Immune cell dynamics deconvoluted by single-cell RNA sequencing in normothermic machine perfusion of the liver

Normothermic machine perfusion (NMP) has emerged as an innovative organ preservation technique. Developing an understanding for the donor organ immune cell composition and its dynamic changes during NMP is essential. We aimed for a comprehensive characterization of immune cell (sub)populations, cell trafficking and cytokine release during liver NMP. Single-cell transcriptome profiling of human donor livers prior to, during NMP and after transplantation shows an abundance of CXC chemokine receptor 1⁺/2⁺ (CXCR1⁺/CXCR2⁺) neutrophils, which significantly decreased during NMP. This is paralleled by a large efflux of passenger leukocytes with neutrophil predominance in the perfusate. During NMP, neutrophils shift from a pro-inflammatory state towards an aged/chronically activated/exhausted phenotype, while anti-inflammatory/tolerogenic monocytes/macrophages are increased. We herein describe the dynamics of the immune cell repertoire, phenotypic immune cell shifts and a dominance of neutrophils during liver NMP, which potentially contribute to the inflammatory response. Our findings may serve as resource to initiate future immune-interventional studies.

[Sexual and reproductive health of adolescents living with HIV in pediatric care programs in Abidjan : Structured provision of care and perceptions of health care workers in 2019]

INTRODUCTION

The majority of adolescents living with HIV (ALHIV) reside in sub-Saharan Africa, with sexual and reproductive health (SRH) needs to be met. The health care facilities and professionals involved have a major role to assume in the quality of SRH services offered to these teenagers.

OBJECTIVE

To investigate the SRH services offered to ALHIV subjects in pediatric facilities in Abidjan, Ivory-Coast.

METHODS

In 2019 we conducted an exploratory cross-sectional study using qualitative and quantitative methods in three pediatric facilities caring for ALHIV subjects (CIRBA, CTAP and CePReF) and participating in the IeDEA (International epidemiologic databases to Evaluate AIDS project) in Abidjan, Ivory Coast. This study included: (1) an inventory of SRH services, using a questionnaire and direct observation, describing their adaptation to the teenagers' needs and their inclusion in provision of care; (2 an assessment by means of semi-structured interviews of 14 health professionals' perceptions of the SRH needs of the ALHIV subjects with whom they worked. Quantitative data were expressed in percentages and qualitative data from the interviews were analyzed through inductive thematic analysis.

RESULTS

The care provided in the three facilities was poorly adapted to the teenagers' needs. Few SRH services were effectively provided to the ALHIV subjects in the different centers. The services essentially consisted in condom distribution and organization of SRH-based focus groups. Exceptionally, hormonal contraception was offered to teenage girls. Barriers to the services were largely due to poorly equipped facilities, particularly in terms of SRH offer, health professionals' experience, and support provided for ALHIV subjects and their parents. The health professionals were desirous of SRH skill-building programs enabling them to deliver optimal, adequately contextualized SRH services to the teenagers.

CONCLUSIONS

In pediatric programs addressed to ALHIV subjects in three Abidjan facilities, the teenagers' SRH needs remain unmet. It is urgently necessary to strengthen the health facilities by means of improved equipment, enhanced awareness of teenagers' needs, and training programs enabling the health professionals to provide more adapted sexual and reproductive health services.

Laser produced soft x-ray source diagnostics with temporal, spectral, and spatial resolution

We demonstrate the use of three diagnostic tools which simultaneously view the target from nearly the same direction, and their results are combined to provide temporally, spectrally, and spatially resolved absolutely calibrated target emission information. To demonstrate this capability, Au targets were irradiated by 1.8 kJ, 3 ns laser pulses to produce broadband soft x-ray emission in the 0.1-3.5 keV spectral range. Target diagnostics included a time-resolved x-ray diode array, each measured a partial spectral band, time-integrated spectrally resolved absolutely calibrated transmission grating spectrometer, and static and time-resolved soft x-ray imagers coupled to a charge-coupled device camera and to a streak camera, respectively, measuring spatially and temporally resolved radiation at the main Au target emission bands. The combined temporally, spectrally, and spatially resolved absolutely calibrated target emission result can be compared to simulations and be used to design and analyze experiments in which the source emission is used as a drive for various physical processes.

Allergic patients during the COVID-19 pandemic-Clinical practical considerations: An European Academy of Allergy and Clinical Immunology survey

BACKGROUND

The COVID-19 pandemic has affected health care systems unexpectedly. However, data focusing on practical considerations experienced by health care professionals (HCPs) providing care to allergic patients is scarce.

METHODS

Under the framework of the European Academy of Allergy and Clinical Immunology (EAACI), a panel of experts in the field of immunotherapy developed a 42-question online survey, to evaluate real-life consequences of the COVID-19 pandemic in allergy practice.

RESULTS

The respondents in the survey were 618. About 80% of HCPs indicated being significantly affected in their allergy practice. A face-to-face visit reduction was reported by 93% of HCPs and about a quarter completely interrupted diagnostic challenges. Patients with severe uncontrolled asthma (59%) and anaphylaxis (47%) were prioritized for in-person care. About 81% maintained an unaltered prescription of inhaled corticosteroids (ICS) in asthmatics. About 90% did not modify intranasal corticosteroids (INCS) in patients with allergic rhinitis. Nearly half of respondents kept biological prescriptions unmodified for asthma. About 50% of respondents kept their allergen immunotherapy (AIT) prescription patterns unchanged for respiratory allergies; 60% for insect venom allergies. Oral immunotherapy (OIT) for food allergies was initiated by 27%. About 20% kept carrying out up-dosing without modifications and 14% changed to more prolonged intervals. Telemedicine practice was increased.

CONCLUSIONS

HCPs providing care to allergic patients were affected during the pandemic in diagnostic, management, and therapeutic approaches, including AIT for respiratory, insect-venom, and food allergies. Most HCPs maintained controller treatments for both asthma, and allergic rhinitis consistent with international recommendations, as well as biological agents in asthma. Remote tools are valuable in delivering allergy care.

Isotype-specific binding patterns of serum antibodies to multiple conformational epitopes of Bet v 1

BACKGROUND

Birch pollen is an important elicitor of respiratory allergy. The major allergen, Bet v 1, binds IgE exclusively via conformational epitopes.

OBJECTIVE

To identify Bet v 1-specific epitope repertoires of IgE and IgG from birch pollen-allergic and non-allergic subjects.

