Eosinophilic gastroenteritis

The goal to create a standardized diagnostic classification scheme of food-related gastrointestinal hypersensitivity disease syndromes included the diagnosis of eosinophilic gastroenteritis. This article reviews the history of this diagnosis and the current concepts of this complex disorder. The common symptoms from the literature are discussed. Because no standards for this diagnosis exist, the wide variety of diagnostic criteria from the literature are presented. No consistent immunologic abnormalities have been associated with the diagnosis of eosinophilic gastroenteritis in the literature. A review of the current immunologic concepts associated with the diagnosis of eosinophilic gastroenteritis is presented. The history of this disorder, which spans more than 6 decades is also discussed. The contributions made by the original authors during this period are presented. Attention was directed to the variety of clinical features associated with this disorder, but particular attention was paid to the evolution of the pathophysiologic mechanisms proposed. Some of the difficulties associated with the prospective study of patients with eosinophilic gastroenteritis are also discussed. The establishment of appropriate control populations, as well as the fundamental difficulties encountered with the establishment of the certainty of the link between abnormal immunohistochemical findings, and initial clinical symptoms are presented and discussed. A new classification system is proposed for food-related gastrointestinal hypersensitivity disease syndromes. Age, symptoms, and the region of the gastrointestinal tract involved were the variables that were considered most important by consensus opinion. Finally, recommendations to refocus our collective investigative efforts are presented.

Acute renal failure in the new millennium: time to consider combination therapy

Acute renal failure (ARF) occurs frequently and results in an unacceptably high morbidity and mortality. There is no currently accepted specific therapy that alters the course of ischemic ARF. Recent experimental advances and continued funding of ARF studies should allow rapid progress in the new millennium. This will require novel approaches to both basic and clinical evaluations. New experimental models and studies evaluating multiple therapies are needed. In addition, methods to identify ARF early in its course are likely to improve outcomes. Clinical studies should employ very specific definitions of ARF, outcomes evaluated, indications for renal replacement therapy, and severity of illness evaluation methods. Such studies and aggressive preventative measures will significantly improve the incidence and outcome of ARF in the 21st century.

Purified and recombinant latex proteins stimulate peripheral blood lymphocytes of latex allergic patients

BACKGROUND

Natural rubber latex proteins have been implicated in severe allergy in individuals exposed to latex products, particularly health care workers. Until recently, only crude antigens were available to study the immune response in these patients. In recent years a number of relevant allergens have been purified, but few have been used in lymphocyte studies. Hence, to better understand the immunological mechanisms involved in latex allergy, we investigated the response of peripheral blood mononuclear cells (PBMCs) to various purified natural rubber latex allergens.

METHODS

Using conventional protein purification methods and gene cloning, we have obtained 6 natural rubber latex proteins. We studied allergen-specific IgE levels and PBMC responses to these allergens along with 3 crude latex antigen preparations.

RESULTS

Of the 28 latex-allergic health care workers studied, 16 reacted to one or more of the allergens studied, but PBMCs from controls failed to respond to these antigens. Serum IgE to the antigens was detected in 11-90% of the patients.

CONCLUSION

Fifty-seven percent of the latex-allergic patients demonstrated PBMC responses to at least one of the latex allergens tested, but there was no direct correlation between serum IgE levels and PBMC responses. However, since none of the control subjects showed any PBMC stimulation, this may prove useful in determining sensitization to latex. Among the allergens studied, the predominant mononuclear cell responses were directed against Hev b 2, while serum IgE against rHev b 6 was demonstrable in the greatest number of patients. The crude latex allergens were toxic to PBMCs and hence, the purified allergens may be of greater value in demonstrating sensitization of patients to latex allergens.

Effects of fire fighting uniform (modern, modified modern, and traditional) design changes on exercise duration in New York City Firefighters

