Inborn errors of immunity in adulthood

Inborn errors of immunity (IEIs) are a group of conditions whereby parts of the immune system are missing or dysfunctional. Once thought to primarily be a pediatric disorder, it is now estimated that more than 50% of worldwide incident IEI cases are accounted for by adults. Delayed diagnosis, late symptom onset, and IEI phenocopies can all lead to adult-onset recognition of IEIs. Lack of awareness regarding the diversity of IEI manifestations in adults contributes to diagnostic and treatment delays. Prompt referral to immunology is critical so that patients can receive a precise molecular diagnosis and targeted therapy when available. This article serves as a primer on IEIs in adulthood, highlighting the pathophysiology, epidemiology and clinical features. We present clinical vignettes of three key IEIs to assist clinicians in building illness scripts on their presentations. We provide a framework for the laboratory evaluation of IEIs and their initial treatment, with the aim of improving recognition and management of these conditions.

Recognition of gasoline in fire debris using machine learning: Part II, application of a neural network

The recognition of ignitable liquid (IL) residues in fire debris is a resource intensive but key part of an arson investigation. Due to the highly diverse and heavily loaded chemical matrix of fire debris samples, combined with the broad chemical composition of IL, the interpretation of the laboratory analysis results is a very challenging task for the forensic examiner. Fire debris samples are commonly analyzed using gas chromatography coupled to mass spectrometry (GC-MS). This method delivers both the total ion chromatogram (TIC) with the individually separated compounds and the underlying mass spectrum of each of the separated compounds. In this study, a completely new approach for the recognition of gasoline in fire debris samples is presented. First, the GC-MS data, including retention time, signal intensity, and mass spectrum is converted into a bitmap image. Five different data-to-image conversion approaches are tested, and their advantages and limitations are discussed. Subsequently, a convolutional neural network (CNN) is utilized to allocate the generated images to the classes "with gasoline" or "without gasoline". The applied approaches to generate a digital image and the pattern recognition of the CNN perform very well in the classification of unknown test samples. Depending on the data-to-image generation approach used, the rate of correct sample classification in the test dataset is between 95% and 98%. The machine learning approach in this study, as well as the complementary method presented in an accompanying article, are not only useful for the recognition of gasoline in fire debris but are equally applicable to any additional areas in which the interpretation of complex chromatographic and mass spectrometric is required.

Recognition of gasoline in fire debris using machine learning: Part I, application of random forest, gradient boosting, support vector machine, and naïve bayes

The detection and identification of ignitable liquid (IL) residues in fire debris are two very challenging tasks in a fire investigation. To this day, the recognition of IL in fire debris includes the chemical analysis of the fire debris composition, followed by the examination and interpretation of the analysis result by a trained forensic examiner. Throughout the last decade, chemometrics and artificial intelligence have become increasingly important. In the present study, machine learning algorithms capable of recognizing gasoline residues in fire debris based on GC-MS data have been developed. Four methods, including random forest, gradient boosting, support vector machine, and naïve bayes are applied and used to classify fire debris samples into the two categories "with gasoline" or "without gasoline". A fifth method (logistic regression) did not converge due to well separated classes. A database comprising 360 measurements, including fire debris samples of real cases as well as fire debris samples spiked with known amounts of weathered gasoline (up to 99.6%), was available to train the machine learning algorithms (using 85% of the data) and to subsequently test the performance of the methods when classifying unknown samples (using 15% of the data). In general, the methods perform very well, as three of it succeeded to classify all test samples correctly without any false positive or false negative allocations. One (naïve bayes) was not trained enough to classify other (non-gasoline) IL correctly as "no gasoline". Furthermore, the random forest method reveals which chemical compounds are most relevant for the algorithm to classify the samples. In general, the presented approach is highly promising and could easily be extended or adapted to other types of IL. Similar to the neural network presented in the accompanying paper, such methods have the potential to serve as a fast screening technique for fire debris samples, thus supporting the forensic examiner by providing an additional independent opinion. Nonetheless, the definite identification of IL residues in fire debris always has to be accomplished by a forensic examiner.

Serum IgG Levels and Risk of COPD Hospitalization: A Pooled Meta-analysis

BACKGROUND

Hypogammaglobulinemia (serum IgG levels < 7.0 g/L) has been associated with increased risk of COPD exacerbations but has not yet been shown to predict hospitalizations.

RESEARCH QUESTION

To determine the relationship between hypogammaglobulinemia and the risk of hospitalization in patients with COPD.

STUDY DESIGN AND METHODS

Serum IgG levels were measured on baseline samples from four COPD cohorts (n = 2,259): Azithromycin for Prevention of AECOPD (MACRO, n = 976); Simvastatin in the Prevention of AECOPD (STATCOPE, n = 653), Long-Term Oxygen Treatment Trial (LOTT, n = 354), and COPD Activity: Serotonin Transporter, Cytokines and Depression (CASCADE, n = 276). IgG levels were determined by immunonephelometry (MACRO; STATCOPE) or mass spectrometry (LOTT; CASCADE). The effect of hypogammaglobulinemia on COPD hospitalization risk was evaluated using cumulative incidence functions for this outcome and deaths (competing risk). Fine-Gray models were performed to obtain adjusted subdistribution hazard ratios (SHR) related to IgG levels for each study and then combined using a meta-analysis. Rates of COPD hospitalizations per person-year were compared according to IgG status.

RESULTS

The overall frequency of hypogammaglobulinemia was 28.4%. Higher incidence estimates of COPD hospitalizations were observed among participants with low IgG levels compared with those with normal levels (Gray's test, P < .001); pooled SHR (meta-analysis) was 1.29 (95% CI, 1.06-1.56, P = .01). Among patients with prior COPD admissions (n = 757), the pooled SHR increased to 1.58 (95% CI, 1.20-2.07, P < .01). The risk of COPD admissions, however, was similar between IgG groups in patients with no prior hospitalizations: pooled SHR = 1.15 (95% CI, 0.86-1.52, P =.34). The hypogammaglobulinemia group also showed significantly higher rates of COPD hospitalizations per person-year: 0.48 ± 2.01 vs 0.29 ± 0.83, P < .001.

INTERPRETATION

Hypogammaglobulinemia is associated with a higher risk of COPD hospital admissions.

