The safety and activity of polymerized ragweed: a double-blind, placebo-controlled trial in 81 patients with ragweed rhinitis

Eighty-one patients with ragweed pollinosis were recruited for a double-blind, histamine placebo-controlled study of the safety, immunogenicity, and efficacy of 15 weekly injections of polymerized ragweed (PRW) immunotherapy totaling 1359 allergy units. Patients were paired on the basis of cutaneous end point titration to RAST standardized extracts of giant and short ragweed. One patient of each pair was randomized to receive PRW, and the other patient, a caramelized glucose histamine placebo. Symptom and medication score diaries were completed by 68 patients. All 68 patients received the full maintenance dose. No patient dropped out because of adverse reactions, and there were no systemic reactions. Except for one patient receiving placebo who developed mildly elevated liver function tests, there were no clinically significant changes in routine laboratory tests associated with injections. By Student's test on log-transformed values, blocking antibody rose significantly in the patients receiving PRW but was unchanged in those receiving placebo. By Wilcoxon paired signed-rank test, the symptom and medication scores in the patients receiving PRW were significantly lower than scores in the patients receiving placebo. This study demonstrates the safety, immunogenicity, and activity of PRW in the treatment of ragweed pollinosis.

Levels and specificity of antibody in bronchoalveolar lavage (BAL) and serum in an animal model of trimellitic anhydride-induced lung injury

A study was undertaken to characterize the antibody response in rats exposed to trimellitic anhydride (TMA) by inhalation. Total antibody levels directed to trimellitic rat serum albumin (TM-RSA) from TMA-exposed rats were assayed by an ammonium sulfate technique. Total antibody levels in bronchoalveolar lavage (BAL) and the matched serum were compared by correction for the albumin content of each. An ELISA was developed to detect IgG, IgA, and IgM directed toward TM-RSA in BAL and serum and to compare class-specific antibody levels in BAL and serum by normalizing for albumin content. The specificity of the rat IgG response was determined by ELISA inhibition with TM-RSA and TM-human serum albumin (TM-HSA) and compared with reciprocal inhibition studies with serum from TMA-exposed workers. The levels of total antibody in BAL were three to 15 times greater than the levels found in the matched serum pair. IgG, IgA, and IgM antibodies were detected in the BAL and the serum of TMA-exposed rats but not in control rats. In each of the four rats tested, all antibody classes were present in equal or greater amounts in the BAL than in the serum. Complete inhibition of the rat IgG binding in ELISA was observed when TM-RSA or TM-HSA were added as inhibitors. Human IgG was inhibited in ELISA only by TM-HSA. In an animal model of human lung disease, the levels of total antibody as well as class-specific antibodies directed against TM-RSA were greater in BAL than in serum.(ABSTRACT TRUNCATED AT 250 WORDS)

Practices in cat and dog immunotherapy among allergists

Allergists in each of four groups, board certified with academic affiliation (A), board certified without academic affiliation (B), non-board certified (NB), and previous trainees of our program (PT)--were queried as to their practices and philosophies in cat and dog epidermal immunotherapy (CDI) and pollen immunotherapy (PI). The four groups were similar in numbers of new patients seen and practices of PI. In several instances, with respect to CDI, however, the PT and A groups segregated from the B and NB groups. Most of B and NB allergists would administer CDI to a patient who refused to give up a pet, while most physicians in the PT or the A groups would not. Overall the number of patients placed on CDI was higher and the degree of efficacy was perceived as higher among the NB and B groups than in the PT or A groups.

Strength testing with a portable dynamometer: reliability for upper and lower extremities

