[Epidemiology and treatment of adult patients with atopic dermatitis : Analysis of longitudinal data of the statutory health insurance scheme]

BACKGROUND

The goal was to report incidence, prevalence, and treatment patterns in adult atopic dermatitis (AD) patients in the German statutory health insurance system.

PATIENT AND METHODS

Anonymized claims data were evaluated at patient level for 3.3 million persons insured by six different statutory health insurance companies (SHI). Patients for whom the ICD-10 diagnosis code L20 (AD) was applied at least twice were analyzed and data on prescription patterns for AD were reported for the years 2011-2015.

RESULTS

AD prevalence in adults was 1.6-1.9% in 2012-2015. Annual incidence was 0.28%. In Q3/Q4 2015, 44.2% of the adult population with AD diagnosis by a dermatologist received prescriptions for AD medications: 1.6% low-potency topical glucocorticoids (without previous prescription of systemic drugs), 46.9% moderate or high-potency topical glucocorticoids or topical calcineurin inhibitors, 23.9% current systemic therapy (systemic glucocorticoids, ciclosporin, methotrexate, azathioprine, mycophenolate mofetil) and 27.6% systemic therapy in the past.

CONCLUSIONS

The AD prevalence estimate was in the range of previous reports (1.35-4%) that used different methodologies. Based on treatment proxy, it appeared that almost more than half of AD patients treated with prescription ready-to-use drugs had a severe form of AD which required treatment with systemic drugs.

Abstract PD7-11: The role of multi-gene hereditary cancer panels in male patients with breast cancer

Background/Statement of Purpose: The role of cancer susceptibility genes in the male breast cancer population beyond BRCA1 and BRCA2 (BRCA) is not well defined. While breast cancer has been documented in men with pathogenic variants in a number of other breast cancer susceptibility genes (e.g. CHEK2, PALB2, PTEN), the yield of testing is not well documented nor are predictive clinical features of those likely to harbor causative variants. This study assesses the yield of pathogenic/likely pathogenic variants (collectively, PV) in male breast cancer patients who underwent multi-gene hereditary cancer panel testing. In addition, we aim to examine predictors of identifying a PV in this population.

Methods: Clinical histories and test results were reviewed for men with a diagnosis of breast cancer who underwent panel testing that included a minimum of eight well-described breast cancer susceptibility genes (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, TP53) and up to 24 additional genes. Using t-test and two-tailed Fisher's exact test, we assessed whether age at diagnosis, family history of breast cancer, or the presence of selected second primary cancers (second breast, prostate, pancreatic, colon, or melanoma cancers) were associated with a greater likelihood of identifying a PV.

Results: The clinical histories and test results of 381 men with breast cancer were reviewed, of whom 12.1% had at least one PV (46/381). When we limited our assessment to men who had not had prior negative BRCA testing, 13.3% had at least one PV (42/315). Variants were most commonly detected in BRCA2 (21) and CHEK2 (17), followed by PALB2 (4), BRCA1 (4), and ATM (2). A two sample t-test showed no significant difference (p=0.39) in the average age of diagnosis for those with a PV (62.5y, n=47) compared to those without a PV (60.9y, n=334). Two-tailed Fisher's exact test showed no association between having a PV and a history of a selected second primary (SP) cancer [10.8% (7/65) w/SP vs 12.3% (39/316) w/out SP; p=0.84]. Lastly, two-tailed Fisher's exact test showed those with a family history of breast cancer (fhx br) were more likely to have a PV [15.1% (32/212) fhx br vs. 8.3% (14/169) no fhx br], although this did not reach statistical significance (p=0.06).

Conclusions: While BRCA2 remains the most common gene in which PVs are identified in men with breast cancer, a significant proportion of patients will have a PV in another well-described breast cancer susceptibility gene, particularly CHEK2, PALB2, and ATM. Therefore, it is reasonable to utilize a panel that is inclusive of these genes when testing male breast cancer patients. As the likelihood to harbor a PV was not significantly associated with age of onset, family history of breast cancer, or presence of a second primary, all men with breast cancer could consider genetic testing. Further study is warranted as the current sample size may limit the power to detect associations.

Citation Format: Vogel Postula KJ, Andolina LM, Theobald K, McGill AK, Sutcliffe E, Arvai KJ, Murphy PD, Klein RT, Hruska KS. The role of multi-gene hereditary cancer panels in male patients with breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD7-11.