Clinical Experience with Octagam® 10 %, a solvent detergent virus inactivated intravenous immunoglobulin: a Canadian retrospective review of utilization

In Canada, intravenous immune globulin (IVIg) products are licensed for six disease indications, however it has been demonstrated that patients with a number of other conditions also benefit from IVIg. Here we report the routine clinical use of Octagam^® 10 % across three Canadian institutions. A total of 135 patients were treated with Octagam^®, for conditions represented by five distinct indication groups. The results of this review indicate that Octagam^® has been well adopted and is prescribed to Canadian patients similar to other IVIg products. In alignment with current practices, 85 % of Octagam’s utilization was classified as appropriate based on Canadian IVIg guidelines.

Proceedings of the Canadian society of allergy and clinical immunology annual scientific meeting 2015

A1 Role of fibrocytes in allergic rhinitis

Marie-Ève Côté, Marie-Ève Boulay, Sophie Plante, Jamila Chakir, Louis-Philippe Boulet

A2 Patterns of aeroallergens sensitization in Northern Alberta

Hanan Ahmed, Maria-Beatriz Ospina, Kyriaki Sideri, Harissios Vliagoftis

A3 Addressing acceptable risk for adolescents with Food-Induced Anaphylaxis (FIA)

Sara F. Johnson, Roberta L. Woodgate

A4 Outcomes of matched related and unrelated bone marrow transplantation after reduced-toxicity conditioning for children suffering from Chronic Granulomatous Disease

Guilhem Cros, Pierre Teira, Sonia Cellot, Henrique Bittencourt, Helene Decaluwe, Marie France Vachon, Michel Duval, Elie Haddad

A5 Outcomes of patients with severe combined immunodeficiency (SCID) prior to and after initiation of newborn screening for SCID in Ontario

Vy H.D. Kim, Anne Pham-Huy, Eyal Grunebaum

A6 Detection of regulatory B cells in the airways of subjects with asthma

John-Paul Oliveria, Stephanie Phan, Mark W. Tenn, Damian Tworek, Steven G. Smith, Adrian J. Baatjes, Caitlin D. Obminski, Caroline E. Munoz, Tara X. Scime, Roma Sehmi, Gail M Gauvreau

A7 Characterization of IgE-expressing B cells in the airways and peripheral blood of allergic asthmatic subjects

John-Paul Oliveria, Stephanie Phan, Mark W. Tenn, Brittany M Salter, Steven G Smith, Caitlin D Obminski, Caroline E Munoz, Abbey Schlatman, Tara X Scime, Rick Watson, Roma Sehmi, Gail M Gauvreau

A8 Pregnancy: could it be a risk factor for primary immunodeficient patients

Roya Sherkat, Razieh Khoshnevisan, Saba Sheikhbahaei

A9 Clinical experience with Octagam: a Canadian retrospective chart review

Stephen Betschel, Richard Warrington, Robert Schellenberg

A10 Kounis syndrome secondary to contrast media with inferior ST elevations and bilateral ischemic stroke

Michael N Fein, Jean-Philippe Pelletier

A11 Honey bee venom immunotherapy ineffective in bumble bee-induced anaphylaxis: case report and review of literature

Manstein Kan, Robert Schellenberg

A12 Delayed immune reconstitution occurring after multiple immune complications of hematological stem cell transplantation for a leaky SCID

Roxane Labrosse, Guilhem Cros, Pierre Teira, Henrique Bittencourt, Helene Decaluwe, Michel Duval, Elie Haddad

A13 Comparison of Three Case Reports of Acquired Angioedema: presentation, management and outcome

Raymond Mak, James Loh, Amin Kanani

A14 Sitagliptin-associated angioedema not related to concurrent use of ARB or ACE inhibitor

Dominik A. Nowak, Paul K. Keith

A15 Sneddon-Wilkinson subcorneal pustular dermatosis associated with an IgA monoclonal gammopathy

Daniel Pannozzo, Dominik A. Nowak, Hermenio C. Lima

A16 Omalizumab can be effective in patients with allergic bronchopulmonary aspergillosis

Diana Pham, Hoang Pham, Gonzalo G. Alvarez, Istvan T. Bencze, Krishna B. Sharma, Mark Smith, Shawn Aaron, Jennifer Block, Tara Keays, Judith Leech, David Schneidermen, Jodi Cameron, Jennifer Forgie, Alicia Ring, John W. O’Quinn, Stephanie Santucci, William H. Yang

A17 Efficacious use of omalizumab in the treatment of cystic fibrosis

Diana Pham, Hoang Pham, Ena Gaudet, Shawn Aaron, Stephanie Santucci, William H. Yang

A18 HAE with normal C1-INH with inconsistent response to C1 esterase inhibitor infusion but reliably responsive to icatibant

Hoang Pham, Stephanie Santucci, William H. Yang

A19 Anaphylaxis reaction to lactase enzyme

Mathew R. Voisin, Rozita Borici-Mazi

A20 Risk of solid tumor malignancies in patients with primary immune deficiency

Kateryna Vostretsova, Donald F. Stark

A21 Is it time to adopt the chromogenic assay for measuring C1 esterase inhibitor function in patients with HAE Type 2?

Elizabeth Yeboah, Paul K. Keith

A22 Emergency department visits for anaphylaxis and allergic reactions

Michelle Martin-Rhee, Cheryl Gula, Clare Cheng, Geoff Paltser

A23 START: Susceptibility To food Allergies in a Registry of Twins

Alizée Dery, Ann Clarke, Kari Nadeau, Laurie Harada, Kimberley Weatherall, Celia Greenwood, Denise Daley, Yuka Asai, Moshe Ben-Shoshan

A24 Qualifying the diagnostic approach employed by allergists when managing patients with self-diagnosed non-celiac gluten sensitivity (NCGS)

Lee Horgan, Teresa Pun

A25 Retrospective analysis on the agreement between skin prick test and serum food specific IgE antibody in adults with suspected food allergy

Ling Ling, Maria B. Ospina, Kyriaki Sideri, Harissios Vliagoftis

A26 Staple food hypersensitivity from infancy to adolescence: a report from the BAMSE cohort

Jennifer L.P. Protudjer, Mirja Vetander, Marianne van Hage, Ola Olén, Magnus Wickman, Anna Bergström

A27 Evaluating the impact of supervised epinephrine autoinjector administration during food challenges on perceived parent confidence

Timothy Teoh, Christopher Mill, Tiffany Wong, Ingrid Baerg, Angela Alexander, Kyla J. Hildebrand, John Dean, Boris Kuzeljevic, Edmond S. Chan

