Are referring clinicians aware of patients at risk from intravenous injection of iodinated contrast media?

AIM

The purpose of our study was to assess the level of awareness of referring clinicians to populations at risk for complications of intravascular administration of iodinated contrast media.

SUBJECTS AND METHODS

Two hundred and three physicians from three university hospitals completed an anonymous questionnaire regarding risk factors and contraindications to the intravenous administration of iodinated contrast media. The questionnaire included medical conditions with increased risk for anaphylactoid reaction (asthma, hay fever and food allergy) as well as chemotoxic (ischaemic heart disease, phaeochromocytoma and myasthenia gravis) adverse reactions, some with dependence on renal function (metformin treatment, diabetes mellitus and multiple myeloma). Two additional multiple-choice questions addressed pre-medication protocols and risk of nephrotoxicity in diabetic patients.

RESULTS

Asthma, food allergy and hay fever were recognized as risk factors by 81.3%, 77.8% and 61.6% of respondents respectively, while ischaemic heart disease, phaeochromocytoma and myasthenia gravis were defined as such only by 9.8%, 30.0% and 28.6% respectively. Metformin treatment, diabetes mellitus and multiple myeloma, in the presence of normal renal function, were considered as risk factors by 46.3%, 38.9% and 58.1% of respondents respectively. One of the generally accepted pre-medication protocols was selected by 89.8%. The risk of nephrotoxicity in a diabetic patient was correctly assessed by 63.5% of respondents.

CONCLUSION

We found a relatively high awareness among referring clinicians of a potential anaphylactoid reaction and nephrotoxicity due to iodinated contrast media. However, additional chemotoxic adverse reactions are less well known. Future efforts to improve communication between clinicians and radiologists should be focused in this direction.

Cytokine levels in various intravenous immunoglobulin (IVIg) preparations

The mechanisms of action of intravenous immunoglobulin (IVIg) in autoimmune diseases include modulation of cytokine levels. We examined therefore whether direct infusion of abnormally high levels of 13 different cytokines or cytokine-inhibitors within 5 different IVIg preparations have any role in modulation of their levels. None of the measured cytokines in any of the IVIg preparations tested were above the normal levels, and regarding some no traces could be detected. Hence, modulation of cytokine levels following IVIg therapy involves other mechanisms such as interference with their secretion or cytokine-specific blocking antibodies, rather than direct infusion of cytokines.

Red and/or blonde hair association with pigmentary glaucoma in Israel

PURPOSE

To assess the prevalence of red and/or blonde hair in a defined pigmentary glaucoma (PG) population and to compare their clinical findings with those of PG patients with black or brown hair.

METHODS

Hair color was studied in 35 consecutive PG patients and 35 consecutive primary open angle glaucoma (POAG) patients who served as controls. Patients were classified into red and/or blonde hair group or into black or brown hair group. Clinical characteristics were contrasted between PG patients of red and/or blonde hair with PG patients of black or brown hair.

RESULTS

Of the 35 PG patients, 19 (54.3%) had red and/or blonde hair and 16 (45.7%) had black or brown hair. Of the 35 POAG patients, two (5.8%) had red and/or blonde hair and 33 (94.2%) had black or brown hair. This difference in prevalence of hair color is highly significant (P < 0.001; chi2). Clinical characteristics of the PG patients (age at initial diagnosis, gender, positive family history for glaucoma, initial IOP, refraction, severity of optic nerve damage and prevalence of retinal detachment) were similar in the red and/or blonde hair and the black or brown hair groups.

CONCLUSIONS

A very high prevalence of red and/or blonde hair was found among PG patients in Israel. Should supportive evidence for this association accumulate subsequent to this report, screening of people with these hair colors for PG may be justified.