METHODS

Chimeric proteins were created by grafting individual epitope-sized, contiguous surface patches of Bet v 1 onto a non-allergenic structural homologue and expressed in Escherichia coli. Binding of IgE, IgG1 and IgG4 from sera of 30 birch pollen-allergic and 11 non-allergic subjects to Bet v 1, 13 chimeric proteins and four bacterial Bet v 1 homologues were measured by ELISA. The proportion of epitope-specific in total Bet v 1-specific IgE and the cross-reactivity of Bet v 1-specific IgE with bacterial homologues were determined by competitive ELISA.

RESULTS

Thirteen soluble, correctly folded chimeric proteins were produced. IgE from 27/30 birch pollen-allergic patients bound to 1-12 chimeric proteins (median 4.0) with patient-specific patterns. Three chimeras binding IgE from the majority of sera were identified, whose pgrafted patches overlapped with previously published epitopes. Patterns of IgG1 and IgG4 binding to the chimeric proteins did not correspond to the binding patterns of IgE. Sera of 19/30 birch pollen-allergic patients contained low amounts of IgE to bacterial homologues. Bacterial proteins were able to partially inhibit IgE binding to Bet v 1.

CONCLUSION

Epitopes recognized by Bet v 1-specific antibodies from birch pollen-allergic patients are specific to each patient and differ between IgE, IgG1 and IgG4.

Management of anaphylaxis due to COVID-19 vaccines in the elderly

Older adults, especially men and/or those with diabetes, hypertension, and/or obesity, are prone to severe COVID‐19. In some countries, older adults, particularly those residing in nursing homes, have been prioritized to receive COVID‐19 vaccines due to high risk of death. In very rare instances, the COVID‐19 vaccines can induce anaphylaxis, and the management of anaphylaxis in older people should be considered carefully. An ARIA‐EAACI‐EuGMS (Allergic Rhinitis and its Impact on Asthma, European Academy of Allergy and Clinical Immunology, and European Geriatric Medicine Society) Working Group has proposed some recommendations for older adults receiving the COVID‐19 vaccines. Anaphylaxis to COVID‐19 vaccines is extremely rare (from 1 per 100,000 to 5 per million injections). Symptoms are similar in younger and older adults but they tend to be more severe in the older patients. Adrenaline is the mainstay treatment and should be readily available. A flowchart is proposed to manage anaphylaxis in the older patients.

Placebo effects in allergen immunotherapy-An EAACI Task Force Position Paper

The placebo (Latin "I will please") effect commonly occurs in clinical trials. The psychological and physiological factors associated with patients' expectations about a treatment's positive and negative effects have yet to be well characterized, although a functional prefrontal cortex and intense bidirectional communication between the central nervous system and the immune system appear to be prerequisites for a placebo effect. The use of placebo raises certain ethical issues, especially if patients in a placebo group are denied an effective treatment for a long period of time. The placebo effect appears to be relatively large (up to 77%, relative to pretreatment scores) in controlled clinical trials of allergen immunotherapy (AIT), such as the pivotal, double-blind, placebo-controlled (DBPC) randomized clinical trials currently required by regulatory authorities worldwide. The European Academy of Allergy and Clinical Immunology (EAACI) therefore initiated a Task Force, in order to better understand the placebo effect in AIT and its specific role in comorbidities, blinding issues, adherence, measurement time points, variability and the natural course of the disease. In this Position Paper, the EAACI Task Force highlights several important topics regarding the placebo effect in AIT such as a) regulatory aspects, b) neuroimmunological and psychological mechanisms, c) placebo effect sizes in AIT trials, d) methodological limitations in AIT trial design and e) potential solutions in future AIT trial design. In conclusion, this Position Paper aims to examine the methodological problem of placebo in AIT from different aspects and also to highlight unmet needs and possible solutions for future trials.

[HIV Disclosure to the Child/Adolescent in Central and West Francophone Africa]

We report the attitudes and practices of health care workers involved in the disclosure process to adolescents living with HIV (ALHIV) in a network including West and Central African French-speaking countries, and the experiences of young living with HIV (YLHIV). During a three-day workshop in Abidjan, Côte d'Ivoire, caregivers (doctors, psychologists, social workers) from 19 pediatric HIV treatment sites shared their practices and difficulties, and four YPLHIV their own disclosure experience. Thirty five participants from eight West/Central African countries (Benin, Burkina Faso, Ivory Coast, Cameroon, Mali, Democratic Republic of Congo, Senegal, Togo) contributed: 14 doctors, eight psychologists, six counselors, three social workers. The experience of the centers was variable, but the age at disclosure was late: 34% of 1296 adolescents between 10 and 12 years of age knew their status. The median age at disclosure was 13 years (range: 11-15 years). The practice of the disclosure was often complex, because of multiple factors (fear of the parents of the breaking of the secrecy, lack of communication between professionals). The individual disclosure was the main practice. Four centers practiced HIV disclosure in group sessions to facilitate mirror support, and one used peer-to-peer support. YPLHIV have advocated for an earlier disclosure, from 10 years. In West and Central Africa, the process of HIV disclosure remains complex for parents and caregivers, and occurs too late. The development of a good practice guideline for HIV disclosing adapted to socio-cultural contexts should help to improve this process.

The urgent need for a harmonized severity scoring system for acute allergic reactions

The accurate assessment and communication of the severity of acute allergic reactions are important to patients, clinicians, researchers, the food industry, and public health and regulatory authorities. Severity has different meanings to different stakeholders with patients and clinicians rating the significance of particular symptoms very differently. Many severity scoring systems have been generated, most focusing on the severity of reactions following exposure to a limited group of allergens. They are heterogeneous in format, none has used an accepted developmental approach, and none has been validated. Their wide range of outcome formats has led to difficulties with interpretation and application. Therefore, there is a persisting need for an appropriately developed and validated severity scoring system for allergic reactions that work across the range of allergenic triggers and address the needs of different stakeholder groups. We propose a novel approach to develop and then validate a harmonized scoring system for acute allergic reactions, based on a data-driven method that is informed by clinical and patient experience and other stakeholders' perspectives. We envisage two formats: (i) a numerical score giving a continuum from mild to severe reactions that are clinically meaningful and are useful for allergy healthcare professionals and researchers, and (ii) a three-grade-based ordinal format that is simple enough to be used and understood by other professionals and patients. Testing of reliability and validity of the new approach in a range of settings and populations will allow eventual implementation of a standardized scoring system in clinical studies and routine practice.