A28 Local immunoglobulin production to Aspergillus fumigatus cystic fibrosis

Jonathan Argeny, Mia Gona-Hoepler, Petra Fucik, Edith Nachbaur, Saskia Gruber, Reto Crameri, Andreas Glaser, Zsolt Szépfalusi, Claudio Rhyner, Thomas Eiwegger

A29 Extract consumption with skin prick test (SPT) devices

Greg. Plunkett, Brad Mire

A30 Evaluation of our cases with nonsteroidal anti-inflammatory drug reactions

Mehtap Yazicioglu, Ceren Can, Gokce Ciplak

A31 Reasons for referral and final diagnoses in a tertiary care pediatric allergy clinic

Victoria E. Cook, Kyla J. Hildebrand, Elodie Portales-Casamar, Christopher Mill, Edmond S. Chan

A32 Internist referral practices for inpatients with self-reported penicillin allergies at a tertiary care teaching hospital

Michael N Fein, Emil P Nashi

A33 Assessing the risk of reactions in children with a negative oral challenge after a subsequent use of amoxicillin

Sofianne Gabrielli, Christopher Mill, Marie-Noel Primeau, Christine Lejtenyi, Elena Netchiporouk, Alizee Dery, Greg Shand, Moshe Ben-Shoshan

A34 Validity of self-reported penicillin allergies

Erica Hoe, Joel Liem

A35 Effectiveness of allergy-test directed elimination diets in eosinophilic esophagitis

Jason K. Ko, David J.T. Huang, Jorge A. Mazza

A36 Allergy testing and dietary management in pediatric eosinophilic esophagitis (EoE): A retrospective review of a tertiary Canadian centre’s experience

Mary McHenry, Anthony Otley,Wade Watson

A37 Visualizing the impact of atopic and allergic skin disease

Dominik A. Nowak, John N. Kraft

A38 Cystic fibrosis with and without nasal polyposis in pediatric patients: a cross-sectional comparative study

Mihaela Paina, Ahmed A. Darwish Hassan, Delia Heroux, Lynn Crawford, Gail Gauvreau, Judah Denburg, Linda Pedder, Paul K. Keith

A39 Evaluation of macrolide antibiotic hypersensitivity: the role of oral challenges in children

Bahar Torabi, Marie-Noel Primeau, Christine Lejtenyi, Elaine Medoff, Jennifer Mill, Moshe Ben-Shoshan

A40 Venom allergy testing: is a graded approach necessary?

Jaclyn A. Quirt, Xia Wen, Jonathan Kim, Angel Jimenez Herrero, Harold L. Kim

A41 The role of oral challenges in evaluating cephalosporin hypersensitivity reactions in children

Magdalena J. Grzyb, Marie-Noël Primeau, Christine Lejtenyi, Elaine Medoff, Jennifer Mill, Moshe Ben-Shoshan

A42 Breastfeeding and infant wheeze, atopy and atopic dermatitis: findings from the Canadian Healthy Infant Longitudinal Development Study

Meghan B. Azad, Zihang Lu, Allan B. Becker, Padmaja Subbarao, Piushkumar J. Mandhane, Stuart E. Turvey, Malcolm R. Sears, the CHILD Study Investigators

A43 IL33 DNA methylation in bronchial epithelial cells is associated to asthma

Anne-Marie Boucher-Lafleur, Valérie Gagné-Ouellet, Éric Jacques, Sophie Plante, Jamila Chakir, Catherine Laprise

A44 NRF2 mediates the antioxidant response to organic dust-induced oxidative stress in bronchial epithelial cells

Michael Chen, Toby McGovern, Mikael Adner, James G. Martin

A45 The effects of perinatal distress, immune biomarkers and mother-infant interaction quality on childhood atopic dermatitis (rash) at 18 months

Nela Cosic, Henry Ntanda, Gerald Giesbrecht, Anita Kozyrskyj, Nicole Letourneau

A46 Examining the immunological mechanisms associated with cow’s milk allergy

Bassel Dawod, Jean Marshall

A47 Tryptase levels in children presenting with anaphylaxis to the Montréal Children’s Hospital

Sarah De Schryver, Michelle Halbrich, Ann Clarke, Sebastian La Vieille, Harley Eisman, Reza Alizadehfar, Lawrence Joseph, Judy Morris, Moshe Ben-Shoshan

A48 Secondhand tobacco smoke exposure in infancy and the development of food hypersensitivity from childhood to adolescence

Laura Y. Feldman, Jesse D. Thacher, Inger Kull, Erik Melén, Göran Pershagen, Magnus Wickman, Jennifer L. P. Protudjer, Anna Bergström

A49 Combined exposure to diesel exhaust and allergen enhances allergic inflammation in the bronchial submucosa of atopic subjects

Ali Hosseini, Tillie L. Hackett, Jeremy Hirota, Kelly McNagny, Susan Wilson, Chris Carlsten

A50 Comparison of skin-prick test measurements by an automated system against the manual method

Saiful Huq, Rishma Chooniedass, Brenda Gerwing, Henry Huang, Diana Lefebvre, Allan Becker

A51 The accurate identification and quantification of urinary biomarkers of asthma and COPD through the use of novel DIL- LC-MS/MS methods

Mona M. Khamis, Hanan Awad, Kevin Allen, Darryl J. Adamko, Anas El-Aneed

A52 Systemic immune pathways associated with the mechanism of Cat-Synthetic Peptide Immuno-Regulatory Epitopes, a novel immunotherapy, in whole blood of cat-allergic people

Young Woong Kim, Daniel R. Gliddon, Casey P. Shannon, Amrit Singh, Pascal L. C. Hickey, Anne K. Ellis, Helen Neighbour, Mark Larche, Scott J. Tebbutt

A53 Reducing the health disparities: online support for children with asthma and allergies from low-income families

Erika Ladouceur, Miriam Stewart, Josh Evans, Jeff Masuda, Nicole Letourneau, Teresa To, Malcolm King

A54 Epigenetic association of PSORS1C1 and asthma in the Saguenay-Lac-Saint-Jean asthma study

Miriam Larouche, Liming Liang, Catherine Laprise

A55 IL-33 induces cytokine and chemokine production in human mast cells

Stephanie A. Legere, Ian D. Haidl, Jean-Francois Legaré, Jean S. Marshall

A56 Reference ranges for lung clearance index from infancy to adolescence for Canadian population

Zihang Lu, Malcolm Sears, Theo J. Moraes, Felix Ratjen, Per Gustafsson, Wendy Lou, Padmaja Subbarao

A57 Kingston Allergy Birth Cohort: cohort profile and mother/child characteristics to age 2