Helix-coil transition of PrP106-126: molecular dynamic study

A set of 34 molecular dynamic (MD) simulations totaling 305 ns of simulation time of the prion protein-derived peptide PrP106-126 was performed with both explicit and implicit solvent models. The objective of these simulations is to investigate the relative stability of the alpha-helical conformation of the peptide and the mechanism for conversion from the helix to a random-coil structure. At neutral pH, the wild-type peptide was found to lose its initial helical structure very fast, within a few nanoseconds (ns) from the beginning of the simulations. The helix breaks up in the middle and then unwinds to the termini. The spontaneous transition into the random coil structure is governed by the hydrophobic interaction between His(111) and Val(122). The A117V mutation, which is linked to GSS disease, was found to destabilize the helix conformation of the peptide significantly, leading to a complete loss of helicity approximately 1 ns faster than in the wild-type. Furthermore, the A117V mutant exhibits a different mechanism for helix-coil conversion, wherein the helix begins to break up at the C-terminus and then gradually to unwind towards the N-terminus. In most simulations, the mutation was found to speed up the conversion through an additional hydrophobic interaction between Met(112) and the mutated residue Val(117), an interaction that did not exist in the wild-type peptide. Finally, the beta-sheet conformation of the wild-type peptide was found to be less stable at acidic pH due to a destabilization of the His(111)-Val(122), since at acidic pH this histidine is protonated and is unlikely to participate in hydrophobic interaction.

Mutations of CD40 gene cause an autosomal recessive form of immunodeficiency with hyper IgM

CD40 is a member of the tumor necrosis factor receptor superfamily, expressed on a wide range of cell types including B cells, macrophages, and dendritic cells. CD40 is the receptor for CD40 ligand (CD40L), a molecule predominantly expressed by activated CD4(+) T cells. CD40/CD40L interaction induces the formation of memory B lymphocytes and promotes Ig isotype switching, as demonstrated in mice knocked-out for either CD40L or CD40 gene, and in patients with X-linked hyper IgM syndrome, a disease caused by CD40L/TNFSF5 gene mutations. In the present study, we have identified three patients with an autosomal recessive form of hyper IgM who fail to express CD40 on the cell surface. Sequence analysis of CD40 genomic DNA showed that one patient carried a homozygous silent mutation at the fifth base pair position of exon 5, involving an exonic splicing enhancer and leading to exon skipping and premature termination; the other two patients showed a homozygous point mutation in exon 3, resulting in a cysteine to arginine substitution. These findings show that mutations of the CD40 gene cause an autosomal recessive form of hyper IgM, which is immunologically and clinically undistinguishable from the X-linked form.

Catastrophic antiphospholipid syndrome: remission following leg amputation in 2 cases

OBJECTIVE

The antiphospholipid syndrome is characterized by venous and arterial thrombotic events that are often recurrent, thrombocytopenia, recurrent fetal loss, and elevated titers of antiphospholipid antibodies. A subtype of patients with a particularly overwhelming clinical picture has been termed catastrophic antiphospholipid syndrome (CAPS). In this report, we present 2 patients who exhibited a similar multisystem disorder associated with gangrenous changes in the lower extremities.

METHODS

Two patients with CAPS are presented, highlighting the impact of this disorder on the patients and the response to various therapeutic modalities.

RESULTS

Both patients had pulmonary, cardiac, cutaneous, and neurologic findings consistent with CAPS. In addition, they had large purulent leg ulcers associated with livedo reticularis. Amputation of the legs in each case induced remission of the systemic illness.

CONCLUSIONS

We believe that infection plays a significant role in the pathogenesis and amplification of the antiphospholipid syndrome. In certain patients, this association probably is mediated via immune mechanisms, which also enhance the genesis of atherosclerosis. After the foci of infection (suppurative leg ulcers) were removed, the underlying illness improved. These case studies provide an opportunity to study the interrelationship between several confounding factors that converge and lead to the development of this autoimmune condition.

Congenital insensitivity to pain with anhidrosis (CIPA): the spectrum of radiological findings

BACKGROUND

Congenital insensitivity to pain with anhidrosis (CIPA) is an exceedingly rare, hereditary, sensory autonomic neuropathy (HSAN).

