-time seizure detection for these patients.

Biomechanical assessment of the aortic root using novel force transducers

In recent years the use of valve sparing techniques has become more common in selected patients with aortic valve insufficiency. However, limited experimental research has been performed to document the biomechanical effect of these techniques. One experimental platform is to evaluate how the normal physiological aortic root forces are altered or re-established after the surgical intervention. Hence, the aim of this project was to develop new implantable force transducers for a biomechanical description of various aortic root repair techniques. Two novel force transducers were developed. Both transducers were manufactured using rapid prototyping and were instrumented with miniature strain gauges. Before implantation both transducers were calibrated using a dedicated setup, yielding very linear correlation between the applied load and transducer output. The developed force transducers were implanted and tested in an 80kg porcine model. In the post-cardioplegic heart, the peak annular forces varied in the range of 2-4N and the commissural forces varied from 0.4 to 0.8N with a left ventricular pressure of 111mmHg. In conclusion, the two new force transducers to measure forces in the aortic root have successfully been developed. With these new devices a novel versatile and direct force measurement system has been provided.

IgG4 but no IgG1 antibody production after intralymphatic immunotherapy with recombinant MAT-Feld1 in human

Allergy immunotherapy (AIT) mediates protection against allergen exposure in part due to allergen-specific antibodies. While immunization typically stimulated IgG1 and IgG2, AIT is often associated with production of IgG4. Here, twenty cat dander-sensitized patients were randomized to receive three injections of intralymphatic immunotherapy (ILIT) with MAT-Feld1 adsorbed to aluminum hydroxide or just aluminum hydroxide (placebo) in a double-blind setting (ClinicalTrials.gov NCT00718679). Whereas the clinical data, showing benefit of Mat-Feld1 ILIT was published in 2012 (Senti et al., J Allergy Clin Immunol, vol 129(5):1290-1296), the current study investigated the cat allergen-specific antibody responses. Blood was drawn prior to ILIT, as well as 1, 3, and 12 months after first ILIT. The sera were analyzed to characterize all IgG subclasses and IgE antibody responses. ILIT with MAT-Feld1 elicited high levels of total IgG that were maintained for at least 12 months. Interestingly, a strong increase in IgG4 and some increase in IgG2 were observed throughout the study, while production of cat-specific IgG1 and IgG3 was not stimulated by MAT-Feld1 ILIT. The IgE levels remained constant.

The value of routine bone marrow biopsy in patients with diffuse large B-cell lymphoma staged with PET/CT: a Danish-Canadian study

BACKGROUND

The added diagnostic and prognostic value of routine bone marrow biopsy (BMB) in patients with diffuse large B-cell lymphoma (DLBCL) undergoing positron emission tomography combined with computed tomography (PET/CT) staging is controversial.

PATIENTS AND METHODS

Patients with newly diagnosed DLBCL who underwent both staging PET/CT and BMB were retrospectively identified in British Columbia, Aalborg, and Copenhagen. Original written PET/CT and pathology reports were retrospectively reviewed to determine Ann Arbor stage and outcomes, with and without the contribution of BMB.

RESULTS

A total of 530 patients were identified: 146 (28%) had focal bone marrow (BM) lesions on PET/CT and 87 (16%) had positive BMB. Fifty-two of 146 patients (36%) with positive PET/CT had a positive BMB [39 DLBCL, 13 indolent non-Hodgkin lymphoma (iNHL)], while 35 of 384 patients (9%) with negative PET/CT had positive BMB (12 DLBCL, 23 iNHL). BMB upstaged 12/209 (6%) of stage I/II patients to stage IV, although this was the case for only 3 (1%) patients with DLBCL in the BMB. PET/CT identified BM involvement by BMB with sensitivity 60%, specificity 79%, positive predictive value 36%, and negative predictive value 91%. Concordant histological involvement of the BM by DLBCL was associated with worse overall survival and progression-free survival than discordant or no involvement in univariate and multivariate analyses.

CONCLUSIONS

In patients with DLBCL, staging PET/CT can miss BM involvement with concordant DLBCL (less common) or discordant iNHL (more common). Routine BMB does not add relevant diagnostic or prognostic value over PET/CT alone in the majority of patients with DLBCL.

Doubling the single-dose infusion rate of tocilizumab in rheumatoid arthritis is safe and efficacious

OBJECTIVES

To investigate the impact of enhanced infusion rate of tocilizumab on the occurrence of infusion reactions, overall safety, and efficacy in rheumatoid arthritis (RA).