Fire departments have replaced traditional uniforms with modern, more thermal protective gear. Although the new uniforms afford superior burn protection, they may reduce work time. Our purpose was to determine if exercise time was (1) reduced by wearing the modern versus traditional uniform, and (2) increased by a design change to a modified modern uniform (T-shirt and short pants rather than a shirt and long pants under the outer uniform). Male firefighters (n = 23; age 27 to 59) performed a maximum exercise test in gym clothes (maximal oxygen consumption = 46 +/- 9 ml/kg/min) and then returned on separate days to exercise using a moderately high intensity, constant work rate treadmill protocol while wearing fire fighting breathing apparatus and each of three uniforms. Firefighters exceeded anaerobic threshold by 1 minute and eventually reached or exceeded maximum heart rate and maximal oxygen consumption. Exercise time in modern (15 +/- 3 min) was significantly less than in traditional (18 +/- 5 min) uniform. Exercise time in modified modern (17 +/- 5 min) was significantly greater than in modern and not significantly different than in traditional uniforms. The rate of change in oxygen consumption and water loss were significantly affected by uniform type, with faster rates in modern compared with modified modern or traditional uniforms. These findings show the impact that design changes have on energy demands and exercise duration.

Tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6 levels in febrile, young children with and without occult bacteremia

OBJECTIVE

To determine the utility of plasma levels of tumor necrosis factor-alpha (TNF), interleukin 1 beta (IL-1), and interleukin 6 (IL-6) in the prediction of occult bacteremia in febrile, young children.

STUDY DESIGN

Prospective, case-control study conducted in a large, urban, children's hospital emergency department. Eligibility criteria were: 0 to 36 months of age, febrile, nontoxic appearing, immunocompetent, no apparent bacterial source for fever on physical examination, and blood culture obtained. Additional blood, procured at the time of the blood culture, was analyzed by enzyme-linked immunosorbent assay for TNF, IL-1, and IL-6. Children with positive blood cultures for pathogenic bacteria served as cases. Two age-matched controls for each case were selected from the children with negative cultures.

RESULTS

Out of 1329 enrollees, 33 cases and 66 controls were evaluated. IL-6 levels were significantly higher for the cases than controls but with moderate overlap in their ranges. TNF and IL-1 levels were not significantly different between cases and controls. Height of fever, duration of fever, acute illness observation score, absolute band count, and white blood cell count were all much less predictive of bacteremia than either IL-6 or absolute neutrophil count (ANC). The optimum IL-6 threshold value had a sensitivity of 88%, a specificity of 70%, a positive predictive value (PPV) of 7.0%, a negative predictive value (NPV) of 99.6%, and an odds ratio (OR) of 16.7 (95% confidence interval [CI], 4.8-71.6). The optimum ANC threshold value had a sensitivity of 82%, a specificity of 74%, a PPV of 7.5%, a NPV of 99.4%, and an OR of 12.8 (95% CI, 3.2-59.7). The best predictor was a combination of IL-6 and ANC. It had a sensitivity of 100%, a specificity of 78%, a PPV of 10.4%, a NPV of 100%, and an OR which is undefined because of the 100% sensitivity (95% CI, 33.0-infinity). For comparison, a WBC >15 x 10(9) cells/L had a sensitivity of 48%, a specificity of 79%, a PPV of 5.5%, a NPV of 98.3%, and an OR of 3. 5 (95% CI, 1.1-10.7).

CONCLUSIONS

In febrile children 0 to 36 months of age, IL-6 levels may be helpful in the prediction of occult bacteremia, but TNF and IL-1 levels are not. IL-6 levels alone or notably when combined with an ANC were more predictive of occult bacteremia than traditional tests and clinical criteria. The wide range in the IL-6 values for cases and controls detracts from the precision of the findings. The lack of rapid processing and clinical availability of IL-6 assays hampers its present application. However, despite these drawbacks and given the poor ability of traditional clinical and laboratory criteria to predict occult bacteremia, these results suggest a possible future role for IL-6 in predicting occult bacteremia when rapid assays become available.

The incidence, prevalence, and severity of sarcoidosis in New York City firefighters

OBJECTIVE

The etiology of sarcoidosis is unknown, but epidemiology suggests that environmental agents are a factor. Because firefighters are exposed to numerous toxins, we questioned whether sarcoidosis was increased in this cohort.

SETTING

The New York City Fire Department (FDNY), employing > 11,000 firefighters and nearly 3,000 emergency medical services (EMS) health-care workers (HCWs).

DESIGN

In 1985, FDNY initiated a surveillance program to determine the incidence, prevalence, and severity of biopsy-proven sarcoidosis in firefighters. In 1995, EMS HCWs were added as control subjects.