Squamous Cell Carcinoma Antigen for Monitoring Cervical Cancer

The tumour-associated antigen was determined in the plasma of patients with squamous cell carcinoma (SCC) of the uterine cervix by radioimmunoassay. Setting a limit of 2 ng/ml, levels were abnormal in 13.4% of healthy controls, in 14% of patients with carcinoma in situ and in 62% of patients with invasive cervical SCC. The incidence of elevated SCC antigen levels and the absolute antigen plasma concentration were dependent upon the tumour load, increasing significantly with advanced stage disease. Abnormal SCC antigen values in operable cervical cancer declined to normal within one week after radical hysterectomy with pelvic lymphadenectomy. In cases of radiotherapy antigen values took 4-6 weeks after the start of treatment to return to normal. The success of both treatment modalities was announced by an early rise in the SCC antigen in the initial phase of therapy, followed by normalisation. After successful primary treatment and a complete remission during further follow-up SCC antigen in plasma was only increased in 3.8% of the cases. Retrospective evaluations in ten patients with progressive disease showed the reappearance of abnormal SCC titers and further increase preceeding the clinically detectable relapse or progression, with a median interval of 8 weeks. The present study indicates that SCC antigen determination is not useful for the early diagnosis of cervical cancer, but it is a potential means for monitoring the efficacy of individual anticancer therapy of SCC of the uterine cervix and for detecting recurrent disease.

Ca 15.3 as a Tumour Marker in Breast Cancer

CA 15.3 is an antigenic determinant associated with human mammary carcinomas. Two murine monoclonal antibodies have been raised against the determinants, and an immunoradiometric assay (IRMA-Kit, Centocor, USA) has been developed to determine the antigen levels in plasma of cancer patients. Based on the 99% confidence limit of healthy women, plasma values above 30 U/ml are considered abnormal. Plasma samples from 357 women were examined in the present study. Healthy females (n = 84) ranged below the cut-off level between < 10 and 29 U/ml. Higher values were found in 12.5% of benign breast diseases and in 23.6% of breast cancer patients, including all stages. Depending on the stage of the disease, there were elevated levels in 11% of operable breast cancer patients preoperatively, in 7% of the cases with no evidence of disease after primary treatment and in 63.5% ofpatients with disseminated mammary carcinoma. In metastasized breast cancer the frequency and the degree of abnormal titers were closely related to the extent of the metastatic disease. Follow-up examinations of 63 patients under cytotoxic therapy showed CA 15.3 changes correlating well with the clinical course in up to 90% of the antigen positive cases. The present data indicate that CA 15.3 may be useful in the surveillance of breast cancer patients. However in our study one third of the patients with metastatic breast cancer did not show any increase in CA 15.3 and must be regarded as antigen negative.

Allergen manufacturing and quality aspects for allergen immunotherapy in Europe and the United States: An analysis from the EAACI AIT Guidelines Project

Adequate quality is essential for any medicinal product to be eligible for marketing. Quality includes verification of the identity, content and purity of a medicinal product in combination with a specified production process and its control. Allergen products derived from natural sources require particular considerations to ensure adequate quality. Here, we describe key aspects of the documentation on manufacturing and quality aspects for allergen immunotherapy products in the European Union and the United States. In some key parts, requirements in these areas are harmonized while other fields are regulated separately between both regions. Essential differences are found in the use of Reference Preparations, or the requirement to apply standardized assays for potency determination. As the types of products available are different in specific regions, regulatory guidance for such products may also be available in one specific region only, such as for allergoids in the European Union. Region-specific issues and priorities are a result of this. As allergen products derived from natural sources are inherently variable in their qualitative and quantitative composition, these products present special challenges to balance the variability and ensuring batch-to-batch consistency. Advancements in scientific knowledge on specific allergens and their role in allergic disease will consequentially find representation in future regulatory guidelines.

EAACI Guidelines on allergen immunotherapy: IgE-mediated food allergy

Food allergy can result in considerable morbidity, impairment of quality of life, and healthcare expenditure. There is therefore interest in novel strategies for its treatment, particularly food allergen immunotherapy (FA-AIT) through the oral (OIT), sublingual (SLIT), or epicutaneous (EPIT) routes. This Guideline, prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Task Force on Allergen Immunotherapy for IgE-mediated Food Allergy, aims to provide evidence-based recommendations for active treatment of IgE-mediated food allergy with FA-AIT. Immunotherapy relies on the delivery of gradually increasing doses of specific allergen to increase the threshold of reaction while on therapy (also known as desensitization) and ultimately to achieve post-discontinuation effectiveness (also known as tolerance or sustained unresponsiveness). Oral FA-AIT has most frequently been assessed: here, the allergen is either immediately swallowed (OIT) or held under the tongue for a period of time (SLIT). Overall, trials have found substantial benefit for patients undergoing either OIT or SLIT with respect to efficacy during treatment, particularly for cow's milk, hen's egg, and peanut allergies. A benefit post-discontinuation is also suggested, but not confirmed. Adverse events during FA-AIT have been frequently reported, but few subjects discontinue FA-AIT as a result of these. Taking into account the current evidence, FA-AIT should only be performed in research centers or in clinical centers with an extensive experience in FA-AIT. Patients and their families should be provided with information about the use of FA-AIT for IgE-mediated food allergy to allow them to make an informed decision about the therapy.

Challenges in the implementation of the EAACI AIT guidelines: A situational analysis of current provision of allergen immunotherapy

PURPOSE

The European Academy of Allergy and Clinical Immunology (EAACI) has produced Guidelines on Allergen Immunotherapy (AIT). We sought to gauge the preparedness of primary care to participate in the delivery of AIT in Europe.

METHODS

We undertook a mixed-methods, situational analysis. This involved a purposeful literature search and two surveys: one to primary care clinicians and the other to a wider group of stakeholders across Europe.

RESULTS

The 10 papers identified all pointed out gaps or deficiencies in allergy care provision in primary care. The surveys also highlighted similar concerns, particularly in relation to concerns about lack of knowledge, skills, infrastructural weaknesses, reimbursement policies and communication with specialists as barriers to evidence-based care. Almost all countries (92%) reported the availability of AIT. In spite of that, only 28% and 44% of the countries reported the availability of guidelines for primary care physicians and specialists, respectively. Agreed pathways between specialists and primary care physicians were reported as existing in 32%-48% of countries. Reimbursement appeared to be an important barrier as AIT was only fully reimbursed in 32% of countries. Additionally, 44% of respondents considered accessibility to AIT and 36% stating patient costs were barriers.