Comparison of basal insulin therapies with regard to the risk of acute myocardial infarction in patients with type 2 diabetes: an observational cohort study

AIMS

To assess the risk of acute myocardial infarction (AMI) in patients with type 2 diabetes mellitus treated with long-acting insulin analogues in comparison with other basal insulin therapy.

METHODS

We used German insurance claims data from the years 2004-2009 to conduct a study in a retrospective cohort of patients with type 2 diabetes. Naïve insulin users were defined as patients who had an insulin-free history before the first prescription of long-acting analogue insulin, human NPH insulin or premixed insulin and who were pretreated with oral antidiabetic drugs. Adjusted hazard ratios (HRs) of AMI and corresponding 95% confidence intervals (CIs) were calculated using sex-stratified Cox models. Propensity-score-matched analyses were conducted as sensitivity analyses.

RESULTS

We identified 21,501 new insulin users. Patients treated with premixed insulin were older than patients treated with analogue or NPH insulin (mean age 70.7 vs. 64.1 and 61.6 years, respectively) and had more comorbidities. Regarding the risk of AMI, adjusted HRs showed no statistically significant difference between NPH and analogue insulin (HR 0.94, 95% CI 0.74-1.19), but a higher risk for premixed than for analogue insulin (HR 1.27, 95% CI 1.02-1.58). Contrary to the primary analysis, the propensity-score-matched analysis did not show an increased risk for premixed insulin.

CONCLUSIONS

In contrast to a former database study, no difference was observed for the risk of AMI between long-acting analogue and NPH insulin in this study. Neither long-acting analogue insulin nor premixed insulin appears to be associated with AMI in patients with type 2 diabetes.

Treatment satisfaction and quality-of-life between type 2 diabetes patients initiating long- vs. intermediate-acting basal insulin therapy in combination with oral hypoglycemic agents--a randomized, prospective, crossover, open clinical trial

Background

Pharmacological and clinical differences between insulin glargine and NPH insulin may translate into differences in patient reported outcomes, but existing data are equivocal.

Methods

In this 48-week, open-label, randomized, multi-center, crossover phase IV trial, insulin naïve type 2 diabetes patients with blood glucose not at target on oral hypoglycemic agents had basal insulin added to their treatment regimen. A total of 343 patients were randomized to either receive insulin glargine (n = 176; sequence A) or neutral protamine Hagedorn (NPH) insulin (n = 167; sequence B) in period 1 (weeks 1–24) and vice versa in period 2 (weeks 25–48). The primary objective was to assess patient reported outcomes using a composite Diabetes Related Quality of Life (DRQoL) score based on an unweighted Insulin Treatment Experience Questionnaire (ITEQ) score, a Problem Areas in Diabetes (PAID) questionnaire score, and the mental health score in the Short Form (SF)-12® Health Survey, analyzed by analysis of covariance (ANCOVA).

Results

Patients (mean age 62.3 ± 9.0; 39.5 % female) had a mean diabetes duration of 9.6 ± 5.9 years, a mean baseline HbA1c of 8.15 ± 0.72 %, and a mean fasting blood glucose (FBG) level of 9.37 ± 2.19 mmol/L. A total of 229 patients were available for primary endpoint evaluation (modified intention to treat population). Combining all data from both periods for each insulin treatment, on a 0–100 scale, the mean DRQoL score was 69.6 (±9.04) with insulin glargine and 70.0 (±9.40) with NPH insulin. Neither an effect of treatment with insulin glargine vs NPH insulin (p = 0.31) nor a period effect (p = 0.96), nor a sequence effect (p = 0.76) was observed using ANCOVA.

Conclusions

The results show that in a patient population with sub-optimal glycemic control at baseline, and a low target achievement rate together with a low rate of hypoglycemia, differences in the patient reported outcomes evaluated in this study were negligible between insulin glargine and NPH insulin.