METHOD

We conducted a 24-week multicentre, open-label, randomized parallel group study comparing adverse event (AE) and effect profiles following tocilizumab IV 8 mg/kg every 4 weeks over 31 min vs. standard 60-min infusions in patients with RA and an inadequate clinical response to disease-modifying anti-rheumatic drugs (DMARDs) and/or tumour necrosis factor (TNF)-α inhibitors.

RESULTS

A total of 47 patients were enrolled in the study and randomized to fast infusions (n = 25) and controls (n = 22). Incidences of infusion reactions were similar between the two groups, neither of them leading to withdrawal. Likewise, the incidence of additional AEs did not differ between the treatment arms. Two serious adverse events (SAEs) were reported, in the control group. Four patients withdrew due to AEs, two from each arm. Efficacy at week 24 was comparable between groups.

CONCLUSIONS

In RA, monthly tocilizumab infusions of 8 mg/kg provided over 31 or 60 min during 24 weeks did not differ concerning safety or efficacy.

Determinants of efficacy and safety in epicutaneous allergen immunotherapy: summary of three clinical trials

The results of our third trial on epicutaneous allergen-specific immunotherapy (EPIT) will be presented and discussed in the context of our previous trials. This monocentric, placebo-controlled, double-blind phase I/IIa trial included 98 patients with grass pollen rhinoconjunctivitis. Prior to the pollen season 2009, patients received six patches (allergen extract: n = 48; placebo: n = 50) with weekly intervals, administered onto tape-stripped skin. Allergen EPIT produced a median symptom improvement of 48% in 2009 and 40% in the treatment-free follow-up year 2010 as compared to 10% and 15% improvement after placebo EPIT (P = 0.003). After allergen EPIT but not placebo EPIT, conjunctival allergen reactivity was significantly decreased and allergen-specific IgG4 responses were significantly elevated (P < 0.001). In conclusion, our three EPIT trials found that allergen EPIT can ameliorate hay fever symptoms. Overall, treatment efficacy appears to be determined by the allergen dose. Local side-effects are determined by the duration of patch administration, while risk of systemic allergic side-effects is related to the degree of stratum corneum disruption.

A critical appraisal of analyzing nasal provocation test results in allergen immunotherapy trials

BACKGROUND

The statistical analysis of nasal provocation tests is very complex. We compared the conventional analysis with the maximally selected test statistics and the hierarchical ordered logistic model.

METHODS

We re-analyzed data from a trial with 112 patients suffering from grass pollen allergy. The patients had been randomized to receive either intralymphatic immunotherapy (ILIT) or subcutaneous immunotherapy (SCIT).

RESULTS

The conventional analysis indicated that the logarithmized ratio between the pre- and the post-treatment threshold concentration was significantly lower for ILIT than for SCIT. The maximally selected test statistics was used to test different threshold symptom scores that would imply positive clinical symptoms at the given allergen concentration. A threshold score of 3 maximised the difference in improvement between the ILIT and the SCIT groups. The hierarchical ordered logistic model does not take threshold allergen concentrations as the basis for analysis, but the single scores measured at each concentration. This approach simultaneously considers the treatment effect (ILIT versus SCIT), the time effect (pre- versus post-treatment), and the dose effect (different allergen concentrations). The hierarchical ordered logistic model revealed that the clinical improvement was greater after ILIT than after SCIT.

CONCLUSION

As the choice of method can affect the outcome, guidelines for analysis are highly needed.

Electrode placement in bioimpedance spectroscopy: evaluation of alternative positioning of electrodes when measuring relative dehydration in athletes

In order to maintain a homeostatic environment in human cells, the balance between absorption and separation of water must be retained. Imbalance will have consequences on both the cellular and organ levels. Studies performed on athletes have shown coherence between their hydration status and ability to perform. A dehydration of 2-7% of total body weight resulted in a marked decrease in performance. Measurement and monitoring of hydration status may be used to optimize athlete performance. Therefore, in this current study bioimpedance spectroscopy is used to determine the hydration status of athletes. Trials were made to investigate alternative ways of electrode placement when performing bioimpedance spectroscopy in order to measure relative dehydration. A total of 14 test subjects underwent measurements before, during, and after a cycle test of 3×25min. Electrodes where placed to measure body impedance in three different ways: wrist-ankle (recommended method), wrist-wrist, and transthoracic. Furthermore, the relative loss in weight of the subjects during the trial was registered. The study showed no relation between relative weight loss and the wrist-wrist and transthoracic placement method, using bioimpedance spectroscopy to measure relative dehydration. The inability of the method to detect such relative changes in hydration may be due to the bioimpedance spectroscopy technology being extremely sensitive to changes in skin temperature, movement artifacts, thoroughness in placing the electrodes, and the physiological impact on the human body when performing exercise. Therefore, further research into the area of bioimpedance spectroscopy is needed before this methodology can be applied in monitoring active athletes. Hence, a simple weight measurement still seems a more useful way of determining a relative change of hydration in an active setting.