CONCLUSIONS

Successful working with primary care providers is essential to scaling-up AIT provision in Europe, but to achieve this, the identified barriers must be overcome. Development of primary care interpretation of guidelines to aid patient selection, establishment of disease management pathways and collaboration with specialist groups are required as a matter of urgency.

Challenges in the implementation of EAACI guidelines on allergen immunotherapy: A global perspective on the regulation of allergen products

Regulatory approaches for allergen immunotherapy (AIT) products and the availability of high-quality AIT products are inherently linked to each other. While allergen products are available in many countries across the globe, their regulation is very heterogeneous. First, we describe the regulatory systems applicable for AIT products in the European Union (EU) and in the United States (US). For Europe, a depiction of the different types of relevant procedures, as well as the committees involved, is provided and the fundamental role of national agencies of the EU member states in this complex and unique network is highlighted. Furthermore, the regulatory agencies from Australia, Canada, Japan, Russia, and Switzerland provided information on the system implemented in their countries for the regulation of allergen products. While AIT products are commonly classified as biological medicinal products, they are made available by varying types of procedures, most commonly either by obtaining a marketing authorization or by being distributed as named patient products. Exemptions from marketing authorizations in exceptional cases, as well as import of allergen products from other countries, are additional tools applied by countries to ensure availability of needed AIT products. Several challenges for AIT products are apparent from this analysis and will require further consideration.

Hymenoptera stings in the head region induce impressive, but not severe sting reactions

Stings in the head region are considered to be a risk factor for severe systemic reactions to hymenoptera stings. We supposed that stings in skin areas, which are well supplied with blood, lead to more severe reactions and tested our hypothesis in 847 patients with confirmed hymenoptera venom allergy. However, symptom severity was independent from sting site: only 16.3% of patients with severe reactions were stung on the head (P = 0.017). But we confirmed age > 40 years (P < 0.001) as well as elevated basal tryptase levels (P = 0.001) as risk factors. Taking antihypertensive drugs seemed to have an influence: 41.7% of patients taking antihypertensive drugs experienced a severe reaction compared to 29.5% of patients, not taking such drugs (P = 0.019). However, considering patients' age in regression analysis, taking antihypertensive drugs had no effect on symptom severity (P = 0.342). Importantly, in most patients with severe reactions, cutaneous signs were absent (P < 0.001).

Allergen immunotherapy for insect venom allergy: protocol for a systematic review

Background

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines for Allergen Immunotherapy (AIT) for the Management of Insect Venom Allergy. We seek to critically assess the effectiveness, cost-effectiveness and safety of AIT in the management of insect venom allergy.

Methods

We will undertake a systematic review, which will involve searching international biomedical databases for published, in progress and unpublished evidence. Studies will be independently screened against pre-defined eligibility criteria and critically appraised using established instruments. Data will be descriptively and, if possible and appropriate, quantitatively synthesised.

Discussion

The findings from this review will be used to inform the development of recomendations for EAACI’s Guidelines on AIT.

How immunosuppressive therapy affects T cells from kidney transplanted patients of different age: the role of latent cytomegalovirus infection

The average age of patients receiving renal transplantation is increasing as programmes have been established which support the donation of organs from elderly donors to older recipients. Little is known about the effect of immunosuppressive therapy on the immune system of older patients. In this study, T cell function and the composition of the T cell repertoire were analysed in immunosuppressed renal transplant recipients of different age and cytomegalovirus (CMV) status in comparison to age- and CMV-matched controls. Independent of age and CMV status, the production of interleukin (IL)-2 and interferon (IFN)-γ by T cells was decreased in the patient groups and autologous serum from patients was capable of inhibiting the proliferation of CD3⁺ T cells. CXCR5 expression on T cells was increased in patients versus controls reflecting reduced endogenous IL-2 signalling under immunosuppressive therapy. In CMV-seronegative patients kidney transplantation and immunosuppressive therapy did not induce changes in the CD8⁺ T cell pool, but there was a moderate increase in CD4⁺CD28⁻ effector T cells when compared to age-matched controls. In contrast, latent CMV infection triggered a shift from early to late differentiated CD4⁺ and CD8⁺ T cells in patients and controls. This shift was most pronounced in elderly transplant patients under immunosuppressive therapy. In conclusion, our results demonstrate that immunosuppressive therapy following kidney transplantation is effective in patients older than 65 years. Latent CMV infection, however, accelerates age-related changes in the T cell repertoire in elderly people under immunosuppressive therapy. These patients should therefore be monitored with special care.

Research needs in allergy: an EAACI position paper, in collaboration with EFA

In less than half a century, allergy, originally perceived as a rare disease, has become a major public health threat, today affecting the lives of more than 60 million people in Europe, and probably close to one billion worldwide, thereby heavily impacting the budgets of public health systems. More disturbingly, its prevalence and impact are on the rise, a development that has been associated with environmental and lifestyle changes accompanying the continuous process of urbanization and globalization. Therefore, there is an urgent need to prioritize and concert research efforts in the field of allergy, in order to achieve sustainable results on prevention, diagnosis and treatment of this most prevalent chronic disease of the 21st century.The European Academy of Allergy and Clinical Immunology (EAACI) is the leading professional organization in the field of allergy, promoting excellence in clinical care, education, training and basic and translational research, all with the ultimate goal of improving the health of allergic patients. The European Federation of Allergy and Airways Diseases Patients' Associations (EFA) is a non-profit network of allergy, asthma and Chronic Obstructive Pulmonary Disorder (COPD) patients' organizations. In support of their missions, the present EAACI Position Paper, in collaboration with EFA, highlights the most important research needs in the field of allergy to serve as key recommendations for future research funding at the national and European levels.Although allergies may involve almost every organ of the body and an array of diverse external factors act as triggers, there are several common themes that need to be prioritized in research efforts. As in many other chronic diseases, effective prevention, curative treatment and accurate, rapid diagnosis represent major unmet needs. Detailed phenotyping/endotyping stands out as widely required in order to arrange or re-categorize clinical syndromes into more coherent, uniform and treatment-responsive groups. Research efforts to unveil the basic pathophysiologic pathways and mechanisms, thus leading to the comprehension and resolution of the pathophysiologic complexity of allergies will allow for the design of novel patient-oriented diagnostic and treatment protocols. Several allergic diseases require well-controlled epidemiological description and surveillance, using disease registries, pharmacoeconomic evaluation, as well as large biobanks. Additionally, there is a need for extensive studies to bring promising new biotechnological innovations, such as biological agents, vaccines of modified allergen molecules and engineered components for allergy diagnosis, closer to clinical practice. Finally, particular attention should be paid to the difficult-to-manage, precarious and costly severe disease forms and/or exacerbations. Nonetheless, currently arising treatments, mainly in the fields of immunotherapy and biologicals, hold great promise for targeted and causal management of allergic conditions. Active involvement of all stakeholders, including Patient Organizations and policy makers are necessary to achieve the aims emphasized herein.