Michelle L. North, Elizabeth Lee, Vanessa Omana, Jenny Thiele, Jeff Brook, Anne K. Ellis

A58 Cow’s milk protein specific IgE, IgA and IgG4 as a predictor of outcome in oral immunotherapy

Tanvir Rahman, Duncan Lejtenyi, Sarah De Schryver, Ryan Fiter, Ciriaco Piccirillo, Moshe Ben-Shoshan, Bruce Mazer

A59 Age of peanut introduction and development of reactions and sensitization to peanut

Elinor Simons, Allan B. Becker, Rishma Chooniedass, Kyla Hildebrand, Edmond S. Chan, Stuart Turvey, Padmaja Subbarao, Malcolm Sears

A60 Multi-omic blood biomarker signatures of the late phase asthmatic response

Amrit Singh, Casey P. Shannon, Young Woong Kim, Mari DeMarco, Kim-Anh Le Cao, Gail M. Gauvreau, J. Mark FitzGerald, Louis-Philippe Boulet, Paul M. O’Byrne, Scott J. Tebbutt

A61 Early life gut microbial alterations in children diagnosed with asthma by three years of age

Leah T. Stiemsma, Marie-Claire Arrieta, Jasmine Cheng, Pedro A. Dimitriu, Lisa Thorson, Sophie Yurist, Boris Kuzeljevic, Diana L. Lefebvre, Padmaja Subbarao, Piush Mandhane, Allan Becker, Malcolm R. Sears, Kelly M. McNagny, Tobias Kollmann, the CHILD Study Investigators, William W. Mohn, B. Brett Finlay, Stuart E. Turvey

A62 The relationship between food sensitization and atopic dermatitis at age 1 year in a Canadian birth cohort

Maxwell M. Tran, Diana L. Lefebvre, Chinthanie F. Ramasundarahettige, Allan B. Becker, Wei Hao Dai, Padmaja Subbarao, Piush J. Mandhane, Stuart E. Turvey, Malcolm R. Sears

A63 Allergen inhalation enhances Toll-like receptor-induced thymic stromal lymphopoietin receptor expression by hematopoietic progenitor cells in mild asthmatics

Damian Tworek, Delia Heroux, Seamus N. O’Byrne, Paul M. O’Byrne, Judah A. Denburg

A64 The Allergic Rhinitis Clinical Investigator Collaborative – replicated eosinophilia on repeated cumulative allergen challenges in nasal lavage samples

Laura Walsh, Mena Soliman, Jenny Thiele, Lisa M. Steacy, Daniel E. Adams, Anne K. Ellis

A65 The CHILD Study: optimizing subject retention in pediatric longitudinal cohort research

Linda Warner, Mary Ann Mauro, Robby Mamonluk, Stuart E. Turvey

A66 Differential expression of C3a and C5a in allergic asthma

ChenXi Yang, Amrit Singh, Casey P. Shannon, Young Woong Kim, Ed M. Conway, Scott J. Tebbutt

Economic benefits of subcutaneous rapid push versus intravenous immunoglobulin infusion therapy in adult patients with primary immune deficiency

Objective

The objective of this study is to evaluate the economic benefits of immunoglobulin replacement therapy achieved subcutaneously (subcutaneous immunoglobulin, SCIG) by the rapid push method compared to intravenous infusion therapy (intravenous immunoglobulin, IVIG) in primary immune deficiency (PID) patients from the healthcare system perspective in the context of the adult SCIG home infusion program based at St Paul's Hospital, Vancouver, Canada.

Materials and methods

SCIG and IVIG options were compared in cost-minimisation and budget impact models (BIMs) over 3 years. Sensitivity analyses were performed for both models to evaluate the impact of varying modality of IVIG treatments and proportion of patients switching from IVIG to SCIG.

Results

The cost-minimisation model estimated that SCIG treatment reduced cost to the healthcare system per patient of $5736 over 3 years, principally because of less use of hospital personnel. This figure varied between $5035 and $8739 depending on modality of IVIG therapy. Assuming 50% of patients receiving IVIG switched to SCIG, the BIM estimated cost savings for the first 3 years at $1·308 million or 37% of the personnel and supply budget. These figures varied between $1·148 million and $2·454 million (36 and 42%) with varying modalities of IVIG therapy. If 75% of patients switched to SCIG, the reduced costs reached $1·962 million or 56% of total budget.

Conclusion

This study demonstrated that from the health system perspective, rapid push home-based SCIG was less costly than hospital-based IVIG for immunoglobulin replacement therapy in adult PID patients in the Canadian context.

Urticaria and angioedema

Urticaria (hives) is a common disorder that often presents with angioedema (swelling that occurs beneath the skin). It is generally classified as acute, chronic or physical. Second-generation, non-sedating H1-receptor antihistamines represent the mainstay of therapy for both acute and chronic urticaria. Angioedema can occur in the absence of urticaria, with angiotensin-converting enzyme (ACE) inhibitor-induced angioedema and idiopathic angioedema being the more common causes. Rarer causes are hereditary angioedema (HAE) or acquired angioedema (AAE). Although the angioedema associated with these disorders is often self-limited, laryngeal involvement can lead to fatal asphyxiation in some cases. The management of HAE and AAE involves both prophylactic strategies to prevent attacks of angioedema (i.e., trigger avoidance, attenuated androgens, tranexamic acid, and plasma-derived C1 inhibitor replacement therapy) as well as pharmacological interventions for the treatment of acute attacks (i.e., C1 inhibitor replacement therapy, ecallantide and icatibant). In this article, the authors review the causes, diagnosis and management of urticaria (with or without angioedema) as well as the work-up and management of isolated angioedema, which vary considerably from that of angioedema that occurs in the presence of urticaria.

2010 International consensus algorithm for the diagnosis, therapy and management of hereditary angioedema

BACKGROUND

We published the Canadian 2003 International Consensus Algorithm for the Diagnosis, Therapy, and Management of Hereditary Angioedema (HAE; C1 inhibitor [C1-INH] deficiency) and updated this as Hereditary angioedema: a current state-of-the-art review: Canadian Hungarian 2007 International Consensus Algorithm for the Diagnosis, Therapy, and Management of Hereditary Angioedema.

OBJECTIVE

To update the International Consensus Algorithm for the Diagnosis, Therapy and Management of Hereditary Angioedema (circa 2010).