Trial registration

Clinicaltrials.gov identifier: NCT00941369

Relevance of indirect comparisons in the German early benefit assessment and in comparison to HTA processes in England, France and Scotland

Early benefit assessment in Germany under the legislative framework of AMNOG (Arzneimittelmarktneuordnungsgesetz) requires direct comparisons of the new drug with appropriate comparators determined by the Federal Joint Committee (G-BA). In case no head-to-head studies are available for direct comparisons, the submission of indirect comparisons is permitted to assess the additional benefit of the new drug. However, the Institute for Quality and Efficiency in Health Care (IQWiG) states a clear preference for head-to-head trials and defines strict requirements for indirect comparisons to be considered in the benefit assessment. Similar requirements also exist in other countries with mandatory health technology assessments (HTA), like France, England and Scotland. Our evaluation shows that a comparison of the different HTA regarding indirect comparisons is difficult. Overall, external preconditions and methodological requirements are demanding and hardly to fulfill by pharmaceutical companies for implementation of indirect comparisons in early benefit assessment. The determination of the appropriate comparators, outcomes, patient subgroups and study choice are the main target within indirect comparisons for the future. To compare and assess submitted indirect comparisons it would be desirable that a transparent process was established, including the mandatory publication of HTA-reports within Europe and international guidelines, accepted by a large number of HTA-agencies.

Indirect comparison of lixisenatide versus neutral protamine Hagedorn insulin as add-on to metformin and sulphonylurea in patients with type 2 diabetes mellitus

Objective: There is currently a lack of evidence from direct comparisons of treatment outcomes with lixisenatide versus neutral protamine Hagedorn (NPH)-insulin in type 2 diabetes mellitus (T2DM) patients with suboptimal glycaemic control with oral antidiabetic drugs (OADs). Hence, the current analysis indirectly compared available evidence on the risk of hypoglycaemia and weight change between lixisenatide and NPH-insulin based on randomized controlled trial (RCT) data with exenatide, insulin glargine and placebo as common references.

Methods: A systematic search of PubMed, Embase, the Cochrane database and clinical registries identified English- and German-language articles published from January 1980 to October 2012 reporting data from RCTs. Only publications of trials that reported outcomes from 24 to 30 weeks comparing glucagon-like peptide-1 receptor agonists or basal insulin versus another antidiabetic agent or placebo were included. Hypoglycaemia, patients at glycated haemoglobin (HbA_1c) target and discontinuations due to adverse events (AEs) were treated as binary variables, with risk ratios and odds ratios (ORs) calculated. HbA_1c and body weight were treated as continuous variables with difference in mean change from baseline (MD) calculated. Meta-analyses were performed with random effects models and indirect comparisons were performed according to Bucher’s method.

Results: Seven RCTs (n=3,301 patients) comparing the efficacy and safety of lixisenatide, exenatide, insulin glargine and NPH-insulin with different antidiabetic treatments in adult patients with T2DM were included in the final analysis. In the adjusted indirect comparison, there was a significant difference in symptomatic hypoglycaemia (OR = 0.38; 95% CI = [0.17, 0.85]) and in confirmed hypoglycaemia (OR = 0.46; 95% CI = [0.22, 0.96]) favouring lixisenatide over NPH-insulin and comparable changes in HbA_1c from baseline (MD = 0.07%; 95% CI = [–0.26%, 0.41%]). In contrast to NPH-insulin, there was a significant reduction in body weight with lixisenatide (MD = –3.62 kg; 95% CI = [–5.86 kg, –1.38 kg]) at study completion. The number of discontinuations due to AEs numerically favoured NPH-insulin over lixisenatide (OR = 2.64; 95% CI = [0.25, 27.96]), with a broad confidence interval.

Conclusions: Lixisenatide treatment was associated with a lower risk of hypoglycaemia and a greater weight loss compared with NPH-insulin. Glycaemic control with lixisenatide treatment was comparable with NPH-insulin. These data suggest that lixisenatide is a beneficial treatment option for T2DM patients with inadequate glycaemic control on OADs, and is associated with reduced risk of hypoglycaemia and weight gain.

