Exercise with latex sport bands represents a risk for latex allergic patients

Based on two clinical observations of adverse reactions during exercise with latex sport bands, we aimed to assess the possible risk for allergic patients posed by this equipment by investigating allergen content and IgE binding potential. Protein extracts of three different latex sport bands were characterized with sera of latex allergic patients. The IgE recognition profile of the allergic patients was identified by component resolved diagnosis and the allergen composition of the extracts was characterized by inhibition assays with the recombinant latex allergens Hev b 1, 3, 5, 6.02, and 8. The sera showed pronounced IgE binding to all three blotted extracts, however with diverse patterns. Inhibition assays revealed the presence of Hev b 1, 3, 5, and 8 in latex sport band extracts. The clinical relevance of contained allergens was demonstrated by strong skin reactions when testing with latex sport bands. From our results we conclude that latex sport bands contain clinically relevant allergens and may cause latex allergic individuals to experience allergic symptoms, potentially amplified by exercise-induced mechanisms. Even though latex is labeled on products, it is important that patients as well as athletic trainers and physical therapists recognize the risk of adverse reactions with these bands.

Autograft regurgitation and aortic root dimensions after the Ross procedure: the German Ross Registry experience

BACKGROUND

Autograft regurgitation and root dilatation after the Ross procedure is of major concern. We reviewed data from the German Ross Registry to document the development of autograft regurgitation and root dilatation with time and also to compare 2 different techniques of autograft implantation.

METHODS AND RESULTS

Between 1990 and 2006 1014 patients (786 men, 228 women; mean age 41.2+/-15.3 years) underwent the Ross procedure using 2 different implantation techniques (subcoronary, n=521; root replacement, n=493). Clinical and serial echocardiographic follow up was performed preoperatively and thereafter annually (mean follow up 4.41+/-3.11 years, median 3.93 years, range 0 to 16.04 years; 5012 patient-years). For statistical analysis of serial echocardiograms, a hierarchical multilevel modeling technique was applied. Eight early and 28 late deaths were observed. Pulmonary autograft reoperations were required in 35 patients. Initial autograft regurgitation grade was 0.49 (root replacement 0.73, subcoronary 0.38) with an annual increase of grade 0.034 (root replacement 0.0259, subcoronary 0.0231). Annulus and sinus dimensions did not exhibit an essential increase over time in both techniques, whereas sinotubular junction diameter increased essentially by 0.5 mm per year in patients with root replacement. Patients with the subcoronary implantation technique showed nearly unchanged dimensions. Bicuspid aortic valve morphology did not have any consistent impact on root dimensions with time irrespective of the performed surgical technique.

CONCLUSIONS

The present Ross series from the German Ross Registry showed favorable clinical and hemodynamic results. Development of autograft regurgitation for both techniques was small and the annual progression thereof is currently not substantial. Use of the subcoronary technique and aortic root interventions with stabilizing measures in root replacement patients seem to prevent autograft regurgitation and dilatation of the aortic root within the timeframe studied.

Affinity of IgE and IgG against cross-reactive carbohydrate determinants on plant and insect glycoproteins

BACKGROUND

Cross-reactive carbohydrate determinants (CCDs) are probably the most widely occurring IgE epitopes. Approximately one fifth of patients with allergy develop IgE antibodies against such glycans. However, they appear to be of low clinical significance.

OBJECTIVE

We wanted to elucidate the reasons for this lack of clinical symptoms on contact with CCD allergens by determination of the binding affinities of patients' IgE and IgG antibodies.

METHODS

IgE and IgG against CCDs were affinity-purified from sera of selected patients. The binding affinity to defined glyco-epitopes was measured by surface plasmon resonance.

RESULTS

From a pool of CCD-positive sera, we isolated 0.1 and 25 microg CCD-specific IgE and IgG, respectively. The binding affinity of purified IgE antibodies to core alpha1,3-fucosylated glycans was in the 10(-10) mol/L range. The affinity was highest when both fucose and xylose were present, whereas xylosylation alone did not cause IgE binding. CCD-specific IgG exhibited a dissociation constant of approximately 10(-8) mol/L. IgG(4) amounted to only 20% of the CCD-specific IgG (as well as total IgG).

CONCLUSION

Low binding affinity of anti-CCD IgE cannot be the reason for the observed clinical insignificance of IgE against plant/insect glycan epitopes. Notably, the affinity of IgG to CCDs is higher than that to protein allergens, and it may therefore function as blocking antibody.