Evaluation of the iPLEX® Sample ID Plus Panel designed for the Sequenom MassARRAY® system. A SNP typing assay developed for human identification and sample tracking based on the SNPforID panel

Sequenom launched the first commercial SNP typing kit for human identification, named the iPLEX(®) Sample ID Plus Panel. The kit amplifies 47 of the 52 SNPs in the SNPforID panel, amelogenin and two Y-chromosome SNPs in one multiplex PCR. The SNPs were analyzed by single base extension (SBE) and Matrix Assisted Laser Desorption/Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS). In this study, we evaluated the accuracy and sensitivity of the iPLEX(®) Sample ID Plus Panel by comparing the typing results of the iPLEX(®) Sample ID Plus Panel with those obtained with our ISO 17025 accredited SNPforID assay. The average call rate for duplicate typing of any one SNPs in the panel was 90.0% when the mass spectra were analyzed automatically with the MassARRAY(®) TYPER 4.0 genotyping software in real time. Two reproducible inconsistencies were observed (error rate: 0.05%) at two different SNP loci. In addition, four inconsistencies were observed once. The optimal amount of template DNA in the PCR was ≥10ng. There was a relatively high risk of allele and locus drop-outs when ≤1ng template DNA was used. We developed an R script with a stringent set of "forensic analysis parameters" based on the peak height and the signal to noise data exported from the TYPER 4.0 software. With the forensic analysis parameters, all inconsistencies were eliminated in reactions with ≥10ng DNA. However, the average call rate decreased to 69.9%. The iPLEX(®) Sample ID Plus Panel was tested on 10 degraded samples from forensic case-work. Two samples could not be typed, presumably because the samples contained PCR and SBE inhibitors. The average call rate was generally lower for degraded DNA samples and the number of inconsistencies higher than for pristine DNA. However, none of the inconsistencies were reproduced and the highest match probability for the degraded samples typed with the panel was 1.7E-9 using the stringent forensic analysis parameters. Although the relatively low sensitivity of the iPLEX(®) Sample ID Plus Panel makes it inappropriate for typing of trace samples from crime scenes, the panel may be interesting for relationship testing and for identification of e.g. samples in biobanks because of the low reagent costs, the limited hands-on time of the iPLEX(®) assay and the automatic analysis of the mass spectra.

The contact sensitizer diphenylcyclopropenone has adjuvant properties in mice and potential application in epicutaneous immunotherapy

BACKGROUND

Epicutaneous vaccination has gained increasing interest during the past decade as it offers a safe, needle-free, and patient-friendly alternative to invasive vaccine administrations. Recently, the safety and early efficacy of epicutaneous immunotherapy were also demonstrated in patients with hay fever, as an alternative to conventional subcutaneous allergen-specific immunotherapy (SCIT). One major challenge to epicutaneous vaccination is the barrier function of the stratum corneum, which must be overcome either by abrasive methods or by hydration. Such barrier function of the stratum corneum also hampers the use of common adjuvants used to enhance the efficacy of vaccination.

METHODS

In a mouse model of allergy, we tested the adjuvant potential of diphenylcyclopropenone (DCP), a strong contact sensitizer, which is currently used for the treatment of a T cell-mediated hair loss disease (alopezia areata).

RESULTS

Diphenylcyclopropenone enhanced antigen-specific IgG2a antibody responses as well as IL-10 cytokine production after epicutaneous immunization with ovalbumin (OVA). Epicutaneous allergen-specific immunotherapy (EPIT) with OVA and DCP also protected sensitized mice from anaphylaxis and asthma. The protective effect was more robust than that of conventional SCIT, which did not significantly alleviate the symptoms of allergy in the murine models of anaphylaxis and asthma.

CONCLUSIONS

This preclinical study confirmed previous clinical data that have demonstrated the potential of the skin as a target for allergen immunotherapy. The study also suggests that epicutaneous immunization or immunotherapy can be improved when an appropriate adjuvant such as DCP is used.

Low-dose cytosine arabinoside therapy in a patient with myelofibrosis during transformation to acute non-lymphocytic leukemia

A patient with myelofibrosis transforming into acute non-lymphocytic leukaemia (ANLL) was treated with low doses of cytosine arabinoside (ARA-C). Complete remission was obtained twice without serious toxicity. It is suggested that low-dose ARA-C may be an effective and rather non-toxic therapy in patients with myeloproliferative disorders transforming to ANLL.

