Successful oral tolerance induction in severe peanut allergy

BACKGROUND

Peanut allergy is common, potentially severe and rarely resolves causing impaired quality of life. No disease-modifying treatment exists and there is therefore a need to develop a therapeutic intervention.

AIMS OF THE STUDY

The aim of this study was to investigate whether peanut oral immunotherapy (OIT) can induce clinical tolerance to peanut protein.

METHODS

Four peanut-allergic children underwent OIT. Preintervention oral challenges were performed to confirm clinical allergy and define the amount of protein required to cause a reaction (dose thresholds). OIT was then administered as daily doses of peanut flour increasing from 5 to 800 mg of protein with 2-weekly dose increases. After 6 further weeks of treatment, the oral challenge was repeated to define change in dose threshold and subjects continued daily treatment.

RESULTS

Preintervention challenges confirmed peanut allergy and revealed dose thresholds of 5-50 mg (1/40-1/4 of a whole peanut); one subject had anaphylaxis during challenge and required adrenaline injection. All subjects tolerated immunotherapy updosing to 800 mg protein and i.m. adrenaline was not required. Each subject tolerated at least 10 whole peanuts (approximately 2.38 g protein) in postintervention challenges, an increase in dose threshold of at least 48-, 49-, 55- and 478-fold for the four subjects.

CONCLUSIONS

We demonstrated a substantial increase in dose threshold after OIT in all subjects, including the subject with proven anaphylaxis. OIT was well tolerated and conferred protection against at least 10 peanuts, more than is likely to be encountered during accidental ingestion.

Potentially modifiable risk factors associated with myocardial infarction in China: the INTERHEART China study

BACKGROUND

Lifestyle changes associated with the rapidly developing economy increase cardiovascular disease (CVD), myocardial infarction (MI) and cardiovascular risk factors (CVRFs) in China.

OBJECTIVE

To assess and compare regionally, and with other regions of the world, distribution of the nine INTERHEART CVRFs, their relationship to MI and the CVD epidemic in China in order to determine how this may influence the future of CVD in China.

METHODS

Patients with first acute MI (n = 3030) and age- and sex-matched controls (n = 3056) were enrolled from 26 centres in China.

RESULTS

Northern Chinese had higher rates of smoking and hypertension, whereas southern Chinese reported lower fruit and vegetable intake and higher rates of depression. Compared with other regions, participants from China were older, with lower body mass index and waist to hip ratios, lower total and low-density lipoprotein cholesterol levels, ApoB lipoprotein and ApoB to ApoA-1 ratios, but higher high-density lipoprotein cholesterol and ApoA-1. All nine INTERHEART CVRFs, education and income were significantly associated with MI in the Chinese cohort. There was significant heterogeneity in the strength of association between certain CVRFs and MI for China versus other regions, with stronger associations for the Chinese for diabetes (OR 5.10 vs 2.84), depression (2.27 vs 1.37) and permanent stress (2.67 vs 2.06); and lower for the Chinese for abdominal obesity (1.33 vs 2.62) (p for heterogeneity, all <0.001).

CONCLUSIONS

Diabetes and psychosocial factors have strong associations with risk of MI in China, indicating that future increases in these risk factors with societal change in China may hasten rapid increases in CVD.

Ewing tumors of the chest wall: Local control and long-term outcomes

e21501

Background: Primary sarcomas of the lungs and mediastinum are rare and few data are reported on treatment and results of therapy. Methods: We reviewed our experience from 1980 and 2008 including 31 patients (pts). Pts characteristics: median age 41 (19–80 y), male/female 19/12; symptoms at diagnosis: dyspnoea (42%), chest and shoulder pain (39%), cough (35%), hemophtoae (13%), discomfort (10%). 4 pts had a previous history of mediastinal radiation for Hodgkin's and non-Hodgkin's linfomas. 5 mediastinal tumours were located as follows: 2 in anterior part, 1 in posterior and 2 in the middle (sarcomas of the heart). 26 lung sarcomas presented as a singular mass in 23 cases and as a metastatic disease in 3. Results: In 20/31 cases the tumour was immediately resected (3 mediastinal masses and 17 lung sarcomas). In 8/31 cases only biopsy was possible. FNA was done in 25 pts. Neoadjuvant chemotherapy was performed in 4 cases (3 resected). Resection was complete in 11/23 cases and in 12/23 incomplete. The histology were: peripheral nerve tumour 7, leiomyosarcoma 4, MFH 2, fibrosarcoma 2, liposarcoma 1, angiosarcoma 2, undifferentiated sarcoma 1, solitary fibrous tumour 2, rhabdomyosarcoma 2, synovialsarcoma 2, pulmonary artery sarcoma 1, pleuropolmonary blastoma 1, malignant hemangiopericytoma 1, mixoid chondrosarcoma 1, ectopic osteosarcoma 1, aggressive fibromatosis 1. Only 4 pts received neoadjuvant chemotherapy, 11 adjuvant CT, 5 exclusive CT + RT for inoperable disease. Radiotherapy was completed in 26 pts (21 adjuvant). Local relapse or metastatic progression were recorded in 16/23 pts and 12 received one or more lines of palliative CT. Data about survival are disposable only for the more recently recorded pts (1998–2008: 17 pts). Of these only 8 are alive (2 with disease). Volume of disease, complete resection and grading are the dominant prognostic factors. Conclusions: Primary sarcomas of the lungs and mediastinum have a very severe prognosis. Surgical resection is the fundamental therapy, but in the future the role of neoadjuvant CT will increase.