[New developments for surgical ablation of atrial fibrillation]

The Cox-Maze procedure and less complex modifications have gained widespread use as a treatment modality for patients with concomitant atrial fibrillation. Hypothermic or hyperthermic energy sources play a significant role in rapidly creating linear lesions. Endocardial ablation is easy to perform and effective with different energy sources. Epicardial techniques may simplify the procedure by allowing surgery on a beating heart. But epicardial fat and the heat sink effect of the flowing endocardial blood are obstacles to effective ablation. New devices using bipolar (irrigated) radiofrequency, microwave or laser energy, cryoablation or focused ultrasound are in clinical or pre-clinical stages and permit lesions to be created on a beating heart without cardiopulmonary bypass. Minimally invasive or video-assisted surgical techniques and effective devices for epicardial ablation will enable the treatment of patients suffering from lone atrial fibrillation. To facilitate the comparison between different techniques and devices, guidelines for reporting clinical results are necessary.

Cladosporium herbarum translationally controlled tumor protein (TCTP) is an IgE-binding antigen and is associated with disease severity

Cladosporium herbarum represents one of the most important world-wide occurring allergenic fungal species. The prevalence of IgE reactivity to C. herbarum in patients suffering from allergy varies between 5 and 30% in the different climatic zones. Since mold allergy has often been associated with severe asthma, along with other allergic symptoms, it is important to define more comprehensively the allergen repertoire of this ascomycete. In this context we are reporting our successful approach to identify, clone, produce as a recombinant protein, purify and further characterize a new C. herbarum allergen which is a close homolog of the human translationally controlled tumor protein (TCTP, also called histamine releasing factor, HRF). The immunoreactivity of both pure recombinant molecules was investigated by means of immunoblot analyses, enzyme-linked immunosorbent assays as well as histamine release studies. To summarize, IgE antibodies from five out of nine individuals recognized both the human and the fungal protein in immunoblots. The latter was able to cause histamine release from human basophils with about half the efficiency compared to its human homolog HRF. Cross-inhibition assays showed that the patients' IgEs recognize common epitopes on both the human and C. herbarum proteins, but however, only pre-incubation with C. herbarum TCTP could completely inhibit reactivity with HRF. Furthermore, it appears that patients reactive to TCTP have a higher probability to suffer from asthma than other allergic patients.

Premedication with Montelukast Reduces Local Reactions of Allergen Immunotherapy

BACKGROUND

Local reactions (LRs) are a very frequent side effect of specific immunotherapy with allergens and can impair patients' adherence. Antihistamine pretreatment--originally introduced as a safety measure to reduce anaphylactic side effects--has been the only treatment option for LRs so far, although these swellings usually do not appear immediately but after hours. We were interested whether pretreatment with the leukotriene antagonist montelukast would be better suited for preventing those reactions than pretreatment with the antihistamine desloratadine.

METHODS

Fifteen patients with a history of severe anaphylactic reactions to hymenoptera stings were enrolled into a prospective, double-blind, randomized, placebo-controlled pilot study. We selected a rush immunotherapy protocol consisting of 19 injections of hymenoptera venom administered over 5 consecutive days, where the majority is developing LRs, and counted the number of injections until an LR of >3 cm occurred. The patients were randomized to 3 treatment groups: premedication with placebo, 10 mg montelukast and 5 mg of the antihistamine desloratadine.

RESULTS

Compared with placebo, the occurrence of LRs (>3 cm) was significantly delayed by montelukast (p < 0.01, analysis of variance) but not by desloratadine (p = 0.19). The difference between montelukast and desloratadine was close to significant (p = 0.054). Itching, recorded on a scale from 0 to 5, did not differ between the 3 groups.

CONCLUSION

Montelukast can be useful in the prevention of LRs after specific immunotherapy.