METHODS

The Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH) http://www.haecanada.com and cosponsors University of Calgary and the Canadian Society of Allergy and Clinical Immunology (with an unrestricted educational grant from CSL Behring) held our third Conference May 15th to 16th, 2010 in Toronto Canada to update our consensus approach. The Consensus document was reviewed at the meeting and then circulated for review.

RESULTS

This manuscript is the 2010 International Consensus Algorithm for the Diagnosis, Therapy and Management of Hereditary Angioedema that resulted from that conference.

CONCLUSIONS

Consensus approach is only an interim guide to a complex disorder such as HAE and should be replaced as soon as possible with large phase III and IV clinical trials, meta analyses, and using data base registry validation of approaches including quality of life and cost benefit analyses, followed by large head-to-head clinical trials and then evidence-based guidelines and standards for HAE disease management.

Hereditary angiodema: a current state-of-the-art review, VII: Canadian Hungarian 2007 International Consensus Algorithm for the Diagnosis, Therapy, and Management of Hereditary Angioedema

BACKGROUND

We published the Canadian 2003 International Consensus Algorithm for the Diagnosis, Therapy, and Management of Hereditary Angioedema (HAE; C1 inhibitor [C1-INH] deficiency) in 2004.

OBJECTIVE

To ensure that this consensus remains current.

METHODS

In collaboration with the Canadian Network of Rare Blood Disorder Organizations, we held the second Canadian Consensus discussion with our international colleagues in Toronto, Ontario, on February 3, 2006, and reviewed its content at the Fifth C1 Inhibitor Deficiency Workshop in Budapest on June 2, 2007. Papers were presented by international investigators, and this consensus algorithm approach resulted.

RESULTS

This consensus algorithm outlines the approach recommended for the diagnosis, therapy, and management of HAE, which was agreed on by the authors of this report. This document is only a consensus algorithm approach and continues to require validation. As such, participants agreed to make this a living 2007 algorithm, a work in progress, and to review its content at future international HAE meetings.

CONCLUSIONS

There is a paucity of double-blind, placebo-controlled trials on the treatment of HAE, making levels of evidence to support the algorithm less than optimal. Controlled trials currently under way will provide further insight into the management of HAE. As with our Canadian 2003 Consensus, this 2007 International Consensus Algorithm for the Diagnosis, Therapy, and Management of HAE was formed through the meeting and agreement of patient care professionals along with patient group representatives and individual patients.

Primary immune deficiencies presenting in adults: seven years of experience from Iran

Primary immunodeficiencies (PIDs) are not solely diseases of childhood. We describe the clinical presentation and outcome for 55 adult patients with previously unrecognized PIDs. This series provides unique data regarding PIDs presenting in adulthood, and serves as a timely reminder that physicians must consider the diagnosis of PIDs in their adult patients. Using the experience gained from these patients, we outline key "warning signs" suggestive of an underlying PID. Only through increased physician awareness will patients with PIDs receive timely diagnosis and optimal management.

Hereditary Angioedema Managed with Low-Dose Danazol and C1 Esterase Inhibitor Concentrate: A Case Report

BACKGROUND

Hereditary angioedema (HAE) is a rare life-threatening disease that can occur in pregnancy.

CASE

A nulliparous woman was diagnosed as having HAE at 22 weeks of gestation after a series of symptomatic episodes. Following an initial course of C1 esterase inhibitor (C1EI) therapy for an acute episode of HAE, she was treated with danazol for prophylaxis. Danazol did not prevent recurrence of symptoms, its use was discontinued after six weeks. Thereafter, the patient was treated exclusively with C1EI at weekly intervals for exacerbations of her HAE. At 37 weeks' gestation, she delivered healthy 3050 g female neonate. At the time of discharge the female neonate had no signs of virilization or congenital anomalies.

CONCLUSION

Low dose danazol was ineffective in treating this woman's HAE in pregnancy. The use of C1EI in pregnancy is associated with good outcomes.

A randomized phase IIb trial of pulmicort turbuhaler (budesonide) in people with dysplasia of the bronchial epithelium

PURPOSE

Preclinical studies suggest that inhaled budesonide may be an effective chemopreventive agent for lung cancer. We conducted a phase IIb study to determine the effects of inhaled budesonide in smokers with bronchial dysplasia.

EXPERIMENTAL DESIGN

A total of 112 smokers with more than or equal to one site of bronchial dysplasia > 1.2 mm in size identified by autofluorescence bronchoscopy-directed biopsy was randomly assigned to receive placebo or budesonide (Pulmicort Turbuhaler) 800 microg twice daily inhalation for 6 months. The primary end point was change in the histopathologic grade on repeat biopsy of the same sites at the end of 6 months.

RESULTS

There were no significant differences in the regression or progression rates of bronchial dysplasia between the two groups. There was a statistically significant but modest decrease in p53 and BclII expression in the bronchial biopsies after 6 months of Pulmicort Turbuhaler versus placebo (P = 0.01 and P = 0.001, respectively). There was a small but statistically significant decrease in the proportion of computed tomography-detected lung nodules after Pulmicort Turbuhaler compared with placebo (P = 0.024).

CONCLUSIONS

Our results suggest that in smokers, inhaled budesonide in the dose of 1600 microg daily for 6 months had no effect in regression of bronchial dysplastic lesions or prevention of new lesions. Budesonide treatment resulted in a modest decrease in p53 and BclII protein expression in bronchial biopsies and a slightly higher rate of resolution of computed tomography-detected lung nodules. Whether budesonide truly has an effect in preneoplastic lesions in the peripheral airways and alveoli requires additional investigation.

Early treatment of a migraine attack while pain is still mild increases the efficacy of sumatriptan

To investigate the hypothesis that early treatment of a migraine attack with sumatriptan, while pain is still mild, results in higher pain free rates in comparison to delayed treatment, when pain is at least moderate, we performed a prospective, controlled and open label study. Migraineurs with or without aura who fulfilled the diagnostic criteria recommended by the International Headache Society were enrolled in the study and randomly assigned to either 'early' or 'late' treatment with sumatriptan 100 mg tablets. In the early treatment group significantly more patients were pain free at all times measured during two hours after dosing than in the late treatment group. Furthermore, patients in the early treatment group became pain free significantly sooner after dosing than patients who delayed treatment. It is concluded that migraineurs, who are able to differentiate between a migraine attack and other forms of headache, benefit from early intervention with sumatriptan 100 mg tablets.