Schnitzler syndrome: response to anakinra in two cases and a review of the literature

BACKGROUND

Schnitzler syndrome is a rare disease characterized by a chronic urticarial eruption and monoclonal gammopathy, as well as clinical and laboratory signs of inflammation. The pathophysiology is still unknown, although various autoantibody-mediated mechanisms have been described. Complete remission of symptoms has been reported recently in patients with Schnitzler syndrome treated with anakinra, an interleukin-1 receptor antagonist.

METHODS

Two patients with Schnitzler syndrome treated with anakinra therapy are presented.

RESULTS

We report two cases of nearly complete remission of symptoms in Schnitzler syndrome after the initiation of anakinra therapy, and the first observation of a relapse under continuous daily anakinra therapy. A review of the published literature on the treatment of Schnitzler syndrome with anakinra is presented.

CONCLUSIONS

Based on published data, monotherapy with anakinra is currently the most promising treatment for Schnitzler syndrome, because it is able to induce complete remission of symptoms.

Human follicular fluid levels of endothelins in relation to oocyte maturity status

The levels of endothelins 1 and 2 (ET-1 and ET-2) have been examined in 415 follicular fluids of 57 women participating in the IVF-ET programme in the University Women's Hospital, Marburg, in relation to the morphological appearance ("maturity") and fertilizability of harvested oocytes as well as to the levels of inhibin, FSH, IGF-1, estradiol and progesterone. Follicular aspiration was done transvaginally in all patients after down regulation with nafareline and ovarian stimulation using urofollitropin and menotropin. Ovulation was induced by hCG. ETs were measured by RIA using commercial kits supplied by Peninsula Laboratories, Belmont, CA. For FF samples, ET-1 and ET-2 RIAs were revalidated. Immunoreactive ET-1 was detectable in all follicular samples, the average level being 18.5 +/- 11.8 pg/ml, ET-2 was present only in 67.5% of the samples, the average level being 13.6 +/- 16.3 pg/ml. There was no significant difference in the average levels of ET-1 in the fluids of small, medium and large follicles. However, there was a significantly higher level of ET-2 in the fluids of medium compared to large follicles and there was a negative correlation of the ET-2 levels to the volume of the follicle (p < 0.01) which suggests that ET-2 could play a role during the maturation of the ovarian follicles. Unlike ET-1, the mean concentrations of ET-2 were significantly higher in the fluids with oocytes which could be fertilized and cleaved than in those with oocytes which did not fertilize or cleave, thus indicating a role for ET-2 in the process of oocyte maturation. No correlations of ET levels were found with the levels of inhibin, FSH, estradiol and progesterone. However, ET-2 levels significantly correlated with the levels of IGF-1 (p < 0.001) indicating a possible synergistic effect of endothelins and IGF-system. In conclusion, this study is further evidence for a physiological role of the ETs in the human ovary.

Diagnosis of immediate-type beta-lactam allergy in vitro by flow-cytometric basophil activation test and sulfidoleukotriene production: a multicenter study

INTRODUCTION

This multicenter study aimed to evaluate the diagnostic value of 2 cellular tests based on basophil reactivity--the basophil activation test (BAT, Flow-CAST) and the sulfidoleukotriene release assay (CAST-ELISA)--in immediate-type beta-lactam allergy, particularly in patients with a clinical history of allergy and a negative skin test result.

MATERIAL AND METHODS

In a multicenter study encompassing 10 European centers, 181 patients with a history of immediate-type beta-lactam allergy, and 81 controls, we evaluated the diagnostic efficiency of specific IgE determinations and of 2 cellular tests based on basophil reactivity, the BAT and the sulfidoleukotriene release assay.

RESULTS

With Flow-CAST, sensitivity varied for individual beta-lactam allergens from 16% for penicilloyl-polylysine to 33% for amoxicillin, reaching 50% when all 5 allergens were considered. In beta-lactam-allergic patients with negative skin test results (22.8%), Flow-CAST showed positive results for at least 1 of the 5 allergens in 37%. Specificity varied from 89% to 97%, depending on the allergens used. In CAST-ELISA, the overall sensitivity in skin test-positive patients was 41.7%; in patients with negative skin test results it was 27.9%. Both tests were not absolutely correlated, so that when all the results were considered together, sensitivity increased to 64.3% and specificity varied for both tests combined from 73% to 92%. In contrast, specific IgE determinations in the same population yielded a lower sensitivity (28.3%).

CONCLUSIONS

A diagnostic algorithm including skin tests and specific IgE, followed by cellular tests in negative patients and controlled challenge enabled us to confirm beta-lactam allergy in 92% of cases. This procedure would also allow us to avoid two-thirds of the required controlled challenges.

Immunoglobulin E and G antibody profiles to grass pollen allergens during a short course of sublingual immunotherapy

BACKGROUND

Various studies have shown the clinical efficacy of sublingual immunotherapy in grass pollen-induced rhinoconjunctivitis. However, even short-term treatment with grass extracts might cause sensitizations to formerly unrecognized antigens.

OBJECTIVE

To determine whether the antibody profiles are changing in patients receiving a defined grass pollen extract prior to and during the grass pollen season.

METHODS

A randomized, double blind, placebo-controlled, multicenter phase I/I111 trial was started prior to the commencement of the grass pollen season. Patients with grass pollen allergy were randomly allocated to four groups, and received daily a standardized tablet at different doses. Treatment was started 8 weeks prior to the beginning of the pollen season and stopped at the end of the season. Blood samples were taken at the beginning of the study, at the beginning and the end of the pollen season, and one year after commencement of the study.