AIM

To evaluate the various skeletal manifestations and cranial CT features in children affected by CIPA.

MATERIALS AND METHODS

In the semidesert area of the Negev, the Bedouin tribes constitute a closed society where consanguineous marriages are the custom. This has resulted in a group of 20 children being affected by this rare autosomal recessive HSAN. The skeletal surveys and CT scans of these 20 Bedouin patients, 12 girls and 8 boys, ages ranging between 1 month and 8 years, were retrospectively analysed. Cranial CT scans were performed in ten children because of neonatal hypotonia and psychomotor retardation. The skeletal findings were classified as follows: fractures, joint deformities, joint dislocations, osteomyelitis, avascular necrosis and acro-osteolysis.

RESULTS

All 20 patients had fractures of the extremities and acro-osteolysis of the fingers. Six had joint deformities. Three children had recurrent hip joint dislocations and another three had avascular necrosis. Ten patients presented with osteomyelitis of the limbs, acetabulum and scapula. The cranial CT scans disclosed mild brain volume loss with some ventriculomegaly.

CONCLUSIONS

CIPA is a severe autosomal recessive condition that leads to self-mutilation early in life and to fractures, osteomyelitis and limb amputation in older children. Mental retardation is common. Death from hyperpyrexia occurs in almost 20 % of patients in the first 3 years of life.

Deregulation of the expression of the fractalkine/fractalkine receptor complex in HIV-1-infected patients

Fractalkine is the only member of the CX3C chemokine family. Polymorphism of the fractalkine receptor gene may influence the prognosis of human immunodeficiency virus (HIV) infection, but the nature of the cells expressing fractalkine or its receptor in HIV-infected patients remains unknown. We show that, in contrast to HIV-uninfected individuals, a large number of cells expressed fractalkine in T-cell zones of lymph nodes from HIV-infected patients. CD83(+) mature and CD123(+) plasmacytoid dendritic cells as well as plasma cells are involved in this increased expression of fractalkine. Increased numbers of plasmacytoid dendritic cells and plasma cells were present in T-cell zones of HIV-infected patients. CD83(+) dendritic cells were present in similar number in HIV-infected patients and controls, but an increased fraction of these cells produced fractalkine in HIV-infected patients. Many plasma cells in the gut-associated lymphoid tissue from HIV-infected patients also produced fractalkine, whereas few cells produced fractalkine in the gut of controls. The fraction of CD45RO(+) and CD45RO(-) T helper (Th) cells expressing the fractalkine receptor CX3CR1 was higher in HIV-infected patients than in healthy individuals, and these cells were abnormally sensitive to fractalkine stimulation. This increased response correlated with HIV viremia, and it returned to normal levels in patients successfully treated with antiretroviral drugs. The increased expression of the fractalkine/fractalkine receptor complex associated with HIV infection may affect adhesion and migration of Th lymphocytes and their interaction with dendritic cells. Thus, it may influence the equilibrium between depletion and renewal of the Th lymphocyte compartment.

Coronary artery disease but not coronary calcification is associated with elevated levels of cardiolipin, beta-2-glycoprotein-I, and oxidized LDL antibodies

BACKGROUND

Autoimmune factors have been shown to play a role in atherosclerosis. The aim of this study is to correlate 5 autoantibodies (anticardiolipin, anti-CL, beta2-glycoprotein-I, beta2GPI, phosphatidylcholine, oxidized low-density lipoprotein, oxLDL, endothelial cell) with the presence of coronary heart disease, angiographic findings, and with coronary artery calcification.

METHODS

The levels of the 5 autoantibodies and a control antifibroblast line of 126 coronary heart disease patients and 20 healthy controls were measured. Fifty-one patients underwent coronary angiography, and 98 patients had coronary artery calcium determination using spiral computerized tomography (dual mode).

