Deliberate bee sting challenge of patients receiving maintenance venom immunotherapy at 3-month intervals

BACKGROUND

A large part of the cost and inconvenience associated with venom immunotherapy (VIT) is related to the need for monthly treatments. Since VIT is advocated for at least 3 to 5 years, and occasionally longer, reducing the number of venom injections may cut down significantly on both cost and inconvenience.

OBJECTIVE

We evaluated whether maintenance VIT given every 3 months is both safe and effective regarding reactions to treatment injections or field re-stings and lack of systemic reaction (SR) to deliberate challenge sting.

METHODS

The standard 1-month interval was gradually extended to 3 months in 28 patients (mean age 26 years, range 7 to 76) allergic to bee venom (BV), yellow jacket venom, or both venoms. Nineteen patients allergic to BV were deliberately challenged by a live bee sting. In 15 patients the original SR in the field was moderate; in one patient it was mild; and in three patients it was severe.

RESULTS

Mean duration receiving standard maintenance VIT before extending the 1-month interval was 17 months. No patient had an SR while receiving the 3-month VIT therapy. Two patients experienced four field re-stings while receiving the 3-month therapy with no reaction. After the live challenge, there was mild urticaria in a single patient; no SR developed in the rest of the patients.

CONCLUSION

For young patients allergic to BV whose initial SR is mild to moderate and who have already received 1-month VIT for longer than 17 months, the maintenance interval may safely be extended to 3 months while preserving its protective activity against re-stings.

[Diagnosis and misdiagnosis in familial dysautonomia]

The method of diagnosis in 122 patients with familial dysautonomia (FD) was reviewed. In all cases the diagnosis was based on the clinical history, physical examination and results of the histamine test (concentrations of 1:1,000 and 1:10,000). In 8 patients the diagnosis was also supported by a meiotic response to pilocarpine (0.0625 mg/dl). 69 (56%) were diagnosed in the first year of life (19 of them relatives of known FD patients), 16 (13%) in the second year, 31 (25%) from 25 months to 10 years, 3 (2%) from 10.1-20 years, and 3 from 20.1-44 years. At diagnosis the mean age was 2.9 years (SD 5.84) and the median age 11 months. In 17 diagnosis was delayed by an average of 18.5 months (SD 16.9) from the time FD was initially suspected, mainly because of false interpretation of the histamine test. Early correct diagnosis is essential to prevent unnecessary morbidity and mortality from FD.

[Allergic responses to date palm and pecan pollen in Israel]

Date palm (Phoenix dactylifera) and pecan (Carya illinoensis) trees are commonly planted in Israel for fruit, for shade, or as ornamental plants. Pollen grains of both species are allergenic; however, the extent of exposure to such pollen and the incidence of allergic response have not been studied here. We therefore investigated skin-test responses to pollen extracts of 12 varieties of palm and 9 of pecan in 705 allergic patients living in 3 cities and 19 rural settlements. Sensitivity to the pollen extracts of both species was much higher among residents of rural than of urban communities. Moreover, there was a definite relationship between the abundance of these trees in a region and the incidence of skin responders to their pollen. Sensitivity was frequent in settlements rich in these 2 species, such as those with nearby commercial date or pecan plantations. In general, sensitivity to date pollen extracts was lower than to pecan. However, differences in skin responses to pollen extracts of various clones were substantiated. Air sampling revealed that pollen pollution decreased considerably with distance from the trees. At approximately 100 m from a source concentrations of airborne pollen were low. Since planting of male palm and pecan trees in population centers would increase pollen pollution, it should be avoided.

Farewell to the objective analyst

The objective analyst is one who can stand outside of any given situation and make neutral observations, providing his or her countertransference feelings are in hand. The argument against such objectivity offered in this paper is that the activity of analysis involves both prejudice, i.e. one's pre-set ideas, and participation, i.e. a necessary and inevitable change in oneself. Therefore we all see things a bit differently, and we are all effected differently by what we see. Such a view of analysis forces us to insist upon limiting its practice to the analytic setting as well as calling for a recognition of our own subjective states which go beyond countertransference and encompass our whole selves. Since we are never context-free we must recognise that our interpretations are never able to be limited to one fixed reading and so the exchange between patient and analyst is always open and continuous.