This study was designed to determine intraobserver and interobserver reliability of maximal muscle strength for upper and lower extremity muscle groups. Four healthy subjects were tested with a portable muscle dynamometer on two separate occasions by three separate examiners to determine maximal isometric strength of lateral pinch between thumb and index finger, elbow flexion, elbow extension, shoulder flexion, hip flexion, hip extension, hip abduction, knee flexion, and ankle dorsiflexion. A break test was also used to evaluate the strength of cervical flexor muscles and extensor hallucis longus. Pearson correlation coefficients for inter- and intraexaminer testing was good for upper extremity test values from 0.85 to 0.99. The variation coefficient of the methodology error (CV) in all upper extremity muscle tests was between 5.1% and 8.3%. These results seemed reliable for clinical muscle strength testing. However, correlation coefficients for lower extremity testing were poor, with values ranging from -0.20 to 0.96. The CV in these tests was much greater than in the upper extremities and ranged from 11.3% to 17.8%. Both break tests also had high CV, with each being greater than 17%. Our results demonstrate that although the dynamometer is reliable for testing upper extremity muscle groups, it is unreliable for testing lower extremity muscle groups. Further work is needed to evaluate muscle strength quantitatively in the clinical setting in an accurate, valid, and reliable manner.

Provocative challenge with local anesthetics in patients with a prior history of reaction

Possible allergic sensitivity to local anesthetic agents remains problematic for some patients who could benefit from their use. We retrospectively reviewed all our consultations for evaluation of local anesthetic allergy from 1965 to 1985 to assess the safety and efficacy of skin testing and provocative test dosing with a variety of local anesthetic agents. Fifty-nine patients reported 70 reactions from the administration of six different local anesthetics. Fifty-four patients could name one or more local anesthetic agents they believed were responsible, and five patients named only "caine" drugs. Multiple reactions of the same type to the same agent were considered as one reaction. On the basis of their history of reaction, the patients were categorized as follows: anaphylactoid reactions (urticaria, angioedema, wheezing, or hypotension within 1 to 2 hours of exposure), possible anaphylactoid reactions (tachycardia, dizziness, syncope, breathlessness, or pruritus occurring within 1 to 2 hours of exposure), contact dermatitis (a typical eczematous skin eruption after appropriate cutaneous sensitization), and other reactions (nonanaphylactoid reactions other than those already described or those occurring more than 2 hours after exposure). Fifty-nine patients were administered local anesthetics after skin testing and provocative test dosing, including two patients who required intravenous lidocaine (Xylocaine; Astra Pharmaceutical Products, Inc., Westboro, Mass.) acutely to control cardiac arrhythmias. These two patients had reported anaphylactoid reactions to oral antiarrhythmic drugs of the local anesthetic class. Despite the history of previous reactions, there were no positive skin tests or positive provocative drug challenges in any patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Allergic bronchopulmonary aspergillosis. Model of bronchopulmonary disease with defined serologic, radiologic, pathologic and clinical findings from asthma to fatal destructive lung disease

Allergic bronchopulmonary aspergillosis (ABPA) complicates asthma and results in immunologic lung destruction. Respiratory failure or fatalities from end-stage fibrotic lung disease have occurred in patients in the third and fourth decades of life. Allergic bronchopulmonary aspergillosis may be confirmed in patients with varying severity of asthma from minimal to corticosteroid-dependent and has been reported to occur in approximately 10 percent of patients with cystic fibrosis. It has been documented in infants and children, the geriatric patient with asthma, in the presence of a normal chest roentgenogram, in the corticosteroid-dependent asthmatic patient, and on a familial basis. The pathogenesis of ABPA is unclear, but may be related to the array of immunologic abnormalities including: elevation of total serum IgE, not all of which is directed to Aspergillus fumigatus (Af); elevated serum IgE-Af, IgG-Af and IgA-Af; precipitating antibodies to Af; hyperreactivity of peripheral blood basophils to Af and other molds; and sensitized lymphocytes. Research in ABPA should be multidisciplinary and initially should include investigators in allergy-immunology, mycology, pulmonary, and epidemiology.

Histological evaluation of the vascular system for the severity of atherosclerosis in hyper and hypotensive male and female turkeys: comparison between young and aged turkeys