RESULTS

Levels of 3 autoantibodies (anti-CL, beta2GPI, oxLDL) were significantly elevated in coronary heart disease patients compared with controls (p < 0.001, p = 0.001, p < 0.001, respectively). Within the subgroup of patients with significant coronary artery stenosis, anti-CL antibodies were also elevated (p = 0.008). No correlation was found between anti-CL, and anti-beta2GPI autoantibody levels and coronary calcium scores as measured by spiral computerized tomography. However, anti-oxLDL antibodies were raised in patients with no calcification detected by spiral computerized tomography, compared with the patients with any coronary calcification (p = 0.046).

CONCLUSION

Anti-CL, beta2GPI and oxLDL antibodies are elevated in coronary heart disease patients regardless of coronary calcification.

Immunological and virological effects of long term IL-2 therapy in HIV-1-infected patients

We report the long-term outcome of 27 HIV-infected patients treated for over 3 years with IL-2 and binucleoside analogues. These patients experienced a sustained increase in CD4 cells and a decrease of proviral DNA with infrequent IL-2 cycles. In three cases, virus could not be isolated from activated peripheral cells. A high frequency of HIV-1-specific memory CD4 T cells was found in the patients studied. IL-2 maintains specific effector cells and reduces the pool of infected cells in patients, albeit treated only with binucleosides.

High-dose intravenous immunoglobulins for lupus nephritis--a salvage immunomodulation

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease with a great diversity of clinical manifestations which is difficult to manage. IVIGs represent promising immunoregulatory agents with the ability to control SLE without subsequent predisposition to infectious complications. Despite the implied risk of developing renal failure due to IVIG, considerable beneficial effects on lupus nephritis are reported. In this review, the clinical and adverse effects, and mechanism of action, with special emphasis on modulation, of idiotypic network is discussed.

Adverse effects of intravenous immunoglobulin therapy in 56 patients with autoimmune diseases

OBJECTIVE

To test the adverse effects and viral safety of intravenous immunoglobulin (IVIg) use in autoimmune diseases.

METHODS

Fifty-six patients with various autoimmune diseases who were treated with one to six IVIg courses were evaluated for the presence of adverse effects following IVIg therapy and were screened before and after the treatment for the presence of serum human immunodeficiency virus antibodies, hepatitis C virus antibodies, and hepatitis B surface antigen.

RESULTS

Among the 56 patients, 20 (36%) had at least one adverse effect following at least one of the treatment courses. These included headache, low-grade fever, chills, anemia, low-back pain, transient hypotension, nausea, intensified perspiration, and superficial and deep vein thromboses. Whereas the presence of adverse effect to IVIg was unrelated to either the clinical response to the treatment or to the nature of the autoimmune disease, the occurrence of an adverse effect in the first treatment course was significantly associated with a greater chance for an adverse effect in the subsequent courses. No transmission of any of the three viral agents examined could be detected.

CONCLUSIONS

Although IVIg use in autoimmune diseases is associated with adverse effects in about one third of the patients, these effects are usually mild and transient. Patients who develop adverse effects during the first treatment course may be at increased risk of adverse effects during the subsequent IVIg courses.