Strength training increases resting metabolic rate and norepinephrine levels in healthy 50- to 65-yr-old men

Resting metabolic rate (RMR) decreases with age, largely because of an age-related decline in fat-free mass (FFM). We hypothesized that a strength-training program capable of eliciting increases in FFM would also increase RMR in older individuals. To test this hypothesis, RMR, body composition, and plasma concentrations of certain hormones known to affect RMR were measured before and after a 16-wk heavy-resistance strength-training program in 13 healthy men 50-65 yr of age. Average strength levels, assessed by the three-repetition maximum test, increased 40% with training (P < 0.001). Body weight did not change, but body fat decreased (25.6 +/- 1.5 vs. 23.7 +/- 1.7%; P < 0.001) and FFM increased (60.6 +/- 2.2 vs. 62.2 +/- 2.1 kg; P < 0.01). RMR, measured by indirect calorimetry, increased 7.7% with strength training (6,449 +/- 217 vs. 6,998 +/- 226 kJ/24 h; P < 0.01). This increase remained significant even when RMR was expressed per kilogram of FFM. Strength training increased arterialized plasma norepinephrine levels 36% (1.1 +/- 0.1 vs. 1.5 +/- 0.1 nmol/l; P < 0.01) but did not change fasting glucose, insulin, or thyroid hormone levels. These results indicate that a heavy-resistance strength-training program increases RMR in healthy older men, perhaps by increasing FFM and sympathetic nervous system activity.

Establishment of cell lines from B-cell precursor acute lymphoblastic leukemia

In an attempt to establish permanent cell lines from children with B-cell precursor acute lymphoblastic leukemia (BCP-ALL), 123 clinical samples from 117 patients were cultured in vitro. Using a method which was successful for the growth of ALL with T-cell phenotype, 3% (2/74) of BCP-ALL samples from patients at diagnosis and 31% (9/29) of BCP-ALL samples from patients at relapse were established as cell lines. However, in most cultures, leukemic cells survived for only a few weeks and the majority of viable cells present after 28 days of culture were esterase-positive mononuclear cells. Based on the hypothesis that mononuclear cells inhibited leukemic cell growth, we evaluated the effect of a monocyte toxin, L-leucine methyl ester (Leu-OMe), on the growth of four frozen BCP-ALL samples. Thawed leukemic cells treated with Leu-OMe, but not untreated control cells, proliferated in three samples and one new cell line was established. Subsequently, when Leu-OMe was added to fresh leukemia cells in culture, leukemic cell lines were grown from 29% (4/14) of samples at diagnosis and 66% (4/6) of relapse samples. Overall, 20 BCP-ALL cell lines were established, all were Epstein-Barr virus (EBV)-negative, and authenticity of each cell line was verified by a direct comparison of the immunophenotype, karyotype, and genotype with the patient's tumor cells. This improved method of cell culture permits a higher success rate of cell line establishment from patients with BCP-ALL thereby aiding in analysis of B-lymphocyte transformation and neoplasia.

Sexualization and desexualization

This paper is a reconsideration of the role of sexualization in psychoanalysis. After a review of the accepted definitions of sexualization as defense and/or part of normal sexuality, a new explanation is offered. This posits sexualization as a psychological manifestation of a structural deficit and suggests analytic treatment as a process of structuralization. These terms are defined and illustrated. A case example demonstrates the thesis, and some implications of this concept are discussed.

Once-daily, extended-release gemfibrozil in patients with dyslipidemia. The Lopid SR Work Group I

This randomized, parallel-group, multicenter clinical trial compared a newly developed, once-daily, extended-release formulation of gemfibrozil (Lopid SR) and gemfibrozil twice daily (Lopid) in terms of lipid-regulating effects and toxicity. Patients were men and women with elevations of low-density lipoprotein cholesterol and low levels of high-density lipoprotein cholesterol. The trial consisted of a 1-week screening period, an 8-week diet baseline period (Step One Diet), and a 24-week double-blind treatment period (extended-release gemfibrozil 1,200 mg once daily vs gemfibrozil 600 mg twice daily). At the end of the trial, the 2 treatment groups showed comparable improvements in all primary lipid factors: mean percent changes in triglyceride, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol were -32, +10 and -10% for extended release (n = 325) and -36, +11 and -10% for twice daily (n = 330). The 90% confidence interval for the relative difference between the treatment means fell within the equivalence bounds of +/- 35% for all 3 factors, demonstrating equivalence of efficacy. Adverse events were reported at low rates and were similarly distributed in frequency and intensity between treatment groups; they were preponderantly mild or moderate, and gastrointestinal effects were the most frequent. The once-daily formulation of gemfibrozil may afford better control of dyslipidemia through improved compliance by patients who have this asymptomatic disease.