Quality assurance in non-interventional studies

Nowadays, drug research and surveillance after authorisation becomes more and more important for several reasons. Non-interventional studies (NIS) investigate various aspects of drug use including efficacy and safety under real life conditions. Such kind of health services research should be on a high scientific, methodological and organisational level. Therefore accompanying measures to improve or to keep the quality are highly recommended. The aim of quality management is: first to avoid bias of results by using an appropriate study design and an adequate data analysis, second to assure authenticity, completeness and validity of the data and third to identify and resolve deficiencies at an early stage. Basic principles are laid down in corresponding guidelines and recommendations of authorities, institutes and societies. Various guidelines for good epidemiological practice (GEP) were published by the U.S. Food and Drug Administration (FDA) and international and regional societies for epidemiology. In addition in Germany the Federal Institute for Drugs and Medical Devices (BfArM) together with the Paul Ehrlich Institute (PEI) and the German Association of Research-Based Pharmaceutical Companies (VFA) have published respectively recommendations dealing with quality aspects of non-interventional observational studies. Key points are the advanced publishing of information about the project, developing of a study plan/protocol containing the scientific objectives, a sample size justification and a description of the planned analyses and the publishing of a summary of the results timely after completion of the study. The quality of the data can be improved by using standardized case report forms (CRF) and the CRF should be reviewed and tested before start of study by some participants. A source data verification (SDV) should be performed in randomly selected centres – in between 2% and 5% of the centres depending on the number of participating centres. Before start of statistical analysis a statistical analysis plan (SAP) should be created. The use of standardized tables and figures is highly recommended. The basis of the report writing should be the STROBE-statement “Strengthening the Reporting of Observational studies in Epidemiology Initiative” containing a checklist of 22 points to be covered in the report. The development of own standard operating procedures (SOP) describing the processes during planning, conduct and evaluation of a non-interventional study as well as the quality management and the regular training of all involved people is also highly recommended. All accompanying measures to improve or to keep the quality of the NIS should not violate the concept of non-intervention.

Insulin glulisine, insulin lispro and regular human insulin show comparable end-organ metabolic effects: an exploratory study

AIMS

To compare the end-organ metabolic effects of insulin glulisine (glulisine), insulin lispro (lispro) and regular human insulin (RHI) in patients with type 1 diabetes mellitus.

METHODS

Eighteen patients with type 1 diabetes mellitus (mean age 36.9 +/- 8.6 years, BMI 23.6 +/- 2.8 kg/m(2), haemoglobin A(1c) 7.4 +/- 0.9%) were randomized in this single-centre, double-blind, three-period cross-over, standard Latin-square, euglycaemic glucose clamp trial. Patients received sequential, primed stepwise intravenous infusions of glulisine, lispro or RHI (infusion rates were increased in a stepwise manner from an initial rate of 0.33 [180 min] to 0.66 [180 min] and 1.00 [180 min] mU/kg/min). The primary variables were the suppression of endogenous glucose production (S(EGP)) and glucose uptake (GU).

RESULTS

Mean basal endogenous glucose production (EGP) was 1.88, 2.12 and 2.12 mg/kg/min for glulisine, lispro and RHI respectively. Mean (+/-s.e.) maximum absolute S(EGP) (adjusted for basal EGP) was -1.64 +/- 0.06, -1.72 +/- 0.05 and -1.56 +/- 0.05 mg/kg/min respectively. Mean (+/-s.e.) maximum absolute increase in GU (adjusted for basal GU) was 6.46 +/- 0.26, 6.23 +/- 0.24 and 6.72 +/- 0.24 mg/kg/min respectively. There were no clinically relevant differences between the three insulin treatments with respect to serum insulin, free fatty acid (FFA), glycerol or lactate levels. No serious adverse events and no episodes of severe hypoglycaemia were reported.

CONCLUSIONS

This study shows that glulisine, lispro and RHI have similar effects on S(EGP), GU, FFA, glycerol and lactate levels, providing evidence for similar end-organ metabolic effects.

Systemic Risk Score Evaluation in Ischemic Stroke Patients (SCALA)

BACKGROUND AND PURPOSE

Stratification of patients with transient ischemic attack (TIA) or ischemic stroke (IS) by risk of recurrent stroke can contribute to optimized secondary prevention. We therefore aimed to assess cardiovascular risk factor profiles of consecutive patients hospitalized with TIA/IS to stratify the risk of recurrent stroke according to the Essen Stroke Risk Score (ESRS) and of future cardiovascular events according to the ankle brachial index (ABI) as a marker of generalized atherosclerosis

METHODS

In this cross-sectional observational study, 85 neurological stroke units throughout Germany documented cardiovascular risk factor profiles of 10 consecutive TIA/IS patients on standardized questionnaires. Screening for PAD was done with Doppler ultrasonography to calculate the ABI.

RESULTS

A total of 852 patients (57% men) with a mean age of 67+/-12.4 years were included of whom 82.9 % had IS. The median National Institutes of Health stroke sum score was 4 (TIA: 1). Arterial hypertension was reported in 71%, diabetes mellitus in 26%, clinical PAD in 10%, and an ABI < or = 0.9 in 51%. An ESRS > or = 3 was observed in 58%, which in two previous retrospective analyses corresponded to a recurrent stroke risk of > or = 4%/year. The correlation between the ESRS and the ABI was low (r = 0.21).