RESULTS

Between 1985 and 1998, 4 prior cases and 21 new cases of sarcoidosis were found in FDNY firefighters. Annual incidence proportions ranged from 0 to 43.6/100,000, and averaged 12.9/100,000. On July 1, 1998, the point prevalence was 222/100,000. For EMS HCWs, annual incidence proportions were zero. Radiographic stage 0 or stage 1 sarcoidosis was found in 19 firefighters (76%), and stage 3 was found in 1 firefighter (4%). Pulmonary function (FVC, FEV(1), and diffusing capacity for carbon monoxide) was normal in 17 firefighters (68%), and reduced to </= 65% predicted in 2 firefighters (8%). Maximum oxygen consumption (MVO(2)) was normal in 10 of 17 firefighters (59%), and reduced to 65% predicted in 3 firefighters (12%). Five of seven firefighters (71%) with abnormal MVO(2) had gas exchange abnormalities, and none had O(2) desaturation. All returned to fire fighting.

CONCLUSIONS

Annual incidence proportions and point prevalence were increased in FDNY firefighters as compared to EMS HCWs and historical controls. Radiographs and physiologic measurements demonstrated only minimal impairment.

Protection from toxicant-mediated renal injury in the rat with anti-CD54 antibody

BACKGROUND

The benefit of the potent chemotherapeutic agent cisplatin in treating neoplasms is limited by nephrotoxicity. We tested the hypothesis that CD54 [intercellular adhesion molecule-1 (ICAM-1)] is an important mediator in cisplatin-mediated renal failure.

METHODS

The effect of a monoclonal anti-CD54 antibody was evaluated in a rat model of cisplatin toxicity. Renal function, histopathology, renal myeloperoxidase activity, and mortality were determined in the anti-CD54 and placebo groups.

RESULTS

Renal CD54 mRNA expression was markedly increased by 24 hours after exposure to cisplatin in mice. An improvement in renal function, mortality, and histological abnormalities was evident in animals exposed to cisplatin and treated with anti-CD54 antibody (mAb). Seven days after the administration of cisplatin, the mean creatinine was 0.65+/-0.05 mg/dl in the rats that received anti-CD54 mAb and 4.76+/-1.42 in control animals (P<0.02). Mortality was lower in experimental animals (0 vs. 29% in control rats seven days following cisplatin, P<0.04). Histological evidence of cell injury was markedly attenuated (P<0.04) in the treated compared with the control rats.

CONCLUSION

CD54 may be critical in the pathophysiology of renal injury following cisplatin, perhaps by its effects on leukocyte-endothelial interactions.

Impact of a modern firefighting protective uniform on the incidence and severity of burn injuries in New York City firefighters

The New York City Fire Department (FDNY) is the largest fire department in the United States, with over 11,000 firefighters. In 1994, FDNY changed to a modern firefighting protective uniform. The major difference between traditional and modern uniforms is that modern uniforms include both protective over-coat and over-pant, whereas traditional uniforms include only the over-coat. Furthermore, modern uniforms are manufactured using improved thermal protective textiles that meet or exceed current National Fire Protection Association standards for structural firefighting. The purpose of this study was to determine the impact of the modern uniform on the incidence and severity of FDNY burn injuries. We also evaluated the incidence and severity of other non-burn injuries to determine whether there was serious adverse impact. The number of lower-extremity burns decreased by 85% when 2 years' experience while wearing the modern uniform was compared with 2 years while wearing the traditional uniform. Upper-extremity burns and head burns decreased by 65% and 40%, respectively. Severity indicators (days lost to medical leave, hospital admissions, and skin grafts) for lower- and upper-extremity burn injuries were all substantially reduced. This occurred without significant change in the incidence or severity of trunk burns, heat exhaustion, inhalation injuries (actually decreased), or cardiac events. The reduction in the incidence and severity of burn injuries, the major occupational injury affecting this workforce, has been so dramatic and without untoward effects that the introduction of the modern uniform must be characterized as a sentinel event in the history of firefighter health and safety.