Nedocromil sodium inhibits T-cell function in vitro and in vivo

Nedocromil sodium, a topical antiinflammatory agent recommended as a prophylactic regimen for asthma, is known to inhibit both allergic and nonallergic inflammatory processes in which an essential role for T cells has been implicated. Therefore the direct effects of this drug on several aspects of T-cell activity were analyzed in the present study. By using murine lymphocytes we found that NS at concentrations of 10(-8) to 10(-6) mol/L inhibited the mitogen- or antigen-induced proliferative responses of these cells. It is interesting to note that higher concentrations were ineffective. Preincubation of immune lymph node cells from contact sensitized mice with the drug abrogated their ability to transfer contact sensitivity to naive recipients, an effect that was found to be specific for the treated cells. Nedocromil sodium also interfered with the mitogen-induced interleukin-2 and tumor necrosis factor production by T cells and with their ability to adhere to the bound protein components of the extracellular matrix laminin and fibronectin. All these effects may be attributed to the inhibition of the increase of cytosolic calcium, which accompanies the early phase of T-cell activation and which is an essential step in inducing the aforementioned phenomena.

The Missouri Cardiovascular Health Plan: a focus on prevention

The authors describe a framework for planning, implementing, and evaluating cardiovascular health programs in Missouri. Populations targeted for intervention are identified, and the role of the physician in supporting community-based cardiovascular health promotion is explored.

Intranasal absorption of flurazepam, midazolam, and triazolam in dogs

Intranasal delivery of flurazepam, midazolam, and triazolam was studied in a dog model as a possible alternate route of drug administration for treatment of insomnia. Four beagles received each hypnotic by both intranasal and oral routes on two separate occasions. Plasma concentrations for each hypnotic after dosing were measured by electron-capture gas-liquid chromatography. The mean intranasal absorption rates (tmax) of flurazepam, midazolam, and triazolam were 1.7, 2.0, and 2.6 times faster, respectively, compared with oral dosing. The mean dose-normalized peak concentrations (Cmax) after intranasal delivery were 16.4, 2.9, and 3.4 times higher, respectively, versus oral administration. The mean dose-normalized AUCs estimated for these compounds after nasal administration were 2.4-, 2.5-, and at least 2-fold larger than after oral administration for midazolam, triazolam, and flurazepam, respectively. If these observations can be extrapolated to humans, the faster absorption achieved by the intranasal route would appear to benefit insomniacs characterized by difficulty in falling asleep because of an anticipated faster sedative effect onset. The higher peak concentrations and larger amounts absorbed in the case of intranasal midazolam and triazolam delivery may lead to dose reduction.

Cutaneous responses to histamine, compound 48/80, and codeine in patients with chronic renal failure

Pruritus is a common symptom associated with chronic renal failure (CRF). But increased plasma histamine levels and skin mast cell proliferation previously reported in these patients did not correlate with the intensity of the pruritus. Since increased mast cell releasability was described in chronic idiopathic urticaria, we attempted to examine whether this mechanism could explain pruritus in patients with CRF. Twenty-five patients with end stage renal failure were skin tested with histamine, codeine, and compound 48/80. There were nine patients on continuous ambulatory peritoneal dialysis, eight patients on hemodialysis, (tested both before and after dialysis) and eight patients with advanced CRF. Wheal area after intradermal injection of three concentrations of the above substances was measured. In general, the wheal areas in all patients with CRF were either similar to or smaller than those of the control group who were without renal impairment. In conclusion, patients with CRF with or without dialysis therapy demonstrated unchanged or decreased skin test responses to histamine, codeine, and compound 48/80. Increased mast cell releasability cannot explain the pruritus in patients with CRF.