CONCLUSION

A high proportion of patients had asymptomatic atherosclerotic disease and a considerable risk of recurrent stroke according to the ABI and ESRS category. The prognostic accuracy as well as the potential benefit of various risk stratification scores in secondary stroke prevention require validation in a larger prospective study.

Critical care education: an examination of students' perspectives

Specialist nursing education at the tertiary level is a relatively recent occurrence in Australia. With this move to higher education a variety of issues such as course duration, award level and clinical versus theoretical outcomes provided the impetus for this study. This study examined critical care nursing students' perceptions of undertaking post-graduate education within the higher education sector. Four themes arose from analysis of eight focus group interviews with a total of 42 students from 35 courses offered in eight universities across Australia. The first theme, student burden, included subthemes of financial, heavy workload and student-work conflicts. Student benefits, the second theme, encompassed financial and other benefits. The third theme, clinical experience, incorporated clinical capability, synthesizing, support required and clinical learning. The final theme of student attitude included the subthemes of individual, technology and course. Without student evaluations, curricular improvements including assessment and clinical experience will not evolve to the best of their potential.

Preparing for coronary angioplasty: the patients' experiences

Coronary angioplasty and stent placement procedures now represent one of the fastest growing specialties in cardiac care; patients undergo a short stay admission with limited care time with nurses. The purpose of this study was to describe participants' experiences of preparing for angioplasty in such an environment. Eight men and three women were interviewed 1 month after discharge from hospital. Verbatim transcripts were analysed for major themes using the qualitative techniques of grounded theory. Participants described working through a problem solving process in response to the perceived health threat associated with undergoing angioplasty. In step one, the problem was identified. In step two, coping responses were taken to try and solve the problem. In step three, the results of the coping responses were appraised or evaluated. The two problems identified were ongoing chest pain and anxiety related to fear of the unknown. The coping responses initiated included acquiring knowledge of the angioplasty, confidence in the skill of the doctor, support from family and gearing up psychologically. In the final appraisal of the coping responses, the participants decided to either go ahead with, or delay the angioplasty procedure. The results of this study indicate that the preparation for angioplasty represents a period of adjustment that may be anxiety provoking. Participants' experiences provide new knowledge of the concerns and challenges faced when undergoing such an invasive procedure in a short stay environment. The results clearly highlight that psychosocial aspects of nursing care are an essential component of nursing practice for angioplasty patients.

Apnea of prematurity: diagnosis, implications for care, and pharmacologic management

Apnea is a disorder of respiratory control commonly seen in premature infants. Several mechanisms have been proposed to explain apnea, and many clinical conditions have been associated with its development. Apnea of prematurity is seen in infants less than 37 weeks gestation, with the incidence increasing as gestational age decreases. Expert and consistent nursing care is essential for management of premature infants with apnea. This article reviews the differential diagnosis, pathogenesis, and implications for care of apnea of prematurity.

The patients' perception of recovery after coronary angioplasty

Coronary angioplasty and stent placement is associated with short hospital stays. Patients are expected to recover at home, alone, following limited care time with nurses. The purpose of the study was to describe participants' perceptions of recovery after angioplasty. Eight men and three women were interviewed 1 month after discharge from hospital. Verbatim transcripts were analysed for major themes using the qualitative techniques of grounded theory. Data analysis revealed three major categories: awareness of the problem, coping response and appraisal of the situation. These were linked via a problem solving process. In step one, the problem was identified. In step two, coping responses were taken to try and solve the problem. In step three, the results of the coping responses were appraised or evaluated. These categories were further defined by four phases identified as: pre-admission, admission, during the angioplasty and recovery. This paper describes the recovery phase. Awareness of the problem in the recovery phase was associated with 'relief from chest pain' for most participants. In contrast, anxiety continued and was associated with 'uncertainty over future health'. Participants described coping responses of "taking control of their life again" by undertaking both physical and psychological strategies. Finally, the situation was appraised to be either a 'good' or a 'bad' recovery. This appraisal was based on such considerations as the absence of chest pain, improvement in well-being and energy levels. The results of this study highlight patients' concerns and support the need for greater emphasis on their psychosocial needs. This care must be provided within the time constraints of short hospital stays. Nurses must also consider providing support to patients in the pre-admission and recovery phases.