Relationships among age, blood pressure, and atherosclerosis were studied in turkeys genetically selected for high and low systolic blood pressure ranging in age from 2 days to 104 weeks. Relationships between sex and atherosclerosis were studied only at 104 weeks of age. Abdominal aortas were examined in all birds in each age group. The left and right internal, external, and common carotid arteries, cranial and caudal thoracic aortas, area of coeliac orifice, sciatic junction, left and right sciatic arteries, left and right coronary arteries, and left and right deep branches of the coronary arteries were examined in the 104-week-old group. Mean abdominal aortic plaque scores for the different age groups increased linearly to the age of 12 weeks; after this time scores reached a plateau. Except for the first and last time period, the hypertensive group of males showed a significantly greater abdominal aortic plaque score than the hypotensive group. The right sciatic artery was the only other blood vessel in the 104-week-old group that had a significantly greater plaque score in the hypertensive line when compared with the hypotensive line. In the 104-week period, only the left and right sciatic arteries showed significantly higher plaque scores in the males than in the females. Also, only the male turkeys showed an increase in plaque scores with a concomitant rise in systolic pressure. In 104-week-old females there was no evidence of intimal change in either the left and right internal carotids, left and right common carotids, cranial thoracic aorta, or the right coronary artery. The hypertensive line had significantly greater blood pressure and greater ventricular weight, length, and sagittal width than the hypotensive line. The 104-week-old turkeys had more lipid staining material within the plaque than the younger birds, and calcification was evident in two of the older turkeys.

Evaluation and management of corticotropin allergy

Subsequent use of an adrenocorticotropic hormone (ACTH) preparation may be considered in some instances in a patient who has demonstrated a suspected or proven allergic reaction to corticotropin on prior administration. We describe a patient with multiple sclerosis with a history of anaphylaxis to porcine ACTH in whom another course of treatment with ACTH was being considered. The patient had immediate cutaneous reactivity to porcine ACTH but not to the synthetic ACTH peptide, cosyntropin. With a test-dose schedule, we were able to uneventfully administer cosyntropin to the patient. The presence of serum IgE antibody directed against porcine ACTH and absence of IgE antibody against cosyntropin were demonstrated by ELISA technique, corroborating the skin test results. These studies are consistent with previous evidence that immediate hypersensitivity reactions to corticotropin are IgE mediated and support the value of skin testing in the clinical evaluation and management of known or suspected corticotropin hypersensitivity.

Diagnosis of animal allergy

The aims of the diagnostic evaluation are to establish the presence and severity of disease and the importance of animal exposure as the etiology of the disease. The evaluation of the importance of animals may be part of a general allergy evaluation or specifically directed toward an animal in certain cases, such as occupational exposure. The diagnostic techniques are medical history, physical examination, allergy skin tests or in vitro tests for IgE antibody and correlation of improvement in symptoms with animal avoidance.

IgE against ethylene oxide-altered human serum albumin (ETO-HSA) as an etiologic agent in allergic reactions of hemodialysis patients

Ethylene oxide (ETO) is used to sterilize hemodialyzers and other medical equipment. In an attempt to confirm a link between ETO and hypersensitivity reactions during hemodialysis (HD) we quantitated IgE and total antibody directed against ETO-altered human serum albumin (ETO-HSA) in the sera of 65 hemodialysis patients. In 24 patients who had experienced anaphylaxis during HD, the levels of IgE and total antibody against ETO-HSA were significantly higher than the corresponding levels in 41 patients who had not. Our data demonstrate an association between the presence of IgE and total antibody against ETO-HSA and immediate anaphylactic reactions to HD. In further studies we characterized the ETO-HSA antigen by immunoelectrophoresis, gel filtration chromatography, and cross-inhibition immunoassay. Our results suggested that ETO gas can alter HSA and induce new antigenic determinants on the molecule. Recently, we encountered a peritoneal dialysis patient with rash and eosinophilia. Suspecting ETO allergy, we measured serum IgE and total antibody to ETO-HSA and found both to be present. The data suggest that, in addition to the familiar HD reactions, ETO sensitization might cause other allergic diseases as well.