A proteomic study of the major allergens from yellow jacket venoms

The venoms of stinging insects belong to the most dangerous allergen sources and can cause fatal anaphylactic reactions. Reliable prediction of a patient's risk to anaphylactic reactions is vital, and diagnosis requires the knowledge of the relevant allergens. Recently, a new hyaluronidase -like glycoprotein from Vespula vulgaris (Ves v 2b) was identified. This led us to investigate hyaluronidases and also other major allergens from V. germanica and four additional Vespula species. By MALDI-Q-TOF-MS, the new hyaluronidase-like protein was shown to be the major component of the 43-kDa band in all Vespula species studied. LC-ESI-Q-TOF-MS/MS sequencing of Ves g 2a and Ves g 2b facilitated the cloning of their cDNA. Ves v 2b and Ves g 2b turned out to be essentially identical on protein level. Whereas the less abundant "a" form displayed enzymatic activity, the new "b" homologue did not. This is probably caused by amino acid exchanges in the active site, and it raises questions about the physiological role of this protein. Sequence comparisons by MS/MS of antigen 5 and phospholipases from V. vulgaris, germanica, maculifrons, pensylvanica, flavopilosa and squamosa revealed the latter as a taxonomic outlier and led to the discovery of several not previously reported amino acid differences.

Mapping ofMalus domestica allergens by 2-D electrophoresis and IgE-reactivity

The importance of apple allergens has been repeatedly emphasized, and their presence has been confirmed both in pollen and in fruits. In the present study, a combination of proteomic tools have been used to build a complete allergen map of apple. The water-soluble fraction of an apple extract was precipitated using a phenol-based procedure and separated by 2-DE. Initially four previously classified allergens, Mal d 1, Mal d 2, Mal d 3 and Mal d 4, could be identified in Western blots with polyclonal rabbit antibodies directed to the four respective allergens, and subsequently matched to the bands recognized by several patient sera. Further, all four known apple allergens were localized on a 2-DE map and they were matched with spots recognized by sera of patients with different allergic patterns. Moreover, a new, putative allergen could be identified using MS. We evaluated the influence of post-translational modifications and the immunoreactivity under different analytical conditions. The comparison of different visualization methods for 2-DE gels and blots revealed that even very low concentrations of the intact epitopes are detectable by IgEs of patients, and therefore might be sufficient to trigger allergic symptoms in sensitized individuals.

Is the Ross operation still an acceptable option in children and adolescents?

BACKGROUND

The Ross operation is increasingly accepted as an alternative to conventional valve prostheses for children, adolescents, and young adults. We review patients younger than 20 years of age.

METHODS

Of 404 Ross operations done before November 2004, 60 were young patients with a median age of 12 years (range, 1 to 20 years). The pulmonary autograft technique universally was as a free root. A cryopreserved pulmonary homograft reconstructed the right ventricular outflow tract.

RESULTS

Early postoperative complications were reentry for bleeding in 2 patients and one pacemaker insertion. No thromboembolic or hemorrhagic events occurred during the follow-up of 42 +/- 27 months. Two late deaths occurred, one from myocardial infarction after 3 months and another sudden death after 5 years, probably from critical pulmonary homograft stenosis. Echocardiographic follow-up revealed a median peak gradient of 6.3 +/- 3 mm Hg across the autograft. The median pulmonary homograft peak gradient of 19.1 +/- 13.7 mm Hg was increased to more than 30 mm Hg in 6 patients. Another 6 patients had moderate but clinically insignificant pulmonary homograft regurgitation. Altogether, 6 patients required reoperation for replacement of stenotic homografts. No autograft related reoperation occurred.

CONCLUSIONS

Young patients with the Ross operation had good mid-term autograft function and no perioperative mortality. Factors that justify the choice of the Ross operation for young patients are the normal physiologic hemodynamics and growth of the autograft as well as freedom from anticoagulation. A 10% reoperation rate, elevated pulmonary homograft gradients, and the surgical complexity remain limiting factors.

Allergische Kontakturtikaria durch ein Chamäleon

A 31-year-old man presented with a long history of rhinoconjunctivitis and sneezing that lasted from March to May. The man kept a chameleon (Chamaeleo calyptratus) as a pet and reported about recurrent urticarial lesions, erythema, and itch after skin contact with the animal. The reactions started within a few minutes and were restricted specifically to the contact sites with the animal's claws. No comparable reactions occurred in other subjects. Allergy testing confirmed allergy to hazel, alder, birch, and ash pollen, and additionally revealed sensitization to house dust mite, cat, and Ficus benjamina. Apparently the contact dermatitis originated from passive transfer of Ficus benjamina allergens to the patient's skin by the reptile which habitually climbed on a big Ficus benjamina tree in the patient's home, thereby contaminating its claws with the plant's allergenic milky sap. Careful examination revealed strong perforation of many leaves by the pointed claws. The patient denied respiratory symptoms from Ficus benjamina and intolerance of Ficus-associated fruits.