Galectin-8 Functions as a Matricellular Modulator of Cell Adhesion

The interaction of cells with the extracellular matrix regulates cell adhesion and motility. Here we demonstrate that different cell types adhere and spread when cultured in serum-free medium on immobilized galectin-8, a mammalian beta-galactoside-binding protein. At maximal doses, galectin-8 is equipotent to fibronectin in promoting cell adhesion and spreading. Cell adhesion to immobilized galectin-8 is mediated by sugar-protein interactions with integrins, and galectin-8 triggers integrin-mediated signaling cascades including Tyr phosphorylation of focal adhesion kinase and paxillin. Cell adhesion is potentiated in the presence of Mn(2+), whereas it is interrupted in the presence of soluble galectin-8, integrin beta(1) inhibitory antibodies, EDTA, or thiodigalactoside but not by RGD peptides. Furthermore, cells readily adhere onto immobilized monoclonal galectin-8 antibodies, which are equipotent to integrin antibodies in promoting cell adhesion. Cell adhesion to immobilized galectin-8 is partially inhibited by serum proteins, suggesting that complex formation between immobilized galectin-8 and serum components generates a matrix that is less supportive of cell adhesion. Accordingly, cell motility on immobilized galectin-8 readily takes place in the presence of serum. Truncation of the C-terminal half of galectin-8, including one of its two carbohydrate recognition domains, largely abolishes its ability to modulate cell adhesion, indicating that both carbohydrate recognition domains are required to maintain a functional form of galectin-8. Collectively, our findings implicate galectin-8 as a physiological modulator of cell adhesion. When immobilized, it functions as a matrix protein equipotent to fibronectin in promoting cell adhesion by ligation and clustering of cell surface integrin receptors. In contrast, when present in excess as a soluble ligand, galectin-8 (like fibronectin) forms a complex with integrins that negatively regulates cell adhesion. Because of its dual effects on the adhesive properties of the cells and its association with fibronectin, galectin-8 might be considered a novel type of matricellular protein.

Quality assessment of oral anticoagulant treatment in the Beer-Sheba district

OBJECTIVE

To evaluate the adequacy of oral anticoagulation therapy in patients with either prosthetic heart valves or atrial fibrillation.

DESIGN

Adequacy of anticoagulation therapy of patients treated with warfarin was determined before and after implementation of an improvement programme.

SETTING

The central haematology laboratory of the Soroka Medical Center, Beer-Sheba Israel.

STUDY PARTICIPANTS

One hundred and ten patients treated with chronic anticoagulation therapy were evaluated by measuring the international normalized ratio of the prothrombin time before and after implementation of an improvement plan aimed at improving anticoagulation control.

INTERVENTION

A programme that included physician and patient education and procedural changes covering all aspects of anticoagulation therapy was implemented.

MAIN OUTCOME MEASURE

The percent of international normalized ratio tests below, within and above the therapeutic range was determined.

RESULTS

Prior to implementation of an improvement plan, only 32% of the measured international normalized ratio values were within the therapeutic range. 16% were above and 52% were below therapeutic range. Improvement intervention led to an increase in the proportion of international normalized ratio tests that fell within the therapeutic range from 32% to 43.2%.

CONCLUSIONS

Improvement in the control of anticoagulation therapy of patients receiving long-term warfarin treatment is possible. A combined effort involving the community, physician and patient is required.

[Eosinophilic ascites as a presenting symptom of the hypereosinophilic syndrome]

We report a case of a 22 year old man with a history of bronchial asthma, suffering from diarrhea, eosinophilic ascites and prominent blood and bone marrow eosinophilia. The patient responded to corticosteroid treatment. Later, hydroxyurea was added to this treatment because of recurrence of eosinophilia, ascites and hepatosplenomegaly. Eosinophilic ascites is rarely the outstanding symptom of the hypereosinophilic syndrome. Following the exclusion of other reasons for eosinophilia, concomitant unexplained hepatosplenomegaly suggested the diagnosis of a hyperereosinophilic syndrome.

Optimization of solutions for the one plant protection problem

Plant protection problems are simulated by a system of ordinary differential equations with given initial conditions. The sensitivity and resistance of pathogen subpopulations to fungicide mixtures, fungicide weathering, plant growth, etc. are taken into consideration. The system of equations is solved numerically for each set of initial conditions and parameters of the disease and fungicide applications. Optimization algorithms were investigated and a computer program was developed for optimization of these solutions. 14 typical cases of the disease were simulated and optimized in order to determine optimal fungicide treatments. The optimized strategy for fungicide application differs considerably from the commonly used method and seems to be an important new principle in plant protection. The approach developed in this study may be useful for a wide spectrum of purposes in the simulation of leaf diseases. It may also help the biologist to decrease or pinpoint experimental work and analyze its results and is perspective for plant disease control.