Occupational immunologic lung disease

Occupational immunologic lung diseases either asthma or hypersensitivity pneumonitis, can occur in a wide variety of occupations from numerous antigens. New OILD syndromes and antigens are being reported constantly. In the case of some occupational agents that have been reported like isocyanates, formaldehyde, and Western red cedar, there is current investigation into the incidence of disease, mechanisms, and appropriate diagnostic criteria. A key principle in OILD is that prevention or at least early treatment by environmental control should be the goal. Determination of threshold limits for sensitization and adherence to these limits would be useful, for instance. In manufacturing processes in which this is not possible, workers and management in high risk industries should be educated so that affected workers are recognized early and avoidance can be instituted. Currently, there are no pre-employment screening criteria that have been shown to be very useful in predicting OILD. Prospective studies of animal handlers are underway and may provide useful information. In the case of TMA-exposed workers, prospective studies have demonstrated that serial immunologic studies are useful in predicting workers at risk for OILD and that reduction of airborne exposure will reduce prevalence. This sort of approach will probably be useful in studying other occupational agents. Such studies are complex and, to succeed, generally require cooperation and collaboration of physicians, industry, labor, industrial hygiene, and governmental agencies.

Management of drug allergy in patients with acquired immunodeficiency syndrome

Management of patients with acquired immunodeficiency syndrome (AIDS) is complicated by a high frequency of adverse drug reactions to trimethoprim-sulfamethoxazole and pentamidine. Because of the lack of suitable alternative antiparasitic drugs, some patients who have experienced previous allergic-type reactions to antimicrobial agents may require readministration with incriminated drugs. We report the outcome of seven drug-allergic patients with AIDS evaluated from 1982 to 85. Readministration of pentamidine was carried out without repeated reactions in three patients, and sulfadiazine and sulfamethoxazole-trimethoprim were readministered after very cautious test dosing in two other patients. A generalized maculopapular rash developed after 10 days of sulfadiazine therapy for Toxoplasma chorioretinitis but has been managed with prednisone, 20 to 30 mg/day for 3 months, and sulfadiazine has been continued. The administration of prednisone, 100 to 200 mg daily for treatment of severe cutaneous vasculitis from azulfidine in another patient, did not result in suprainfection. The complexities and potential legal risk of readministration of drugs in the drug-allergic patient with AIDS are emphasized in that coincidental deaths occurred in two patients 48 and 96 hours after readministration of pentamidine.

Specificity of immunoglobulin E and immunoglobulin G against human (recombinant DNA) insulin in human insulin allergy and resistance

Using an enzyme-linked immunosorbent assay method, we have demonstrated immunoglobulin E (IgE) and immunoglobulin G (IgG) against human (recombinant DNA) insulin in serum samples of a patient whose insulin therapy was only with human insulin. Within 12 days of initiation of human insulin for gestational diabetes, large local reactions developed in the patient in association with high levels of IgE to human insulin. As the local reactions subsided, the levels of IgE to human insulin decreased. The patient's insulin requirement was unusually high for pregnancy and tended to decrease in parallel with falling levels of IgG to human insulin, suggesting an element of immunologic insulin resistance. In addition to IgE and IgG against human insulin, we were able to demonstrate the presence of IgE and IgG against porcine and bovine insulin in the serum samples of this patient. The patient had similar immediate cutaneous reactivity to each insulin. In inhibition studies, similar amounts of porcine insulin, bovine insulin, or human insulin were found to produce 50% inhibition of human insulin binding to IgE or IgG against human insulin. Excess porcine insulin or bovine insulin resulted in total inhibition of human insulin binding to IgE or IgG. Thus even in a patient whose initial form of insulin therapy was human insulin, there was development of insulin allergy and of IgG to human insulin that may have contributed to insulin resistance. Moreover, the antigenic determinants recognized by antibody induced by human insulin may also be present on bovine insulin and porcine insulin as demonstrated in this case.

Stage V (fibrotic) allergic bronchopulmonary aspergillosis. A review of 17 cases followed from diagnosis

A review of the records of 17 patients with stage V (fibrotic stage) allergic bronchopulmonary aspergillosis observed since initial diagnosis (mean observation period, 4.9 years) demonstrated that, of the 11 surviving patients, four have very severe respiratory impairment. The other seven patients have mild or moderate functional impairment, but most of these have not shown clinical deterioration during the observation period. The occurrence of new roentgenographic infiltrates after the time of diagnosis was observed in only one patient in this series. Serum IgE and IgG levels against Aspergillus fumigatus, when compared with those of a control pool of serum samples from asthmatic patients with immediate cutaneous reactivity to Aspergillus, were the most useful immunologic studies diagnostically. Lung biopsy specimens obtained in five patients were of relatively little diagnostic value. All patients have required long-term prednisone therapy for control of asthma. Those patients whose forced expiratory volume in 1 s (FEV1) remained less than or equal to 0.8 L after initial corticosteroid treatment demonstrated a poor prognosis. When only moderate lung damage has occurred at the time of diagnosis, a stable subsequent course may be expected even in patients with stage V disease.