The fixed combination of valerian and hops (Ze91019) acts via a central adenosine mechanism

The aim of the study was to demonstrate competition between caffeine and a fixed valerian/hop extract combination (Ze91019) by the central adenosine mechanism. EEG was used to describe the action of caffeine on the central nervous system after oral administration (200 mg) in healthy volunteers. In addition to caffeine, the volunteers (16 in each group) received either placebo or verum (2 and 6 tablets containing the valerian/hop extract). The EEG responses were recorded every 30 min thereafter. The verum medication was capable of reducing (2 tablets) or inhibiting (6 tablets) the arousal induced by caffeine. This pharmacodynamic action was observed 60 minutes after oral administration, indicating not only competition between the antagonist caffeine and the partial agonist, i. e., the valerian/hop extract but also bio-availability of the compound(s) responsible for the agonistic action. In conclusion, the valerian/hop extract acts via a central adenosine mechanism which is possibly the reason for its sleep-inducing and -maintaining activity.

Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomised, placebo controlled study

OBJECTIVES

To compare the efficacy and tolerability of agnus castus fruit (Vitex agnus castus L extract Ze 440) with placebo for women with the premenstrual syndrome.

DESIGN

Randomised, double blind, placebo controlled, parallel group comparison over three menstrual cycles.

SETTING

General medicine community clinics.

PARTICIPANTS

178 women were screened and 170 were evaluated (active 86; placebo 84). Mean age was 36 years, mean cycle length was 28 days, mean duration of menses was 4.5 days.

INTERVENTIONS

Agnus castus (dry extract tablets) one tablet daily or matching placebo, given for three consecutive cycles.

MAIN OUTCOME MEASURES

Main efficacy variable: change from baseline to end point (end of third cycle) in women's self assessment of irritability, mood alteration, anger, headache, breast fullness, and other menstrual symptoms including bloating. Secondary efficacy variables: changes in clinical global impression (severity of condition, global improvement, and risk or benefit) and responder rate (50% reduction in symptoms).

RESULTS

Improvement in the main variable was greater in the active group compared with placebo group (P<0.001). Analysis of the secondary variables showed significant (P<0.001) superiority of active treatment in each of the three global impression items. Responder rates were 52% and 24% for active and placebo, respectively. Seven women reported mild adverse events (four active; three placebo), none of which caused discontinuation of treatment.

CONCLUSIONS

Dry extract of agnus castus fruit is an effective and well tolerated treatment for the relief of symptoms of the premenstrual syndrome.

Effect of the external nasal dilator Breathe Right on snoring

This clinical trial was designed to evaluate the efficacy of the external nasal dilator Breathe Right (nasal strip) on snoring. The assessment of snoring intensity and duration as well as the sleep quality without the Breathe Right nasal strip and after application was performed in 30 out-patients with primary habitual snoring. An all-night polysomnographic investigation including registration of a17-channel EEG, EMG, respiration parameters such as breathing efforts and nasal/oral air flow, snoring vibrations, ECG, oxygen saturation, etc. was conducted in the sleep laboratory of Pro Science Private Research Clinic GmbH. The drug-free strip Breathe Right was able to reduce the maximum snoring intensity (maximum snoring vibration) throughout the night (p = 0.02, sign test), especially during the superficial sleep (sleep stage 1 and 2). The snoring intensity remained almost unchanged during slow wave sleep (SWS) and REM. In comparison with the baseline the maximum snoring intensity was reduced during the second treatment night in 22 of the 30 investigated snorers. The differentiation between snorers with and without obstructive sleep apnea and between mild and heavy snorers allowed to state that especially the snorers without apnea and the time in bed, TIB) can achieve a reduction of the maximum snoring intensity using the strip. Moreover, the number of snores per hour TIB (snoring index, SI) was reduced after application of the nasal strip for the snores with an intensity greater than 20 dB (p = 0.02, sign test). The sleep architecture remained almost unchanged, although the nasal strip led subjectively (SF-A questionnaire) to an improvement of sleep quality. The overall estimation of the subjective efficacy rating revealed that 17 of 30 patients (second treatment night) needed a certain period of time to accustom to the nasal strip. After that they could breathe easily, slept well and felt recuperated in the following morning. No adverse events were observed after adhesion of the nasal strip, except for one patient, who had the sensation as if they needed to sneeze for a short time after the first application of the nasal strip. Consequently, Breathe Right is a safe and easily applied noninvasive method to reduce the maximum snoring intensity, especially in habitual mild snorers.

Pharmacodynamic effects of two different hypericum extracts in healthy volunteers measured by quantitative EEG

A double-blind, randomized, placebo-controlled parallel-group trial (phase I) was performed to evaluate the central pharmacodynamic effects of two hypericum extracts with different contents of hyperforin (0.5% and 5.0%) but identical hypericin content. Three groups of 18 volunteers between 18 and 35 years of age participated in the trial. The volunteers receiving verum took 900 mg of the extract once a day for 8 consecutive days. The primary aim of this study was to observe the frequency bands, i.e., delta (1.25-4.5 Hz), theta (4.75-6.75 Hz), alpha-1 (7.0-9.5 Hz), alpha-2 (9.75-12.5 Hz), beta-1 (12.75-18.5 Hz), and beta-2 (18.75-35 Hz). This was the first study of its kind testing hypericum controlled on the basis of its hyperforin contents. A quantitative topographic EEG (qEEG) was performed on days 1 and 8 as an indicator of drug-induced pharmacological action. The volunteers' electrophysiological data were obtained prior to application and 2, 4, 6, 8, and 10 hours post administration. Plasma samples for evaluation of the pharmacokinetics of hyperforin were also obtained. The qEEG results of the placebo group on days 1 and 8 showed no significant changes with regard to their physiological daily rhythm. In both verum groups (0.5% and 5.0% hyperforin content), reproducible central pharmacodynamic effects were apparent in comparison to placebo, in particular with the extract containing 5.0% of hyperforin. A peak pharmacodynamic efficacy was observed between 4 and 8 hours post administration. These results were confirmed on day 8 of the trial. The extract containing 5.0% hyperforin showed a marked tendency to produce higher increases in qEEG baseline power performances than the one containing 0.5% hyperforin. These higher baseline outputs on day 8 were seen at the delta, theta, and alpha-1 frequency values. Compared to placebo there was a significant increase in qEEG power performance in the delta and beta-1 frequency values exclusively for the extract containing 5.0% hyperforin. The theta and alpha-1 frequency values showed a noticeable tendency more emphasized on day 8 than on day 1. Preclinical trials in rats have been observed with similar changes in the frequency bands mentioned above, especially in the cholinergic (delta), noradrenergic (theta) and serotonergic (alpha) neurotransmitter systems. These experimental findings suggest that hypericum extracts with a high hyperforin content have a shielding effect on the central nervous system.