A murine model of latex allergy-induced airway hyperreactivity

Sensitization to latex proteins can cause immediate IgE mast cell-mediated reactions. Health care workers have been found to be particularly at risk because of high exposure. Latex allergy can be produced in mice as demonstrated by IgE and eosinophil responses. Thus the mouse is a potential animal model for studying this disease, but the airway response to latex sensitization in mice has not been evaluated previously. In the present study, we immunized BALB/c mice intranasally with nonammoniated latex proteins. Animals were anesthetized, and lung mechanics were evaluated plethysmographically. Changes in pulmonary conductance (GL) and compliance (Cdyn) were measured in response to a nonspecific challenge with methacholine or to a direct challenge with intravenous latex antigen. Latex sensitization resulted in elevated levels of IgE and latex-specific IgG1 as well as interstitial infiltrates consistent with an allergic response. The methacholine dose-response ED50 for GL was 116.4 microg for the control mice and fell significantly to 20.9 microg for latex-sensitized mice. The ED50 calculated for Cdyn was also significantly lower after latex sensitization. The GL in latex-sensitized mice challenged with latex antigen fell significantly from a prechallenge value of 1.87 +/- 0.41 (S.E.) to 0. 198 +/- 0.03 ml x s-1 x cmH2O after latex antigen challenge. The results indicate that latex-sensitized mice did exhibit increased airway reactivity in the methacholine challenge test. The latex allergic response in mice is unique in that direct challenge with latex antigen itself also resulted in a significant airway response.

Immune response and airway reactivity in wild and IL-4 knockout mice exposed to latex allergens

BACKGROUND

Natural rubber latex has been reported as a major cause of allergy and asthma in a number of individuals. One of the occupational groups most affected by latex allergy are the health care workers who are frequently exposed to natural rubber latex products in their patient care activities. The immunopathogenesis of latex allergy is not well understood. In order to understand the immune mechanism in latex allergy, we have developed a mouse model of latex allergy.

METHODS

Both wild-type and IL-4 knockout BALB/c mice were challenged intranasally with latex proteins and their immune responses, lung pathology, and airway reactivity were evaluated.

RESULTS

The total serum IgE and latex specific IgE, IgG1, and peripheral blood and lung eosinophil levels in wild type BALB/c mice were enhanced by the latex exposure, while no IgE or eosinophil were detected in IL-4 knockout mice. Latex-specific IgG1 levels in the sera were lower in IL-4 knockout animals compared to wild mice. However, latex-specific IgG2a antibody was higher in all the IL-4 knockout mice compared to wild type mice. Both the wild type and IL-4 knockout animals developed increased airway resistance after antigen challenge when compared to control animals, although the airway resistance response of IL-4 knockout animals was attenuated compared to the wild-type animals. The histology of the lungs of these two groups of animals was similar.

CONCLUSION

In spite of the differences in the immune responses in the two groups of mice, there were comparable lung inflammatory responses, suggesting a multifactorial pathogenetic mechanism.

Latex allergy: a patient and health care system emergency

Latex allergy, an IgE-mediated reaction to proteins retained in finished natural rubber latex products, has become one of the most pervasive problems in medicine. Latex allergy has resulted in death, progressive asthma, severe food allergy from cross-reactivity, and disability of health care professionals with the accompanied loss of self-esteem and income from their inability to work in their chosen profession. This article reviews the risks of latex allergy and proposes strategies for prevention and management of the problem.

Tuberculin skin test conversion rates in New York City Emergency Medical Service health care workers

OBJECTIVE

To determine annual tuberculin skin test conversion (infection) rates for prehospital health care workers (EMTs and paramedics) in an urban environment with a high prevalence of Mycobacterium tuberculosis.

METHODS

We conducted a prospective study of prehospital health care workers for the New York City EMS, EMS Employee Health Service, and the Fire Department Bureau of Health Service to determine the tuberculin skin test conversion rates. In 1992, all current and new EMS prehospital health care workers without a known history of a positive tuberculin reaction received a baseline tuberculin purified protein derivative (PPD) skin test. Thereafter, (January 1, 1993-December 31, 1996) all EMS health care workers who had negative PPD skin test results received annual tuberculin PPD skin tests. Tuberculin skin test conversion was defined as induration of 10 mm or greater in a worker with a documented prior negative test result. The PPD skin test reaction was measured by trained professional readers.

RESULTS

A total of 7,290 PPD test results were read during this study. Compliance with annual testing was 75%. Annual tuberculin skin test conversion rates were 1.3% in 1993, .7% in 1994, .1% in 1995, and .2% in 1996 (average .5%). In a static subgroup with at least 15 years' seniority, compliance with annual testing was 100% and annual tuberculin skin test conversion rates were .5% in 1993, 0 in 1994, .5% in 1995, and 1.5% in 1996 (average .6%).