No significant financial relationships to disclose.

Involvement of interleukin-1 receptor-associated kinase (IRAK)-M in toll-like receptor (TLR) 7-mediated tolerance in RAW 264.7 macrophage-like cells

The effect of toll-like receptor (TLR) 7 ligand pretreatment on the production of tumor necrosis factor (TNF)-alpha in response to TLR7 or TLR2 ligand was examined in order to establish a new TLR-mediated tolerance. RAW 264.7 macrophage-like cells were treated with imiquimod R837 as a TLR7 ligand for 18h, washed and incubated in fresh culture medium 6h. The second challenge with imiquimod R837 as a TLR7 ligand or Pam3CysSK4 as a TLR2 ligand resulted in reduced TNF-alpha production in TLR7 ligand-pretreated cells. There was impaired activation of NF-kappaB, p38 and stress-activated protein kinase (SAPK) in the tolerant cells. The expression of IRAK-M as a negative regulator of TLR signaling was markedly augmented in the tolerant cells while the interleukin-1 receptor-associated kinase (IRAK)-1 functioned normally. The involvement of IRAK-M in the TLR7-mediated tolerance is discussed.

Stem cells in liver regeneration, fibrosis and cancer: the good, the bad and the ugly

The worldwide shortage of donor livers to transplant end stage liver disease patients has prompted the search for alternative cell therapies for intractable liver diseases, such as acute liver failure, cirrhosis and hepatocellular carcinoma (HCC). Under normal circumstances the liver undergoes a low rate of hepatocyte 'wear and tear' renewal, but can mount a brisk regenerative response to the acute loss of two-thirds or more of the parenchymal mass. A body of evidence favours placement of a stem cell niche in the periportal regions, although the identity of such stem cells in rodents and man is far from clear. In animal models of liver disease, adopting strategies to provide a selective advantage for transplanted hepatocytes has proved highly effective in repopulating recipient livers, but the poor success of today's hepatocyte transplants can be attributed to the lack of a clinically applicable procedure to force a similar repopulation of the human liver. The activation of bipotential hepatic progenitor cells (HPCs) is clearly vital for survival in many cases of acute liver failure, and the signals that promote such reactions are being elucidated. Bone marrow cells (BMCs) make, at best, a trivial contribution to hepatocyte replacement after damage, but other BMCs contribute to the hepatic collagen-producing cell population, resulting in fibrotic disease; paradoxically, BMC transplantation may help alleviate established fibrotic disease. HCC may have its origins in either hepatocytes or HPCs, and HCCs, like other solid tumours appear to be sustained by a minority population of cancer stem cells.

Attributes of adult stem cells

While cultured embryonic stem (ES) cells can be harvested in abundance and appear to be the most versatile of cells for regenerative medicine, adult stem cells also hold promise, but the identity and subsequent isolation of these comparatively rare cells remains problematic in most tissues, perhaps with the notable exception of the bone marrow. The ability to continuously self-renew and produce the differentiated progeny of the tissue of their location are their defining properties. Identifying surface molecules (markers) that would aid in stem cell isolation is a major goal. Considerable overlap exists between different putative organ-specific stem cells in their repertoire of gene expression, often related to self-renewal, cell survival and cell adhesion. More robust tests of 'stemness' are now being employed, using lineage-specific genetic marking and tracking to show production of long-lived clones and multipotentiality in vivo. Moreover, the characterization of normal stem cells in specific tissues may provide a dividend for the treatment of cancer. The successful treatment of neoplastic disease may well require the specific targeting of neoplastic stem cells, cells that may well have many of the characteristics of their normal counterparts.