RESULTS

At the beginning of the study, all patients tested positive for the major grass pollen allergens, but negative to the minor antigens. In all patients, the degree of antibody reactivity rose considerably after starting active treatment and fell back to the initial values within one year. Immunoglobulin (Ig) E antibodies to the minor antigens remained negative, independent of treatment and seasonal exposure. In contrast to IgE, specific IgG antibodies to all allergens tested revealed no specific trend.

CONCLUSIONS

Immunotherapy with grass allergen tablets was accompanied by an increase in grass-specific IgE antibodies, which further increased during pollen exposure, followed by a post-treatment drop in patient- and disease-specific antibodies. During this short course of treatment, no patient developed any additional sensitizations.

Rush Hymenoptera venom immunotherapy: a safe and practical protocol for high-risk patients

BACKGROUND

Hymenoptera venom immunotherapy in allergic patients is a well-established treatment modality for the prevention of systemic anaphylactic reactions caused by insect stings. A variety of therapy regimens exists, from conventional to rush and ultrarush modalities that operate on continuous or intermittent schedules.

OBJECTIVE

The aim of this study was to report the 8-year experience with our rush venom immunotherapy regimen in predominantly high-risk patients and to compare data on safety and convenience with the results of 26 studies published from 1978 to 2001.

METHODS

One hundred one patients allergic to bee, yellow jacket, or hornet venom were treated with rush Hymenoptera venom immunotherapy. Diagnosis and selection of patients for venom immunotherapy were carried out according to the recommendations of the European Academy of Allergology and Clinical Immunology. We used a 4-day regimen, and the incidence and nature of systemic reactions (SRs) were documented. Fifty-two patients were treated with honeybee venom, and 49 were treated with yellow jacket venom.

RESULTS

One hundred (99%) patients reached the maintenance dose. We observed 8 injection-related SRs (0.47% of all injections given) in 7 (6.9%) patients. The number of SRs was higher in patients treated with bee venom extract (12%) compared with in patients receiving yellow jacket venom extract (2%). There was no significant difference in the risk of SRs between female and male patients. The incidence of SRs was considerably lower than the average of 17.8% reported in the literature.

CONCLUSION

With a rush immunotherapy regimen over a time period of 8 years in predominantly high-risk patients, the incidence of SRs was low, despite the high number of patients with bee venom allergy, who are more likely to have side effects. Epinephrine as rescue medication was never necessary, and the regimen proved to be safe and convenient for both the patients and the medical staff.

Comparison of the test methods (KRYPTOR, ES 600 and CIS-RIA) for CEA, CA 15-3 and CA 125 follow-up and ONCOCHECK-quality control

We examined whether the automated KRYPTOR/CIS analysis system could replace the routine tumor marker tests. We analysed the sera of 50 patients by EnzymImmunoAssay CEA (ES-600, Roche/Boehringer), CA 15-3 (ELSA/RIA; CIS) CA 125 (Centocor/RIA; CIS) and in parallel by KRYPTOR (CIS). The correlation coefficient for CEA and CA 125 was clearly less than that of Centocor. Although the automated KRYPTOR is suitable for routine analysis a larger number of patients sera must be tested by different methods, especially in view of the lack of international reference material, before completely switching over to KRYPTOR.

The influence of menopause and body mass index on serum leptin concentrations

OBJECTIVE

The aim of this study was to evaluate the influence of menopausal status, serum estradiol and body mass index (BMI) on serum leptin concentration in a large sample of pre- and postmenopausal women.

DESIGN

434 healthy women (mean age +/-s.d., 52.2 +/- 10.3 years) were recruited at the University of Marburg on the occasion of a routine gynecological visit. Two hundred and eighteen (50.2%) women were premenopausal (mean age, 36.5 +/- 10.4 years) and not on oral contraceptives or hormone replacement therapy (HRT) and 216 (49.8%) women were postmenopausal (mean age 61.8 +/- 8.9 years) not on HRT. To evaluate the influence of menopausal status, estradiol level and BMI on serum leptin concentrations, women were allocated to one of the four groups: (a) premenopausal women BMI <25 kg/m(2) (n=137), (b) premenopausal women BMI >25 kg/m(2) (n=81), (c) postmenopausal women BMI <25 kg/m(2) (n=94) and (d) postmenopausal women BMI >25 kg/m(2) (n=122).

RESULTS

Irrespective of the menopausal status, women with a BMI >25 kg/m(2) had significantly higher leptin concentrations in all age groups compared with women with a BMI <25 kg/m(2) (P<0.001). The multiple linear regression analyses showed that BMI was the only statistically significant independent predictor for leptin. In comparison to postmenopausal women, premenopausal women showed a significantly lower mean age, weight, BMI and FSH concentration (P<0. 001), a higher mean height and serum estradiol (P<0.01 and P<0.001 respectively) but significantly lower serum leptin concentration (P<0.01). The multiple linear regression model showed no significant influence of menopausal status or serum estradiol on serum leptin concentration, even after controlling for BMI.

CONCLUSIONS

Serum leptin concentrations are significantly higher in pre- and postmenopausal obese women, compared with normal weight controls. Serum leptin concentrations are not influenced by menopausal status or serum estradiol level.

The effect of long-term, non-suppressive levothyroxine treatment on quantitative ultrasonometry of bone in women

OBJECTIVE

To evaluate the impact of long-term, non-suppressive levothyroxine (L-T(4)) treatment on quantitative ultrasonometry in women.

DESIGN

This was a case-control study.

SUBJECTS AND METHODS

Altogether 667 women (mean age+/-s.d., 49.5+/-13.1 years) were studied. Of these, 156 (23%) had non-toxic goitre or hypothyroidism and had been taking L-T(4) (75-100 microg/day) for at least 5 years (mean+/-s.d., 12.5+/-7.5 years); the remaining 511 (77%) women were not receiving L-T(4). All women had completed a questionnaire on risk factors for thyroid dysfunction and osteoporosis, and those with diseases or treatments known to effect bone metabolism - other than thyroxine or hormone replacement therapy (HRT) - were excluded. Women underwent quantitative ultrasonometry (QUS) at the heel. Speed of sound (SOS), broadband ultrasound attenuation (BUA) and the stiffness index (SI) were compared, first, in all women taking L-T(4) and controls and, secondly, in women taking L-T(4) and controls pair-matched for age, weight, body mass index (BMI), menopausal status and HRT use.