CONCLUSION

Despite the high prevalence of M tuberculosis infection in New York City and the potential for difficulty in the use of respiratory precautions during emergency response operations, EMS prehospital health care workers have an annual tuberculin conversion rate that is relatively low compared with hospital-based health care workers.

Image advertisements for alcohol products: is their appeal associated with adolescents' intention to consume alcohol?

Criticism has been directed toward alcohol advertising, particularly regarding the use of image (lifestyle) advertising, and its potential influence on teenage alcohol consumption. This study sought to determine if adolescents who drink, or intend to drink alcohol at some future time, find image advertisements for alcohol more appealing than product advertisements. The results indicated that image advertising was preferred to product advertising, particularly by younger adolescents. Evidence of an association between preference for image advertisements and intent to drink in the future was found. Policy implications of the findings are discussed.

IgE from latex-allergic patients binds to cloned and expressed B cell epitopes of prohevein

Prohevein is one of the major allergens associated with latex allergy. In the present study, we identified IgE binding regions of prohevein, and expressed multiple IgE binding epitopes by selective cloning. These truncated polypeptides were then used to demonstrate IgE in the sera of patients. Decapeptides of prohevein were synthesized on derivatized cellulose membrane with an offset of one amino acid. The IgE reactivity of these linear peptides was evaluated separately using pooled sera from latex-allergic health care workers (HCW) and spina bifida (SB) patients. A total of 10 IgE binding epitopes representing unique as well as shared epitopes from both the N- and C-domains of the prohevein were identified. Recombinant polypeptides were constructed based on the identified epitopes, and clones carrying DNA fragments were overexpressed. These recombinant peptides were evaluated for IgE binding with sera from HCW, SB, and normal individuals. Recombinant prohevein, hevein, and the C-domain exhibited IgE binding in 84, 88, and 40% of HCW sera, respectively, as against reactivity of 84% with crude latex allergens. However, only 48% of the sera from SB patients showed IgE binding with recombinant prohevein, while 56 and 28% had reactivity with recombinant N- and C-domains, respectively. Among the three remaining recombinant peptides of the C-domain, only CA44-103 showed IgE binding with SB patients. The results of the present study suggest that linear IgE epitope analysis and construction of recombinant peptides increase the sensitivity and specificity of the immunodiagnosis of latex allergy and provide more information on the immunopathogenesis of hypersensitivity reaction mediated by type I allergy.

IgE from latex-allergic patients binds to cloned and expressed B cell epitopes of prohevein

Prohevein is one of the major allergens associated with latex allergy. In the present study, we identified IgE binding regions of prohevein, and expressed multiple IgE binding epitopes by selective cloning. These truncated polypeptides were then used to demonstrate IgE in the sera of patients. Decapeptides of prohevein were synthesized on derivatized cellulose membrane with an offset of one amino acid. The IgE reactivity of these linear peptides was evaluated separately using pooled sera from latex-allergic health care workers (HCW) and spina bifida (SB) patients. A total of 10 IgE binding epitopes representing unique as well as shared epitopes from both the N- and C-domains of the prohevein were identified. Recombinant polypeptides were constructed based on the identified epitopes, and clones carrying DNA fragments were overexpressed. These recombinant peptides were evaluated for IgE binding with sera from HCW, SB, and normal individuals. Recombinant prohevein, hevein, and the C-domain exhibited IgE binding in 84, 88, and 40% of HCW sera, respectively, as against reactivity of 84% with crude latex allergens. However, only 48% of the sera from SB patients showed IgE binding with recombinant prohevein, while 56 and 28% had reactivity with recombinant N- and C-domains, respectively. Among the three remaining recombinant peptides of the C-domain, only CA44-103 showed IgE binding with SB patients. The results of the present study suggest that linear IgE epitope analysis and construction of recombinant peptides increase the sensitivity and specificity of the immunodiagnosis of latex allergy and provide more information on the immunopathogenesis of hypersensitivity reaction mediated by type I allergy.

Pediatric idiopathic anaphylaxis: experience with 22 patients

Idiopathic anaphylaxis in the pediatric population is being increasingly recognized, with symptoms (and therefore classifications) the same as those described in adults. We present a series of 22 patients with special attention to considerations relatively unique to the pediatric population. Prednisone, hydroxyzine, and albuterol were used to control symptoms and induce remission. No deaths occurred during treatment. One adolescent who presented with corticosteroid-dependent idiopathic anaphylaxis was diagnosed with undifferentiated somatoform-idiopathic anaphylaxis. Local physician reluctance to participate in management complicated care for some patients.