Thalidomide inhibits lipopolysaccharide-induced tumor necrosis factor-α production via down-regulation of MyD88 expression

The effect of thalidomide on lipopolysaccharide (LPS)-induced tumor necrosis factor (TNF)-α production was studied by using RAW 264.7 murine macrophage-like cells. Thalidomide significantly inhibited LPS-induced TNF-α production. Thalidomide prevented the activation of nuclear factor (NF)-KB by down-regulating phosphorylation of inhibitory KB factor (IKB), and IKB kinase (IKK)-α and IKK-β Moreover, thalidomide inhibited LPS-induced phosphorylation of AKT, p38 and stress-activated protein kinase (SAPK)/JNK. The expression of myeloid differentiation factor 88 (MyD88) protein and mRNA was markedly reduced in thalidomide-treated RAW 264.7 cells but there was no significant alteration in the expression of interleukin-1 receptor-associated kinase (IRAK) 1 and TNF receptor-associated factor (TRAF) 6 in the cells. Thalidomide did not affect the cell surface expression of Toll-like receptor (TLR) 4 and CD14, suggesting the impairment of intracellular LPS signalling in thalidomide-treated RAW 264.7 cells. Thalidomide significantly inhibited the TNF-α production in response to palmitoyl-Cys(RS)-2,3-di(palmitoyloxy) propyl)-Ala-Gly-OH (Pam3Cys) as a MyD88-dependent TLR2 ligand. Therefore, it is suggested that thalidomide might impair LPS signalling via down-regulation of MyD88 protein and mRNA and inhibit LPS-induced TNF-α production. The putative mechanism of thalidomide-induced MyD88 down-regulation is discussed.

Multi-method evaluation of a paediatric ambulatory care unit (PACU): impact on families and staff

AIM

To assess the impact of a purpose-built, short stay paediatric ambulatory care unit (PACU) on the patient journey and perceptions of parents, staff and referrers.

METHODS

Multi-method evaluation, including a parent survey (n = 104), patient journey mapping (n = 10), staff interviews (n = 10), a referrer survey (n = 16), routine activity analysis, and a comparison with the A&E service (A&E parent survey: n = 41).

RESULTS

Almost all parents attending PACU (94%) were satisfied with the service and significantly more likely to feel "very" satisfied than parents attending A&E (PACU: 51%, A&E: 31%; p = 0.03). Further, over three quarters (77%) of PACU parents preferred the new model to traditional A&E services. They reported receiving sufficient information (93%), reduced anxiety (55% anxious before service, 13% anxious after; p<0.001), "quick" waiting times (median: 35 min), and enhanced confidence (87%) and understanding (89%) in dealing with their ill child. The number of stages in the patient journey was reduced from six ("traditional" A&E pathway) to four (PACU pathway). Staff and referrers reported this was a "superior" model to A&E, but that improvements were required around appropriate referrals and the need for more multi-disciplinary protocols and liaison.

CONCLUSION

Our study suggests that the PACU model is perceived to be an effective alternative to standard A&E services for the assessment and early management of acutely ill children and their families attending a hospital. It is highly valued by users, staff and referrers and enhances the patient journey. Lessons learnt include the need to enhance multi-disciplinary processes and clarify the role of this form of acute care provision in the wider healthcare system.

Unilateral epididymo-orchitis: a rare complication of MMR vaccine

We report the case of an 18-year-old male patient with epididymo-orchitis following MMR vaccine. Salivary gland involvement, meningitis/encephalitis are well-known complications of the MMR vaccine, but involvement and infection of the testis is a rarity. A search for this complication on the medical databases showed no reported cases in the UK.