RESULTS

Even after matching for age, weight, BMI, menopausal and HRT status, women taking L-T(4) had significantly lower values for SOS and SI (P<0.05), but not for BUA. However, absolute T- and Z-scores for SI were not low in either the study or control groups. Lower values were associated, but not significantly so, with years since the menopause and duration of L-T(4) treatment.

CONCLUSIONS

Long-term, non-suppressive L-T(4) treatment in women with goitre or hypothyroidism was associated with a slight reduction in QUS values, which was more pronounced in postmenopausal women. This group could be at higher risk for osteoporotic fracture.

Ras/Rac-Dependent activation of p38 mitogen-activated protein kinases in smooth muscle cells stimulated by cyclic strain stress

p38, a subfamily of the mitogen-activated protein kinases (MAPKs), is a crucial signal transducer between a variety of extracellular stimuli and gene expression in mammalian cells. This kinase is activated in cultured cells stimulated by heat shock, osmotic stress, and proinflammatory cytokines, but a similar activation of p38 MAPKs in vascular smooth muscle cells (SMCs) stimulated by mechanical stress has yet to be studied. We studied signal pathways leading to time- and strength-dependent p38 activation in rat SMCs in response to cyclic strain stress. p38 phosphorylation in stressed SMCs showed maximal activation at 10 minutes. This activation was significantly inhibited by pretreatment of the SMCs with pertussis toxin, a G-protein antagonist, and enhanced by treatment with suramin, a growth factor receptor antagonist, but opposite effects in the activation of extracellular signal-regulated kinases stimulated by mechanical forces were found. p38 activation was markedly reduced in stressed SMCs after protein kinase C depletion. Interestingly, SMC lines stably expressing dominant-negative ras (ras N17) or rac1 (rac1 N17) almost abolished p38 phosphorylation induced by cyclic strain stress. When p38 activation was inhibited by the specific inhibitor SB 202190, SMC migration, determined in a Boyden chamber in response to stimulation with platelet-derived growth factor-BB, and SMC proliferation, stimulated by cyclic strain stress, were abrogated. Thus, we provide the first evidence that cyclic strain stress rapidly activates p38 MAPKs via activation of protein kinase C ras/rac signal pathways, suggesting that p38 MAPKs are important signal transducers mediating the mechanical stress-induced cell responses essential for SMC migration and proliferation.

Detection of anisotropic hyperfine transitions in zero magnetic field using field-cycling techniques

For the first time, we describe the detection of hyperfine transitions in zero magnetic field using field-cycling techniques and pulsed EPR spectroscopy. The sample investigated was coal, which shows an anisotropic electron spin-(13)C hyperfine interaction.

LDL stimulates mitogen-activated protein kinase phosphatase-1 expression, independent of LDL receptors, in vascular smooth muscle cells

Low density lipoprotein (LDL) is a well-established risk factor for atherosclerosis, stimulating vascular smooth muscle cell (SMC) differentiation and proliferation, but the signal transduction pathways between LDL stimulation and cell proliferation are poorly understood. Because mitogen-activated protein kinases (MAPKs) play a crucial role in mediating cell growth, we studied the effect of LDL on the induction of MAPK phosphatase-1 (MKP-1) in human SMCs and found that LDL stimulated induction of MKP-1 mRNA and proteins in a time- and dose-dependent manner. Heparin, inhibiting LDL-receptor binding, did not influence LDL-stimulated MKP-1 mRNA expression, and human LDL also induced MKP-1 expression in rat SMCs and fibroblasts derived from LDL receptor-deficient mice, indicating an LDL receptor-independent process. Pretreatment of SMCs with pertussis toxin markedly inhibited LDL-induced MKP-1 expression. Depletion of protein kinase C (PKC) by phorbol 12-myristate 13 acetate or inhibition of PKC by calphostin C blocked MKP-1 induction, but the phospholipase C inhibitor U73122 had no effect. Pretreatment of SMCs with genistein or herbimycin A abrogated LDL-stimulated MKP-1 induction. The MAPK kinase inhibitor PD98059 abolished LDL-stimulated activation of extracellular signal-regulated protein kinases (ERKs) but not MKP-1 induction. Furthermore, constitutive expression of MKP-1 in vivo reduced LDL-induced expression of Elk-1-dependent reporter genes, and SMC lines overexpressing recombinant MKP-1 exhibited decreased ERK activities and retarded proliferation in response to LDL. Our findings demonstrate that LDL induces MKP-1 expression in SMCs via activation of PKC and tyrosine kinases, independent of LDL receptors and ERK-MAPKs, and that MKP-1 plays an important role in the regulation of LDL-initiated signal transductions leading to SMC proliferation.

Serum leptin and gonadotropin levels in patients with anorexia nervosa during weight gain

Leptin plays an important role in reproductive function. In patients with acute anorexia nervosa, serum leptin levels have repeatedly been shown to be lower than in age-matched controls. We have previously hypothesized that the amenorrhea characteristic of anorexia nervosa is related to this low leptin secretion. In an attempt to address this hypothesis, serum levels of leptin and follicle stimulating hormone (FSH) and luteinizing hormone (LH) of 16 female inpatients with anorexia nervosa or an eating disorder not otherwise specified (atypical anorexia nervosa) were measured on a biweekly basis during weight gain. We hypothesized that a serum leptin level of 1.85 microg L(-1) would be associated with gonadotropin levels at or above the minimal level observed during the menstrual cycle in healthy adult fertile females. Our results revealed that increments of LH levels generally tracked increments of leptin levels during the first weeks of treatment. Similarly, in those patients with low referral leptin levels, FSH initially also tracked leptin levels. In contrast, a relationship between gonadotropin levels and leptin secretion was no longer discernible after LH and FSH levels had peaked. Those patients with exceedingly low leptin levels upon admission revealed a slow increase of gonadotropin levels. Our hypothesis of a threshold leptin level of 1.85 microg L(-1) was supported for LH only.