An oral platelet-activating factor antagonist, Ro-24-4736, protects the rat kidney from ischemic injury

The role of platelet-activating factor (PAF) in ischemic acute renal failure was evaluated by administering an oral PAF antagonist (Ro-24-4736) to rats prior to or after interruption of blood flow to both kidneys for 30 min. In animals treated with the PAF antagonist prior to ischemia, renal function was less impaired and histological abnormalities was less pronounced when compared with postischemic kidneys from vehicle-treated animals. Serum creatinine (mg/ dl) 24 h following renal ischemia was 1.58 +/- 0.17 in the PAF antagonist-treated rats compared with 2.19 +/- 0.15 in rats given placebo (P < 0.01). There was less necrosis in the outer medulla of kidneys of PAF antagonist-treated animals (P < 0.01). Tissue myeloperoxidase activity at 48 and 72 h postischemia was lower in kidneys of PAF antagonist-treated rats (P < 0.05). The PAF antagonist was also protective when administered 30 min but not 2 h following the ischemic insult. The coincident use of anti-intercellular adhesion molecule-1 monoclonal antibody did not confer additional protection over that observed with the oral PAF antagonist alone. These data suggest that PAF contributes to the pathophysiology of renal ischemic injury, perhaps by its effects on leukocyte-endothelial interactions. An orally active PAF antagonist can protect against the development of ischemic acute renal failure.

Self-assessment of tuberculin skin test reactions by New York City firefighters: reliability and cost-effectiveness in an occupational health care setting

OBJECTIVE

To determine whether self-assessment of purified protein derivative of tuberculin (PPD) skin test reactions, done using a simple two-choice approach, is an effective screening method for tuberculosis.

DESIGN

Double-blind comparison between self-assessments and trained professional readings of PPD skin test reactions, done 72 hours after test administration.

SETTING

The New York City Fire Department's Bureau of Health Services.

PARTICIPANTS

2011 New York City firefighters and fire officers were given PPD skin tests during a mandatory retraining course. Thirty-seven persons were excluded because of a history of a positive PPD skin test result or a bacille Calmette-Guérin vaccination. All others agreed to participate in testing and self-assessment done using simple written instructions. Self-assessment results were submitted just before trained professional readings were done.

MEASUREMENTS

Self-assessments and trained professional readings of PPD skin test reactions.

RESULTS

1833 participants (91%) interpreted their test reactions as flat. Of these interpretations, 1824 (99.5%) matched the professional reading and 9 (0.5%) did not. One hundred seventy-eight participants (9%) interpreted their test reactions as not flat; 136 of these interpretations (76.4%) matched the professional reading and 42 (23.6%) did not (kappa = 0.828; lower 95% confidence limit = 0.790). The predictive value of a negative self-assessment reading was 99.5%, and the specificity was 97.7%.

CONCLUSION

In this occupational health care setting, we follow (and recommend to others with similar populations) a tuberculin screening program based on self-assessment. Repeated tests with follow-up are required for all persons who do not report their results. All persons with self-assessments of "not flat" should return for readings by trained professionals, counseling, and treatment.

Purified natural rubber latex antigens show variable reactivity with IgE in the sera of latex allergic patients

Immediate-hypersensitivity reactions related to latex products have increased rapidly in recent years. However, a reliable diagnosis is hampered by lack of purified and well characterized latex allergens. We have purified allergens in natural rubber latex (NRL) after SDS-PAGE by electroelution, and tested specific IgE-binding activities of these isolated allergens by ELISA. Ten sera from spina bifida patients and 5 sera from health care workers with latex allergy were evaluated for specific IgE antibody in the sera using ELISA. Five normal controls with no evidence of latex allergy were also studied. None of the isolated allergens reacted with normal control sera used. Among the latex allergic patients' sera studied, 11, 9, 9, 2, and 6 sera reacted with 27, 23, 21, 17, and 10 kDa isolated allergens, respectively. Each latex allergic serum reacted with at least one of the purified allergens, indicating a diversity in response to latex. The isolated and purified latex allergens may, however, be useful to identify latex allergy in patients.