Severe thrombotic complications associated with activated protein C resistance acquired by orthotopic liver transplantation

We report a patient who developed recurrent hepatic artery thrombosis and deep venous thrombosis following orthotopic liver transplantation. Investigations revealed the presence of activated protein C (APC) resistance due to a mutation in the factor V gene in the transplanted liver. The patient's own peripheral blood cells did not carry the mutation. Although part of factor V is located in the platelets and may be endogenously synthesized by megakaryocytes, this case demonstrates the major clinical importance of hepatic-derived factor V. It may be reasonable to screen liver donors with a history of a thrombotic event for APC, and to consider anticoagulation in the recipients of livers positive for this defect.

A syndrome of transient encephalopathy associated with adenovirus infection

BACKGROUND AND OBJECTIVE

Adenovirus is a common pathogen in the pediatric population. Respiratory, gastrointestinal, or renal systems are often involved in adenovirus infections. Several neurologic syndromes have been attributed to adenovirus, such as adenovirus aseptic meningitis, myelitis, subacute focal encephalitis, and Reye-like syndrome. The purpose of this study was to describe the clinical features and encephalography findings in 7 infants treated in our center for a syndrome of transient encephalopathy associated with adenovirus infection.

STUDY PARTICIPANTS

Three females and 4 males ages 7 to 34 months seen in our department between July 1983 and February 1984 and September 1998 and May 1999 presented with fever of at least 7 days' duration and a gradual decline in the state of alertness. Score on the Glasgow Coma Scale ranged from 9 to 12. Findings on lumbar puncture were normal. In all 7 patients, the encephalogram showed moderate to severe background slowing compatible with encephalopathy. All patients were catarrheal and had mild hepatomegaly with slight elevation of liver enzymes. Some had bronchopneumonia, diarrhea, and conjunctivitis either isolated or in combination.

METHODS AND RESULTS

Adenovirus was isolated by immunfluorescence technique in all patients-from the sputum in 3 patients, nasopharynx in 5, conjunctiva in 4, and rectal swab in 5. In 5 patients, serotyping was performed by an antibody neutralization method. Adenovirus type 3 was ascertained from a nasal swab in 1 patient, sputum specimens in 3, throat swab in 3, and rectal cultures in 5. The clinical course was characterized by a progressive recovery of alertness. After several days, there was a complete reversal of neurologic findings.

CONCLUSION

We suggest that this syndrome of transient encephalopathy is a distinct entity and should be considered as another of the several neurologic syndromes known to be associated with adenovirus infection.

[Intravenous immunoglobulins treatment of patients with Graves' ophthalmopathy]

Graves' ophthalmopathy is an autoimmune disease manifested as exophthalmus, lid lag and diplopia. As in the accompanying autoimmune thyroid disease, there is an autoimmune homonal and cellular attack on the orbita, mainly the retro-orbital tissues. Steroids are the cornerstone of therapy. We reviewed the evidence for a similar therapeutic effect of i.v., immunoglobulins (IVIGs) and their better side affect profile as compared to steroids. We also described an impressive therapeutic success with IVIG given to a patient with resistant ophthalmopathy. The clinical picture of Graves' ophthalmopathy is attributed to a pathologic hyper--activation of orbital fibroblasts, deposition of collagen and glycosaminoglycans in the extra-cellular matrix and eventually fibrosis. These are mediated by leucoregulin, IL-1, IFN-gamma, and TGF-beta--all secreted by lymphocytes and mast cells in the retorbital space. Another mode of cell activation is by binding of autoantibodies (presumably thyroid stimulating Ab's) to an antigenic determinant on the surface of fibroblasts. I.v. immunoglobulins, known today to be active in a variety of autoimmune processes, exert their effect on autoantibodies, complement, phagocytic cells etc. IVIGs also inhibit orbital lymphocytes and fibroblasts through inhibition of IL-1 or/and TGF-beta.