Clinical summary and course of idiopathic anaphylaxis in 73 patients

Seventy-three patients with anaphylaxis of unknown cause were studied. Repeated histories and physical examinations were performed by the Northwestern University (Chicago) allergy service in an attempt to find a cause for the anaphylaxis. Documentation of abnormal physical findings during an episode of anaphylaxis was necessary in each patient. Prior to our initial consultation, these 73 patients had required 115 emergency room visits and 37 hospitalizations. No deaths have occurred in 224 patient years of follow-up from initial presentation. Thirty-eight (52%) patients have infrequent reactions (defined as one episode only or mild episodes less than six times per year) requiring acute treatment alone. Thirty-five (48%) patients have severe or frequent life-threatening reactions (defined as episodes that include syncope, documented hypotension, and airway compromise as major manifestations) requiring maintenance antihistamines and prednisone. Laboratory studies were not helpful in finding a cause of anaphylaxis in any of the 73 patients. Associated atopic conditions were present in 45 patients. Twenty-three patients had chronic idiopathic angioedema, urticaria, or both prior to developing idiopathic anaphylaxis. Sixteen patients only treated acutely for each episode of anaphylaxis and seven patients previously receiving maintenance medication are now asymptomatic without medication for longer than one year.

What causes stereoscopic tilt from spatial frequency disparity

A controversy still exists concerning whether the tilt created with interocular spatial frequency disparity arises from a computation of spatial frequency differences or from cumulative positional disparity. In a first experiment, we examined the influence of positional disparity on tilt created with frequency disparity, reasoning that if tilt were computed from spatial frequency differences, the perceived angle should remain unaltered since adding a positional disparity does not change the harmonic content of the stimulus. The results indicated that positional disparity weakened perceived tilt. In a second experiment, we tested the idea that tilt results from the calculation of increasing positional disparity across the display, arguing if local matches of features in the two eyes are made in computing tilt, then the solution to binocular correspondence may be less ambiguous if the same number of cycles was displayed for both spatial frequencies. Perceived tilt increased when the number of cycles was equal, although the angle of tilt still decreased with positional disparity. In Experiment 3, we further reduced potential sources of ambiguity for the binocular matching process by employing D10s (the tenth derivative of a Gaussian) instead of grating patterns. Positional disparity exerted essentially no influence on the perceived angle of tilt of the D10s. Taken together, the results of these experiments suggest that tilt from frequency disparity can be explained solely on the basis of positional disparity.

Toluene diisocyanate respiratory reactions. I. Reassessment of the problem

A series of workers with exposure to and respiratory symptoms from toluene diisocyanate (TDI) was compared with a group of exposed, asymptomatic workers and with normal controls using immunologic and clinical evaluations. Improved understanding of TDI-induced respiratory disease may best be achieved by categorizing the symptomatic workers into at least 3 and possibly 4 groups: immunologic TDI asthma; pre-existing chronic respiratory disease exacerbated or unaffected by TDI; asthma coincidental with TDI exposure, and possibly TDI respiratory disease secondary to toxic or inflammatory mechanisms.

Are stereoacuity and binocular rivalry related?

Several lines of evidence suggest that the processes of excitation and inhibition associated with good stereoacuity may also underlie binocular rivalry, implying that performance on these two tasks could be related. To test this possibility, we measured stereoacuity and rivalry under similar stimulus conditions in 40 observers. To estimate stereoacuity, a two-alternative, forced-choice procedure was used, wherein observers determined which of two sinusoidal grating patterns appeared displaced in depth. To measure rivalry, observers reported the occurrences of exclusive right- and left-eye dominance; dominance durations and alternation rates were recorded. The results showed that stereoacuity was significantly correlated with binocular rivalry, suggesting that stereoacuity and rivalry may share, at least in part, common neural mechanisms.