Association of tuberculosis with vasculitis retinae

Retinal vasculitis is one of the common causes of blindness among the young adult in this subcontinent. Causes of retinal vasculitis are variable and it is one of the common ocular manifestations of tuberculosis. This case control study was carried out on 45 patients with retinal vasculitis of different age groups. All the patients were purposively selected from the department of ophthalmology, Bangabandhu Sheikh Mujib Medical University and National Institute of Ophthalmology Dhaka. This study reveals that vasculitis retinae is a disease of younger age group (68.9%). Mean+/-SD age of cases were 31.84+/-10.82 years. It occurs more in male (75.6%) and male female ratio is 3.09:1, single or both eye may involve. Retinal vasculitis occurs more in middle socio-economic status persons (62.2%). It present with floaters (58.9%), hazy media (60%), vitreous haemorrhage (57.8%) and retinal haemorrhage (42.2%). All 45 subjects both cases and control groups were tested with Mantoux test. 18(40%) subjects of cases and 13(28.9%) subjects of control group were found positive Mantoux test. It was observed that the association of tuberculosis with vasculitis retinae is not statistically significant. As tuberculosis is common in this country, further specific and extensive study over a longer period of time is necessary for understanding the role of tuberculosis in retinal vasculitis patients.

The influence of different hormone concentration and combination on callus induction and regeneration of Rauwolfia serpentina L. Benth

The influence of media composition on callus induction and subsequent regeneration of Rauwolfia serpentina L. Benth has been studied. High frequency (96.43%) callus induction was obtained when nodal segments from in vitro raised shoots were cultured on MS medium supplemented with 0.5 mg L(-1) BA and 2.0 mg L(-1) NAA. The callus differentiated into adventitious shoots when it was subcultured on MS medium supplemented with 2.0 mg L(-1) BA with 0.2 mg L(-1) NAA. Regenerated shoots were best rooted on half-strength MS medium with 1.0 mg L(-1) each of IBA and IAA.

Mass propagation of Rauwolfia serpentina L. Benth

A protocol for mass propagation through axillary bud proliferation was established for Rauwolfia serpentina L. Benth. (Apocynaceae). MS medium supplemented with 1.5 mg L(-1) BA and 0.2 mg L(-1) NAA elicited the maximum number of shoots (4 multiple shoots) from nodal explants. These adventitious shoots were best rooted on half strength MS medium supplemented with 1.0 mg L(-1) each of IBA and IAA. The in vitro raised plants were acclimatized in glass house and successfully transplanted to field condition with almost 95% survival.

Interleukin-10 inhibits tumor necrosis factor-α production in lipopolysaccharide-stimulated RAW 264.7 cells through reduced MyD88 expression

The mechanism of interleukin (IL)-10-mediated inhibition of tumor necrosis factor (TNF)-α production was studied by lipopolysaccharide (LPS)-stimulated RAW 264.7 macrophage cells. IL-10 inhibited TNF-α production transiently at an early stage after LPS stimulation. IL-10 inhibited the activation of nuclear factor (NF)-κB, p38 and stress-activated protein kinase (SAPK) in LPS-stimulated RAW 264.7 cells. Although the level of MyD88 protein increased in response to LPS, IL-10 prevented the LPS-induced MyD88 augmentation. There was no significant difference in the MyD88 mRNA expression between the cells pretreated with or without IL-10 in response to LPS. Therefore, IL-10 was suggested to inhibit LPS-induced TNF-α production via reduced MyD88 expression.

The mechanism of development of acute lung injury in lethal endotoxic shock using alpha-galactosylceramide sensitization

The mechanism underlying acute lung injury in lethal endotoxic shock induced by administration of lipopolysaccharide (LPS) into alpha-galactosylceramide (alpha-GalCer)-sensitized mice was studied. Sensitization with alpha-GalCer resulted in the increase of natural killer T (NK T) cells and the production of interferon (IFN)-gamma in the lung. The IFN-gamma that was produced induced expression of adhesion molecules, especially vascular cell adhesion molecule-1 (VCAM-1), on vascular endothelial cells in the lung. Anti-IFN-gamma antibody inhibited significantly the VCAM-1 expression in alpha-GalCer-sensitized mice. Very late activating antigen-4-positive cells, as the counterpart of VCAM-1, accumulated in the lung. Anti-VCAM-1 antibody prevented LPS-mediated lethal shock in alpha-GalCer-sensitized mice. The administration of LPS into alpha-GalCer-sensitized mice caused local production of excessive proinflammatory mediators, such as tumour necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6 and nitric oxide. LPS caused microvascular leakage of proteins and cells into bronchoalveolar lavage fluid. Taken together, sensitization with alpha-GalCer was suggested to induce the expression of VCAM-1 via IFN-gamma produced by NK T cells and recruit a number of inflammatory cells into the lung. Further, LPS was suggested to lead to the production of excessive proinflammatory mediators, the elevation of pulmonary permeability and cell death. The putative mechanism of acute lung injury in LPS-mediated lethal shock using alpha-GalCer sensitization is discussed.