Dynamics of participation in a community health project

Although the term 'participation' is widely used in discussing community development strategies, there has been relatively little said about the characteristics of 'participatory relationships', i.e. the interactions between community developers and those who stand to benefit from community development initiatives. There is seen to be a need for case studies which attempt to understand the relational and communicative processes involved in participatory development. The paper presents an analysis of the participatory dynamics of a community health development project. The principal source of data is interviews conducted with thirteen selected participants in the project. Analysis of interview data using a structured hermeneutic method led to a description of the meaning of participation for each of the participants interviewed. Further interpretation led to the identification of a number of modes of participation in the project as a whole. For each mode of participation descriptions were developed of how it was perceived by others not participating from that mode. An attempt was made to understand the dynamics of the project in terms of the relationship between the different modes of participation and in terms of the discrepancies between how participants saw themselves and how others saw them. Finally, these problems were discussed at a general theoretical level and suggestions were made about how such problems might be alleviated.

The syndrome of lung hemorrhage and nephritis is usually an ANCA-associated condition

BACKGROUND

In the absence of evidence of arteritis or Wegener's granulomatosis, the syndrome of lung hemorrhage and nephritis has been commonly associated with anti-glomerular basement membrane (GBM) antibodies. However, it has been increasingly recognized that many cases are associated with antineutrophil cytoplasmic antibodies (ANCAs).

OBJECTIVE

To review available clinical and pathologic findings to determine the diseases accounting for lung hemorrhage and nephritis.

METHODS

We studied the records of 750 patients from whom serum samples were sent to our laboratory for anti-GBM antibody assays between 1981 and 1993 and found 88 patients with evidence of lung hemorrhage and nephritis. Serum samples were retested, using current methods, for anti-GBM antibodies (against noncollagenous 1 domain of the alpha 3 chain of type IV collagen) and for antibodies to proteinase 3 and myeloperoxidase--the two types of ANCA of diagnostic value.

RESULTS

Of 88 patients with evidence of lung hemorrhage and nephritis, 48 had ANCAs, six had anti-GBM antibodies, and seven had both. In 48 patients with ANCAs, the pathologic findings that accounted for the pulmonary renal syndrome were pauci-immune necrotizing and crescentic glomerulonephritis and pulmonary capillaritis. Only eight had convincing evidence (during life) of Wegener's granulomatosis and only one other had documented arteritis. In 27 patients without ANCAs or anti-GBM antibodies, a variety of unrelated renal and pulmonary diseases were found.

CONCLUSIONS

The largest group of patients who present with the syndrome of lung hemorrhage and nephritis have ANCAs and not anti-GMB antibodies. Appropriate tests for antibodies to proteinase 3, antibodies to myeloperoxidase, and anti-GBM antibodies provide reliable guides for making a diagnosis in patients with this pulmonary renal syndrome.

Intercellular adhesion molecule-1-deficient mice are protected against ischemic renal injury

Studies in the rat have pointed to a role for intercellular adhesion molecule-1 (ICAM-1) in the pathogenesis of acute tubular necrosis. These studies used antibodies, which may have nonspecific effects. We report that renal ICAM-1 mRNA levels and systemic levels of the cytokines IL-1 and TNF-alpha increase 1 h after ischemia/ reperfusion in the mouse. We sought direct proof for a critical role for ICAM-1 in the pathophysiology of ischemic renal failure using mutant mice genetically deficient in ICAM-1. ICAM-1 is undetectable in mutant mice in contrast with normal mice, in which ICAM-1 is prominent in the endothelium of the vasa recta. Mutant mice are protected from acute renal ischemic injury as judged by serum creatinine, renal histology, and animal survival . Renal leukocyte infiltration, quantitated morphologically and by measuring tissue myeloperoxidase, was markedly less in ICAM-1-deficient than control mice. To evaluate whether prevention of neutrophil infiltration could be responsible for the protection observed in the mutant mice, we treated normal mice with antineutrophil serum to reduce absolute neutrophil counts to < 100 cells/mm3. These neutrophil-depleted animals were protected against ischemic renal failure. Anti-1CAm-1 antibody protected normal mice against renal ischemic injury but did not provide additional protection to neutrophil-depleted animals. Thus, ICAM-1 is a key mediator of ischemic acute renal failure likely acting via potentiation of neutrophilendothelial interactions.