Iatrogenic pseudoanaphylaxis

A nurse exposed accidentally to chymopapain by ocular exposure was treated vigorously for chymopapain anaphylaxis. Retrospective analysis of the case indicates that there was no evidence of IgE antibody against chymopapain, and the clinical events were inconsistent with anaphylaxis and could be explained by a vasovagal reaction and the cardiorespiratory effects of repeated intravenous epinephrine. Our assessment is that the nurse is currently in a state of good health; however, she did not accept our absence of allergic disease diagnosis and has sought "clinical ecology therapy." Although no litigation in this case has arisen, the legal implications of this case report are reviewed.

Trimellitic anhydride exposure in a 55-gallon drum manufacturing plant: clinical, immunologic, and industrial hygiene evaluation

Nine workers at a 55-gallon drum manufacturing plant had history of exposure to a paint powder that contained trimellitic anhydride (TMA). Environmental monitoring revealed airborne levels of TMA to be over 100 times the OSHA permissible exposure limit of 0.04 mg/m3. The exposed workers were evaluated in a cross-sectional study by questionnaire, physical examination, screening pulmonary function tests, serial peak expiratory flow rates (PEFR), and serum antibody levels. Four workers had symptoms consistent with TMA-induced irritant effects. Three had symptoms and IgG levels consistent with TMA late respiratory systemic syndrome (LRSS). Two of these three had PEFR changes that showed significant drops (greater than 20%) 12-18 hours after the end of a work shift. The material safety data sheet for the paint powder failed to list TMA as an ingredient. Despite the well-described toxic effects of TMA, the present study documents that TMA-related illness may continue to be a problem in situations where workers and management are not properly notified of the potential hazards. The measurement of PEFR may be useful in identifying TMA-exposed workers with LRSS.

A double-blind placebo-controlled trial of polymerized whole grass administered in an accelerated dosage schedule for immunotherapy of grass pollinosis

Forty-four patients were entered into a study of the efficacy and safety of individually polymerized grass (IPG) immunotherapy with an accelerated dosage schedule. Patients were paired on the basis of cutaneous end point titrations to timothy, orchard, and Bermuda grass-pollen extracts. In a double-blind manner, one patient in each pair was treated in nine weekly visits with 13 injections that totaled 24,000 PNU of each grass to which the patient had cutaneous reactivity. The other patient in each pair received caramelized glucose histamine placebo. Symptom and medication score sheets were completed by 33 patients each day of the grass season. Blocking antibody rose significantly in the IPG-treated group but was unchanged in the placebo-treated group. By Wilcoxon paired signed-rank test, the symptom medication scores in the IPG-treated group were significantly lower than those in the placebo-treated group. There were no systemic reactions and no clinically significant changes in routine laboratory tests in either group. In summation, this study demonstrates the safety, immunogenicity, and efficacy of IPG therapy in an accelerated dosage schedule for treatment of grass pollinosis.

Natural history of asthma in patients requiring long-term systemic corticosteroids

To study the natural history of corticosteroid-dependent asthma, we evaluated 40 randomly selected adult patients with severe asthma who were refractory to management with inhaled corticosteroids and bronchodilators and who required long-term prednisone therapy (mean duration, 6.2 +/- 5.1 years). During long-term observation, 13 patients (32.5%) significantly improved; ten (25%) of these tolerated discontinuation of long-term prednisone use and three (7.5%) had decreased prednisone requirements. Three patients (7.5%) had increased requirements for prednisone. Twenty-four patients (60%) had generally unchanged, long-term prednisone requirements; of note, eight of these had significant, but temporary intervals (mean, 3.2 years) when they could be managed without prednisone. Patients with mixed asthma were more likely to tolerate discontinuation of long-term prednisone; no other factors studied were predictive of the course of asthma. Although prior to our care many patients had a history of numerous emergency room visits and hospitalizations (some for life-threatening episodes of status asthmaticus), there were few emergency room visits and hospitalizations while under strict management by our service. Variations observed in the natural history of corticosteroid requirements in asthma must be considered in designing studies seeking to evaluate efficacy of new experimental therapies for asthma.