Induction of mitogen-activated protein kinase phosphatase-1 by arachidonic acid in vascular smooth muscle cells

Arachidonic acid (AA) and its metabolites play important roles in a variety of biological processes, such as signal transduction, contraction, chemotaxis, and cell proliferation and differentiation. It was demonstrated recently that AA can activate mitogen-activated protein kinases (MAPKs), which are crucial for transducing signals initiating cell growth and apoptosis. Here we studied the effect of AA on the induction of MAPK phosphatase-1 (MKP-1) in vascular smooth muscle cells (VSMCs) and found that AA stimulated induction of MKP-1 mRNA and proteins in VSMCs in a time- and dose-dependent manner. Specific inhibitors of cyclooxygenase-, lipoxygenase-, and cytochrome P450-dependent metabolism did not affect AA-induced MKP-1 expression, indicating that eicosanoid biosynthesis was not involved in this process. The glutathione precursor N-acetylcysteine, an antioxidant, abolished AA-stimulated MKP-1 gene expression, whereas inhibition of protein kinase C by calphostin C had no influence on MKP-1 induction. VSMC pretreatment with genistein, a tyrosine kinase inhibitor, completely blocked AA-stimulated MKP-1 induction. MAPK kinase inhibitor PD 98059 did abolish AA-stimulated activation of extracellular signal-regulated kinases but not MKP-1 induction. Furthermore, agonists that increase AA release stimulated MKP-1 induction and activation of MAPKs, including extracellular signal-regulated kinases and c-Jun NH2-terminal protein kinases or stress-activated protein kinases. Taken together, our findings demonstrate that AA induced MKP-1 expression in VSMCs via activation of tyrosine kinases involving AA-induced free radical generation, suggesting an important role for MKP-1 in the regulation of AA-initiated signal transduction in VSMCs.

Expression of mRNA for ovarian steroid-stimulating factor (apolipoprotein A-I and apolipoprotein A-I-like protein) in human granulosa cells

Sequential chromatography of human follicular fluid (hFF) on Sephadex G-50, Q-Sepharose and finally Cibracon Blue yielded a protein molecule which biologically had a stimulating effect on steroid secretion (SSF) by ovarian granulosa cells in vitro. SDS-gel electrophoresis followed by blotting on PVDF membrane of the biologically active fraction revealed 3 bands of ca. 28, 27 and 24 kDa. The N-terminal sequence of the 3 bands corresponded completely with that of apolipoprotein A-I. In view of this, it was of interest to examine whether human ovary expresses apo A-I. Using specific primers for apo A-I and apo A-I-like protein (ALP; Richardson et al., 1996), we could demonstrate the presence of mRNA for apo A-I as well as ALP in the granulosa cells. The expression of ALP was found to be much higher than that of apo A-I. Like hFF-protein, purified apo A-I could also stimulate steroid secretion by human granulosa cells incubated in the presence of cholesterol. The functional role of ovarian apo A-I/ALP may be speculated as a transport molecule for steroid precursors.

The effect of parenteral fish oil on leukocyte membrane fatty acid composition and leukotriene-synthesizing capacity in patients with postoperative trauma

The incorporation of omega-3 and omega-6 fatty acids (FAs) into leukocyte membranes and the leukotriene (LT)B4-, LTB5 -, LTC4-, and LTCs-synthesizing capacity in stimulated leukocytes were measured following parenteral omega-3 FA nutrition in 20 postoperative patients. Total parenteral nutrition (TPN) over 5 days postoperatively was isonitrogenous (0.24 g N x kg-1 x d1) and isoenergetic (92 kJ/22 kcal x kg-1 x d-1), containing 0.15 g fish oil and 0.85 g soybean oil per kg-1 x d-1 (FO) or 1.0 g soybean oil x kg-1 x d-1 (SO). Following 5 days' FO administration, the content of eicosapentaenoic acid (EPA) was increased 2.5-fold, LTB5 1.5-fold, and LTC5 sevenfold. With SO nutrition, EPA and LTB5 generation remained unaltered, whereas LTC5 doubled. The production of LTB4 and LTC4 was not affected in any of the groups. We conclude that a 5-day parenteral fish oil supplementation has an immunomodulatory effect on lipid-mediator generation in human leukocytes in postoperative trauma.

Use of bone mineral content determination by X-ray absorptiometry in the evaluation of osteodystrophy among workers exposed to aluminium powders

Within the framework of a cross-sectional study, we investigated 61 employees in an aluminium powder factory to see if aluminium had an influence on bone mineral content using the non-invasive method of bone density measurement. Thirty-two workers had been employed for, on average, 151 months in the area of aluminium powder production. Twenty-nine employees in the same factory, who had not been engaged in the production of aluminium powder, served as controls. The groups differed significantly in the concentrations of aluminium in urine and plasma. The bone mineral content, which was determined in the lumbar spine by means of photon absorptiometry showed no significant difference between the groups. The bone density value amounted to 1.00 g/cm2 for those exposed and 1.02 g/cm2 for the control group (median values). No correlation could be determined between the values obtained from the biological monitoring of the plasma or the duration of exposure and the bone density values. To summarise, using osteodensitometry as the method of investigation here, no influence could be detected for an occupational exposure to aluminium powders on the mineral salt content of the skeletal system in the area of the lumbar spine.

Modulation of serotonin binding sites in the brain of the Djungarian hamster, Phodopus sungorus, during adaptation to a short photoperiod

During the physiological adaptation of the Djungarian hamster, Phodopus sungorus, to a short photoperiod in autumn the modulation of specific serotonin (5-HT) binding sites of synaptic membranes was investigated in two brain regions, i.e. cerebral cortex and basal brain (CNS without cerebral cortex, cerebellum, pineal gland, and spinal cord). The radioligands [3H]5-HT and [3H]ketanserin were used to characterize total 5-HT1 and 5-HT2 binding sites, respectively. An increase of 5-HT1 and 5-HT2 binding sites was observed in both brain regions within 14 days after reduction of the photoperiod from a 14:10 h light/dark (l/d) cycle to an 8:16 h l/d cycle. The increase was still present after 56 days of the short photoperiod. Binding kinetics assayed after 4 days of the short photoperiod show that maximal specific binding of [3H]5-HT and [3H]ketanserin was increased, while dissociation constants (KD) were not changed. The membrane anisotropy of synaptic membranes, measured by fluorescence polarization, was reduced transiently during the early part of the adaptation. Neither the phospholipids nor the mole ratio of cholesterol to phospholipids were significantly affected by adaptation to short photoperiod. The results suggest an important role of the central nervous 5-HT system in the physiological adaptation of the Djungarian hamster to a short photoperiod.