Functional imaging of headache - first steps in an objective quantitative classification of migraine

A highly sensitive quantitative-topographical EEG was used in order to define first steps in an objective classification of migraine. A 17-channel quantitative EEG was recorded in 30 patients suffering from migraine with or without aura during the painfree interval. These EEG s were compared to EEGs of age related healthy norm groups using a new statistical tool called the Aberration Index. A focal aberration in the area of pain was detected in 26 out of the 30 patients mostly due to an increase of alpha1 EEG power (23 patients). Alpha2 or theta power were also increased in several patients. Furthermore, a decrease in alpha power neighbouring the focus was found in 18 patients and a contralateral reduction of alpha power was seen in 16 patients. No difference was detected between migraine with aura and migraine without aura.

Pathophysiology and psychopharmacology of dementia--a new study design. 2. Cyclandelate treatment--a placebo-controlled double-blind clinical trial

The aim of this randomized, double-blind, placebo-controlled 16-week study was to investigate the clinical efficacy of cyclandelate (Natil, 1,600 mg/day) in 139 adult outpatients with cognitive impairment (70 allocated to cyclandelate; 69 to placebo). Quantitative-topological EEG, event-related potentials (P300) and psychophysiological interview-based rating scales were used. The efficacy of cyclandelate was demonstrated in the confirmatory statistical sense using a global Hailperin-Rüger test on 10 predefined primary variables at global significance level of 0.05 relating to psychopathology, psychometry, neuropsychophysiology and behavior. At psychopathological and behavioral level the reduction of the total scores of the rating scales (Alzheimer Disease Assessment Scale, Sandoz Clinical Assessment Geriatric Scale, and Nürnberger Selbsteinschätzungs-Liste) following a 16-week therapy revealed also an individual significant cyclandelate-placebo distinction in the confirmatory statistical sense. A difference between verum and placebo was also observed by the increase of the number of correct answers during performance of the number symbol test (psychometrical level). The objective electrophysiological data (neuropsychophysiological level) support these findings. Of particular interest is that following cyclandelate treatment the absolute theta power remained almost unchanged and an increase of P300 amplitude was observed. At the same time placebo led to a distinct theta power increase and a decrease of P300 amplitude, which was interpreted as the reflection of an impairment of the initial clinical state. Summarizing, cyclandelate proved to be efficacious compared to placebo in patients with mild to moderate cognitive impairment.

Source density analysis of functional topographical EEG: monitoring of cognitive drug action

Electrical changes of the brain induced by mental work in the presence or absence of a drug formulation containing dimethylaminoethanolorotrate (DMAE), vitamins and minerals were analysed. Sixty elderly volunteers (30 females and 30 males; aged 40 - 65) who lacked concentration and efficiency during mental exercise according to their own opinions participated in a double-blind, placebo-controlled study. The EEG recordings were carried out before and after 12 weeks medication and were analysed according to the electrical charges at the scalp surface (Laplacian estimate) followed by Fast Fourier Transformation to obtain quantitative data. Whereas no change of electrical charge could be observed after 12 weeks of treatment in the placebo group, the verum group taking 1 capsule per day of an established drug containing a biogenic amine-vitamin combination revealed decreases in theta power during rest and increases in absolute theta power induced by mental demand within the area known to change its electrical activity during mental exercise. In the light of the current hypothesis that high theta resting power and low increases at frontotemporal brain areas during mental work indicate mental impairment, treatment with the drug under investigation was seen to successfully reverse these changes. This drug effect was localized in the frontotemporal cortex in a statistically significant manner during both the memory and the symbol recognition tests. The observed effect is fully consistent with a previous study using Fourier transformed data from conventional EEG voltage recordings. It can be concluded that an analysis of EEG data by means of the charge mode provides an excellent tool to quantify drug effects especially in cognitive research. A second perspective arises from the fact that it should be possible to recognize mental impairments at a very early stage by using this method, thus providing the possibility of an early treatment.

Cyclandelate versus propranolol in the prophylaxis of migraine--a double-blind placebo-controlled study

The aim of the present study was to ascertain the comparative efficacy of cyclandelate, a migraine prophylactic with calcium overload blocking properties, versus propranolol, a non-selective beta-adrenergic blocker, and placebo. Based on different statistical analysis procedures (including time series analysis) a responder and nonresponder evaluation for cyclandelate and propranolol was performed. In addition, an attempt was made to identify the dose relationship of the various drugs on headache parameters. In a double-blind placebo-controlled study 84 patients were treated in a placebo run-in phase (4 weeks). The patients were then randomized by the statistical criterion of placebo responder and nonresponder to either the cyclandelate or the propranolol group. The total treatment period included a low-dosage phase (8 weeks) and high-dosage phase (8 weeks). All patients kept a headache diary before, during and after treatment. The data were assessed by time series analysis (ARIMA), as well as by analysis of variance and nonparametric statistics. Based on ARIMA statistics, 39.3% of the patients showed a significant improvement of migraine during treatment with cyclandelate compared with 29.4% placed on propranolol. Higher doses of cyclandelate and propranolol were more effective. Using the qualitative response-criterion of a 50% reduction in migraine symptoms, cyclandelate showed a response in 67.9% and propranolol in 41.2% of all cases. It can therefore be concluded that cyclandelate as well as propranolol are two comparable substances in the prophylactic treatment of migraine, with cyclandelate showing fewer side effects.

Pathophysiology and psychopharmacology of dementia--a new study design. I. Diagnosis comprising subjective and objective criteria

In a double-blind placebo-controlled psychopharmacological study 263 patients with cognitive impairment were screened and 137 of them were selected (following defined inclusion and exclusion criteria) to participate in a clinical trial (for results of treatment phase see part II, in preparation). The pretreatment state was evaluated twice using quantitative-topological EEG (qEEG) and psychopathological rating scales. There is a significant correlation between total score values of nearly all dementia-specific neuropsychological rating scales and absolute spectral power in the lower frequency ranges (delta, theta, alpha 1) at rest. In order to increase the diagnostic power, qEEG was recorded simultaneously with the performance in four different psychometric tests. It was found that the worse the psychopathological rating of a patient, the higher the absolute theta power at rest and the smaller the test- and demand-dependent further increase in theta power. The percentage of task-induced power increase in delta and theta frequency range appeared to be an efficient indicator for a reliable discrimination between healthy elderly individuals and demented patients (rank correlation coefficient for theta in F7: r = +0.55), which will also serve for evaluation of treatment.