The experience of spouses whose partners have suffered a myocardial infarction: a phenomenological study

This phenomenological study describes the lived experience of spouses whose partners have suffered a myocardial infarction. In-depth interviews were conducted with three participants (two females and one male) about their experiences. The findings from the participants were analysed using Giorgi's method (1985). Informants' experiences were captured within five major themes: (i) crushing uncertainty, (ii) overwhelming emotional turmoil, (iii) the need for support, (iv) the lack of information heightened anxiety and (v) the acceptance of lifestyle changes. The implications from this study suggest that health care workers need to: embellish their skills in managing spouses' emotions; communicate with community health professionals regarding support systems; provide families with information concerning the emotional issues associated with MI; provide advice in terms of financial aid; and identify community support groups if these are required. The in-depth knowledge gained from the study will enable nurses to understand how family members feel when a spouse/partner has suffered an MI. It will also provide a framework with which practitioners and families can understand their reactions and assist in the overall rehabilitation of clients.

Critical care nurses' perceptions of their educational needs

A survey of nurses working in critical care units in 89 Queensland hospitals was conducted to investigate their perceptions of critical care nurses' educational needs. Two thirds of the 62 respondents were from rural units and one third were from metropolitan units. Most respondents, irrespective of geographic location, wanted critical care education to be located in hospitals and to be accredited as a graduate diploma course. Rural and metropolitan nurses had similar educational needs and many worked for hospitals that were not offering adequate orientation or inservice critical care education. The findings that nursing staff turnover was a problem in metropolitan units and that the rural workforce was more stable have implications for the development of educational programs.

Vaccination against tick-borne encephalitis (TBE): influence of simultaneous application of TBE immunoglobulin on seroconversion and rate of adverse events

One hundred and twenty-one of 128 enrolled healthy adult subjects were immunized against tick-borne encephalitis (TBE) either by TBE vaccine on days 0 and 28 (61 subjects) or simultaneously by TBE vaccine plus TBE immunoglobulin on day 0 plus TBE vaccine on day 28 (60 subjects). Formation of TBE antibodies were measured in ELISA on days 0, 28 and 56. On day 28 median TBE antibodies were twice as high in the vaccine group (2400) as in the vaccine plus immunoglobulin group (1200). Adverse events were more often observed after the first vaccination than after the second in both groups. In the vaccine group, adverse events after the first vaccine dose were remarkably more frequent (45% of these subjects reported 38 adverse events) than in the group who received vaccine plus immunoglobulin (25% of these subjects reported 18 adverse events). All types of adverse events (chills, flu-like symptoms, injection site pain) were reported less frequently in the vaccine plus immunoglobulin group. After the second vaccination the rate of adverse events was 7% in both groups. Seroconversion was achieved in all subjects on day 56 except one subject in the vaccine plus immunoglobulin group. Simultaneous application of TBE vaccine plus TBE immunoglobulin can be recommended for persons who need immediate protection plus active TBE vaccination.

Pharmacokinetics of single and multiple infusions of 5S intravenous immunoglobulin

A prospective, open and uncontrolled trial was performed to investigate the pharmacokinetics of a 5S intravenous immunoglobulin (IVIG) after single and multiple infusions. Twelve healthy volunteers received a 5S-IVIG enriched in antibodies against Staphylococcus aureus alpha-toxin (aSAT) either as a single infusion or as three infusions in daily intervals. The fate of the injected immunoglobulin was observed by serial measurements of the serum level of aSAT titres. The 5S-IVIG had a half-life with a median of 0.24 (distribution) and 2.0 (terminal) days, respectively. The pharmacokinetic parameters did not differ with dose groups or number of applications. The study medication was well tolerated.

A new vaccine against tick-borne encephalitis: initial trial in man including a dose-response study

A new vaccine against tick-borne encephalitis was investigated in 56 healthy volunteers randomized for five different doses of antigen in a comparative group trial. Good tolerability and high immunogenicity were found using three different antibody test systems. The dose response study revealed that there was a strong relationship between the amount of antigen administered and the antibody response over the range of 0.03-3.0 micrograms antigen per dose.