The antihypertensive effect of pinacidil versus prazosin in mild to moderate hypertensive patients seen in general practice

The antihypertensive effect of a new vasodilating drug, pinacidil, was compared with prazosin in a randomized, open study in general practice including 131 patients with a sitting diastolic blood pressure (DBP) between 100-115 mmHg. At inclusion 108 patients were untreated and the remaining patients were on treatment with thiazide diuretics and/or beta-blockers. The aim was to reduce the sitting DBP to less than or equal to 95 mmHg, which was achieved in 85% of the patients treated with pinacidil and in 77% of the patients treated with prazosin (NS). In the responding patients the reductions were (mean +/- SD) 16 +/- 7 mmHg (p less than 0.001) and 13 +/- 6 mmHg (p less than 0.001) in the pinacidil group (n = 60) and the prazosin group (n = 46), respectively (p less than 0.10). During 5 months of maintenance therapy no statistically significant differences in blood pressures between the two treatment groups were present. Side-effects were typical of vasodilator therapy, i.e. headache, dizziness, tachycardia and edema, leading to discontinuation of therapy in 10 patients in each treatment group. Heart rate (HR) was increased with pinacidil and unchanged with prazosin. Edema was frequently seen with pinacidil and dizziness with prazosin. Because of edema a thiazide diuretic was given to nine patients in the pinacidil group and two patients in the prazosin group. No clinically significant changes in ECG and biochemical variables were observed. In conclusion, the study has demonstrated that pinacidil is as effective an antihypertensive agent as prazosin. Pinacidil may be used as monotherapy. However, the study suggests that pinacidil should be used as add-on therapy to thiazide diuretics.

Storage of polyvinylpyrrolidone (PVP) in tissues following long-term treatment with a PVP-containing vasopressin preparation

The parenteral use of polyvinylpyrrolidone (PVP) leads to PVP retention in the human organism. Four case histories dealing with patients on long-term treatment with a PVP-containing vasopressin preparation are presented and the possibility of a harmful effect of the PVP storage is discussed. The presence of PVP in serum, demonstrated by lipoprotein electrophoresis, is described. Based on the literature and the present findings, a withdrawal of PVP-containing preparations for injectional purposes is advocated.

Targeting the MHC class II pathway of antigen presentation enhances immunogenicity and safety of allergen immunotherapy

BACKGROUND

Current s.c. allergen-specific immunotherapy (SIT) leads to amelioration of IgE-mediated allergy, but it requires numerous allergen injections over several years and is frequently associated with severe side-effects. The aim of this study was to test whether modified recombinant allergens can improve therapeutic efficacy in SIT while reducing allergic side-effects.

METHODS

The major cat allergen Fel d 1 was fused to a TAT-derived protein translocation domain and to a truncated invariant chain for targeting the MHC class II pathway (MAT-Fel d 1). The immunogenicity was evaluated in mice, while potential safety issues were assessed by cellular antigen stimulation test (CAST) using basophils from cat-dander-allergic patients.

RESULTS

MAT-Fel d 1 enhanced induction of Fel d 1-specific IgG2a antibody responses as well as the secretion of IFN-gamma and IL-2 from T cells. Subcutaneous allergen-specific immunotherapy of mice using the modified Fel d 1 provided stronger protection against anaphylaxis than SIT with unmodified Fel d 1, and MAT-Fel d 1 caused less degranulation of human basophils than native Fel d 1.

CONCLUSION

MAT-Fel d 1 allergen enhanced protective antibody and Th1 responses in mice, while reducing human basophil degranulation. Immunotherapy using MAT-Fel d 1 allergen therefore has the potential to enhance SIT efficacy and safety, thus, shortening SIT. This should increase patient compliance and lower treatment costs.

Threshold response of benthic macrofauna integrity to metal contamination in West Greenland

Sediment metal chemistry and benthic infauna surveys have been conducted over 33 years following a BACI protocol in relation to submarine tailings deposition (STD) from a lead-zinc mine in a western Greenland fjord system. We found clear predictable changes of benthic fauna composition in response to STD both temporally and spatially. Faunal re-colonization 15 years after mine closure, was slow and the impacted areas were still dominated by opportunistic species, although the most opportunistic ones (e.g. Capitella species) had decreased in importance. Concentration-response relations between sediment lead and faunal indices of benthic community integrity (e.g. the AMBI and DKI indices) indicated a threshold of ca. 200mg/kg, above which deterioration of faunal communities occurred. Above this threshold, diversity decreased dramatically and dominance of sensitive and indifferent species was substituted by tolerant or opportunistic species. Disposal of metal contaminated tailings may have long lasting effects on the biological system.