Appearance of macrophage migration inhibition factor in patients with systemic reactions to bee venom

Cellular responses in bee venom (BV) allergy is a controversial issue. Previous studies could not reach an agreement whether this mechanism is activated as a result of allergic sensitization to bee venom. All previous works have used lymphocyte proliferation as their method to analyze cell-mediated immunity. In the present work, we tried to explore whether the production of macrophage migration inhibition factor (MIF), which is another in vitro correlate with cellular responses, is increased in these patients. We also examined which of the major antigenic components of BV played a significant role in the cellular response. Peripheral blood lymphocytes from 10 patients with systemic allergic reactions to bee sting and 9 healthy volunteers were examined for their ability to induce positive MIF responses. Macrophage inhibition was significantly increased in allergic patients when tested with BV, phospholipase A2 (PLA2) and with melittin. Positive MIF responses to other components were also more common in allergic patients than in the control group. Our results indicate that cellular response to BV is expressed in patients with systemic allergic reaction to BV. When major antigenic components of BV are examined, PLA2 seems to play the major role in inducing this response.

Elevation of blood lactate and pyruvate levels in acute intermittent porphyria--a reflection of haem deficiency?

Blood lactate concentrations after glucose loading were significantly higher in 6 patients with acute intermittent porphyria in clinical remission than in 6 control subjects and the percentage rise in glucose pyruvate and lactate concentrations were greater in the porphyric subjects than in the control group. It is postulated that the raised lactate levels in the porphyric patient group may reflect haem deficiency affecting the cytochromes of the terminal respiratory chain.

Comparison of hypertension treatment on and off the worksite

A survey was carried out in two plants in Haifa, Israel on the prevalence of treated and controlled hypertension. In both plants hypertension treatment was being carried out by family physicians at regular family clinics. In factory A, after screening, a programme of follow-up and treatment by the plant doctor and nurse was introduced. In factory B all hypertensives continued to be referred to their family physician for treatment and follow-up. One year later all previously detected hypertensives were reassessed. The percentage of treated hypertensives had increased from 70.9% to 100% in factory A, and from 55.0% to 62.1% in factory B. The percentage of controlled hypertensives among those treated had increased from 52.7% to 83.7% in factory A, and from 28.0% to 38.9% in factory B. Thus, the percentage of all hypertensives who were controlled increased from 37.3% to 83.7% in Factory A and from 15.4% to 24.1% in Factory B. The introduction of on-site treatment and follow-up of hypertension by a doctor-nurse team was associated with marked improvement of all aspects of hypertensive care.

DNA fingerprints of chickens selected for high and low body weight for 31 generations

Two lines of White Plymouth Rock chickens that have been divergently selected for 8-week body weight for 31 generations were compared for patterns of DNA fingerprints (DFP). Digestion of DNA with HinfI and hybridization to Jeffreys' minisatellite probe 33.6 resulted in DFPs that were relatively similar within lines (bandsharing = 0.50) and less similar between lines (bandsharing = 0.22). Analyses of scorable DFP bands produced by mixing DNA from individuals within lines indicated that 48% were line-specific. Causes for the differences in DFP patterns between lines and for occurrence of line-specific bands for the two lines divergently selected for body weight are discussed.

LHRH analogue treatment for the prevention of premenstrual attacks of acute porphyria

We have assessed the value of suppressing ovulation with the luteinizing hormone releasing hormone (LHRH) analogue buserelin in seven patients experiencing crises of acute intermittent porphyria related to the menstrual cycle. Clinical course, plasma oestradiol and progesterone levels, and urinary porphyrin and precursor excretion were monitored over a baseline period of approximately one year, and then for a similar period on buserelin treatment. There was a trend towards clinical improvement on buserelin therapy. The median number of attacks fell from seven during the baseline period to three on treatment (p = 0.06). The response to buserelin varied considerably, with those patients in whom the association between baseline attacks and the menstrual cycle was strongest gaining the most benefit. All patients became amenorrhoeic with suppression of plasma oestradiol and progesterone levels. Urinary delta-aminolaevulinic acid and total porphyrin excretion fluctuated widely both before and during treatment. Our experience indicates that ovulation suppression may be of value in the management of young women in whom recurrent attacks of porphyria are related to the menstrual cycle.