Inhibition of histamine release in vitro by a blocking factor from human serum: comparison with the iron binding proteins transferrin and lactoferrin

Recently, we described the presence of a blocking factor (BF) in rat serum, which inhibited the histamine release from rat mast cells in vivo and in vitro. The blocking activity was demonstrated in human serum as well. Qualitative analysis of the purified preparations demonstrated a major component with an apparent molecular weight of 70,000 daltons. In human serum the blocking factor was identified as transferrin (TF) by serological and biochemical methods. BF (DEAE-peak 1) and the iron binding proteins transferrin and lactoferrin (LF) are shown to inhibit the histamine release in vitro. The dose response curves reveal that inhibition by these proteins is dependent on their degree of iron saturation. Furthermore, unlike lactoferrin, the effects of transferrin and BF (DEAE-peak 1) follow the same pattern. Their mechanism of action remains to be elucidated.

Purification of serum proteins with inhibitory activity on the histamine release in vitro and/or in vivo

Recently, we described a factor in rat and human serum with inhibitory activity on the 2-hour passive cutaneous anaphylactic (PCA) reaction in rat skin. The Ca-ionophore-induced histamine release from rat peritoneal mast cells was inhibited as well. In human serum, inhibitory activity for the in vitro histamine release from rat mast cells was shown to be present within two serum fractions. One molecule was purified by 50-70% ammonium sulfate precipitation and subsequent DEAE chromatography at pH 5.4. The main component showed complete identity with transferrin. Commercially available transferrin was active in vitro as well. The dose-response plot revealed two inhibition maxima at transferrin concentrations of 0.05-5 ng/ml and at more than 1 mg/ml, respectively. Subsequently it was shown that the degree of iron saturation was critical for the decrease in histamine release. The mediator release in vivo (PCA) could not be inhibited by the iron transport protein. Inhibitory activity in vivo was however mediated by the second serum fraction, which was characterized by a molecular weight of approximately 150,000 daltons and an IEP within the alkaline range. These data suggest that exogenous factors may be potent modulators of inflammatory reactions.

Inhibition of histamine release from rat peritoneal mast cells by a factor from human serum--identification as transferrin

Recently, we described the presence of a blocking factor (BF) in rat serum which inhibited the histamine release from rat mast cells in vivo and in vitro. The blocking activity was demonstrated in human serum as well. Purification of the human-BF was carried out in a similar way as previously described for the rodent molecule. Both protein fractions produced a marked suppression of histamine release from rat mast cells and human basophils in a dose-dependent fashion. Qualitative analysis of the purified preparations demonstrated a major component with a molecular weight of 70,000 daltons. In human serum the blocking factor was identified as transferrin by serological and biochemical methods. It is suggested that this molecule may play an important role in regulating histamine release during allergic and inflammatory reactions.

Detection of proteins in wheat flour extracts that bind human IgG, IgE, and mouse monoclonal antibodies

Wheat flour was extracted with phosphate-buffered saline. The biologic significance of the extracted cereal proteins was demonstrated. Basophil leukocytes were obtained from patients suffering from "baker's asthma disease." Histamine release in vitro was induced by addition of the aqueous flour extract. By means of ELISA, as well as immunoblotting technique, IgG and IgE binding to wheat flour proteins was demonstrated. Wheat-specific antibodies could be detected in sera obtained from healthy and atopic individuals. Further analysis of the cereal components by monoclonal antibodies revealed that several wheat molecules exhibit identical epitopes.

Effect of thiol-activated toxins (streptolysin O, alveolysin, and theta toxin) on the generation of leukotrienes and leukotriene-inducing and -metabolizing enzymes from human polymorphonuclear granulocytes

The generation of leukotrienes (LTC4, LTD4, LTE4, and LTB4; 12-epi-LTB4 isomer) from human granulocytes by thiol-activated toxins (streptolysin O, alveolysin from Bacillus alvei, and theta toxin from Clostridium perfringens) is described. The release occurs under noncytolytic conditions. Although LTB4 is the major component after calcium ionophore stimulation, more LTC4 as compared with LTB4 is released with the toxins. The 5-lipoxygenase pathway of toxin-mediated activation can effectively be inhibited by caffeic acid, a lipoxygenase inhibitor. The toxins also induce the release of leukotriene-metabolizing enzymes such as gamma-glutamyltranspeptidase, which transfers LTC4 into LTD4, and dipeptidase, which metabolizes LTD4, into LTE4. Dipeptidase activity is more pronounced than the gamma-glutamyltranspeptidase activity but still does not reach the levels obtained when cells were triggered with opsonized zymosan.

Regulation of IgE antibody synthesis

It is well established that IgE-antibodies against allergens are involved in allergic diseases. Thus, the regulation of IgE antibody synthesis appears to be a fundamental approach to its treatment. The mechanisms of the IgE-antibody response are somehow different from IgG production. It appears that the immunocompetent cells involved are distinct and exert a different susceptibility with regard to IgE- and IgG antibody production. A more precise under-standing of the cellular processes involved in IgE-antibody production will lead to novel immunotherapeutic approaches of allergic disease processes.

[Cell biology basis of IgE antibody regulation. Immunotherapeutic approaches]

Recent developments as to the IgE-antibody synthesis in rodents and in the human model are summarized and discussed in reference to our own data. It is by now established that the IgE-antibody response is regulated by interdependent interactions of cellular, humoral and genetic factors. The IgE-bearing B-lymphocyte develops from a surface IgM carrying B-lymphocyte. The transformation into an IgE secreting plasma cell requires T-cell help or soluble T-cell factors. Recent advances in the characterization of human lymphocytes as well as more sophisticated cell biological approaches facilitated the analysis of IgE-antibody synthesis in the human in vitro model. In most of the studies at present available the effect of the polyclonal B-cell mitogen (PWM) was analyzed. PWM either enhanced, suppressed or unlike to other Ig-classes did not affect the IgE-antibody synthesis at all. Immunotherapeutic approaches have to consider to establish the allergen induced in vitro model of IgE-antibody synthesis in humans, to modulate the interactions of T-helper and/or suppressor cells or to generate soluble suppressor factors. In any case the analysis of the IgE-antibody synthesis in humans could be a valuable tool to assess IgE-B-cell memory towards various allergens and to determine the IgE-mediated in patients.

[Biochemical aspects of the pathogenesis of the asthma syndrome]

The induction of asthma is more easily understood by the increasing knowledge of intercellular interactions. It is obvious that a major role for the initiation of extrinsic and mixed form asthma is attributed to IgE-immunoglobulin, which after interaction with the appropriate antigen leads to the release of preformed and newly generated mediators (e.g. leukotriene with chemotactic and spasmogenic [SRS] properties) from mast cells and basophils. The latter mediators are also released from polymorphonuclear neutrophils and macrophages in the course of bacterial adherence, phagocytosis, by bacterial toxins, and via anaphylatoxin dependent mechanisms. It appears likely that the induction of intrinsic asthma might be triggered by these mediators also during viral adsorption and penetration. The interdependency of cellular reactions might be responsible for the complexity of the disease process in asthma.

Characterization of a factor from rat serum with blocking activity in the passive cutaneous anaphylactic reaction

A blocking factor (BF) was obtained from normal and rat reaginic serum which inhibited the passive cutaneous anaphylactic (PCA) reaction of mouse and rat IgE in rat skin. Several chromatographic procedures on DEAE- and CM-cellulose at various pH values were compared in an attempt to obtain BF with high activity. BF-containing fractions after DEAE chromatography at pH 5,4 revealed two components on SDS-polyacrylamide gel: one at 50,000-60,000 and the other at 65,000-70,000 daltons. The latter component was also obtained when normal or rat reaginic serum was adsorbed on Sepharose anti rat IgG. The eluate inhibited the PCA reaction and demonstrated two bands on SDS-polyacrylamide gel, one at 150,000 (IgG) and another at 65,000-70,000 daltons. Purified IgG and rat albumin did not inhibit the PCA reaction. Antisera against BF were obtained with the component at 65,000-70,000 daltons. Anti-BF revealed a specificity for two bands in the cathodal position when assayed against normal rat serum; one of which was IgG. Anti-BF recognized one component in the DEAE fraction when analyzed against the DEAE fraction which contained blocking activity. BF is immunologically distinct from IgG. After immunoadsorption of normal or rat reaginic serum on Sepharose anti-BF columns, an eluate was obtained which showed blocking activity in the PCA reaction and two components on SDS-polyacrylamide gel, one at 150,000 and the other at 65,000-70,000 daltons. Evaluation of blocking factor by isoelectric focussing obtained after various procedures revealed an isoelectric point of 4.7. BF shows dual functions: it inhibits and at high dilutions also enhances the PCA reaction. It is suggested that this factor has a modulatory role in the allergic disease process.