Reflection of mental exercise in the dynamic quantitative topographical EEG

The aim of this study was to investigate the activation process of the central nervous system during mental demand in a complex psychophysiological situation. A 17-channel quantitative topographical EEG was recorded in 48 healthy volunteers (male and female, aged 49 +/- 6 years), using the CATEEM system, during four different psychometric tests (simple reaction time measurement, concentration performance, figure detection and word recall test). The mental load varied with each test, producing a graduated increase in spectral power density in delta and theta frequency range on the EEG in the fronto-temporal, parietal and occipital regions of the cortex and a generalized decrease in alpha power. During the rest periods after each test a graduated increase in alpha 1 power was seen as a possible expression of change in vigilance level. With this method we were able to differentiate two effects of psychometric tests on brain activity: the actual mental demand itself and the influence on the vigilance level.

[A new method for assessment of mental performance during simultaneous, quantitative, topographical electroencephalometry and psychometry in pharmacology. Proof of the effect of a combination of biogenic amines, vitamins, minerals and trace elements]

Assessment of the Mental Performance during Simultaneous Quantitative Topographical Electroencephalometry and Psychometry in Pharmacology/Proof of influence of a biogenic amine-vitamin combination. The aim of this study was to verify the effect of a combination medicine (Vita-Gerin-Geistlich) on the human EEG pattern during psychometric (cognitive) tests given to 43 patients with poor concentration and thinking problems. A randomised, parallel, placebo-controlled double-blind study was performed. Applying 17-channel quantitative electroencephalometry and psychometric tests simultaneously this study revealed a test-dependent increase in absolute spectral EEG power in the delta and theta frequency bands, mainly observed in the frontotemporal cortex. After 8 weeks the increase in EEG power differed significantly with respect to taking placebo and verum (1 capsule/day). Verum caused a stronger rise in spectral delta and theta power, the psychometric test performance also improved. Both effects could be verified statistically. The novel EEG-controlled psychometric test set (enabling artefact-free EEG recording during psychometric tests) which was developed and used in this study represents a valid tool for future pharmacological research.

Quantitative EEG and BPRS data following Haldol-Decanoate administration in schizophrenics

Approximately one-third of schizophrenic patients receiving antipsychotic drugs obtain little or no benefit from them. In some reports, response has been linked with "prognostic" factors, including abnormal EEG and drug response (pharmaco-EEG). Measurements of topological EEG spectral power and Brief Psychiatric Rating Scale (BPRS) values were obtained in 15 schizophrenics over a period of 20 min immediately after the first application, and at weekly intervals after single intramuscular injection of 2 ml depot haloperidol (Haldol-Decanoate). A highly significant increase in the alpha-1 power density at almost all positions and an increase in theta power at parietotemporal regions can be described as electrophysiological parameters of the acute pharmaco-EEG. BPRS values decreased continuously within the first 2 weeks followed by an increase to the predrug level after the fourth week. Over the whole observation period there was a correlation between neurophysiological data (alpha-1 power) and clinical symptomatology (BPRS total score; r = -0.7). Therefore, it can be concluded that quantitative EEG recordings are able to serve as a tool for the optimization of the depot neuroleptic treatment in schizophrenics.

Effect of phospholipase C inhibitor U-73122 on antigen-induced airway smooth muscle contraction in guinea pigs

The importance of phospholipase C (PLC) in airway smooth muscle contraction was studied, using an inhibitor of PLC, 1-[6-[[17 beta-3-methoxyestra-1,3,5(10)-trien-17-yl] amino]hexyl]-1H-pyrrole-2,5-dione (U-73122). Tracheas from ovalbumin (OA)-sensitized guinea pigs contracted rapidly after exposure to low concentrations of antigen (OA). However, tracheas treated with U-73122 for 10 min prior to the addition of antigen, demonstrated a 3 log rightward shift in the OA dose-response curve with an IC50 of 7 microM. The analogue of U-73122, 1-[6[[17 beta-3-methoxyestra-1,3,5 trien-17-yl]amino]hexyl]-2,5-pyrrolidine-dione (U-73433), was approximately 5-fold less active in inhibiting smooth muscle contraction. In addition to the inhibition of antigen-induced smooth muscle contraction, U-73122 inhibited carbachol- and leukotriene D4-induced smooth muscle contraction. Furthermore, U-73122 inhibited in a dose-dependent manner antigen-induced histamine release from guinea pig tracheal tissue. The inhibition of smooth muscle contraction by U-73122 correlated well with the inhibition of polyphosphoinositide mediates smooth muscle contractile responses to muscarinic agonists and leukotrienes as well as antigenic-induced contraction.

EEG- and EP-mapping--possible indicators for disturbed information processing in schizophrenia?

1. Schizophrenic patients have been investigated electroencephalographically to describe disturbed information processing mechanisms. 2. 16-channel quantitative EEG and P300 were recorded at resting conditions before and during neuroleptic depot injection. 3. Reduced occipital alpha-power and alpha-power dependent P300-amplitudes were found in the schizophrenics. 4. Hippocampal structures are involved in the disturbed information processing mechanisms.

Sulfite-containing Canadian pharmaceutical products available in 1991

OBJECTIVE

To compile an inclusive list of Canadian pharmaceutical products available in 1991 that contained sulfites.

DATA SOURCES

Written and oral responses from 94 pharmaceutical companies selected from the 1989 Compendium of Pharmaceuticals and Specialties.

RESULTS

A list of sulfite-containing pharmaceutical products was compiled from data supplied by the 90 responding companies. Companies whose products contained no sulfites were separately identified.

CONCLUSIONS

Sulfites are present in many pharmaceutical products and are one of many excipients and additives that have been reported to cause severe adverse reactions. The provided list should be a useful aid for health care practitioners when prescribing pharmaceutical products for sulfite-sensitive patients.

EEG-brain mapping. A method to optimize therapy in schizophrenics using absolute power and center frequency values

In this study EEG-spectral parameters like mean alpha-power values and center frequency values are computed as maps and compared using significant probability mapping. The parameters are used to describe changes of the functional state of the brain after neuroleptic depot injection (Haldol-Decanoate) in schizophrenic patients. The absolute alpha-power increased significantly (p < 0.01), especially within the first week after injection mostly in the left hemispheric regions. The center frequency decreased most significantly (p < 0.02) between the first and second week after haldol depot injection at the right occipital regions. Both parameters are efficient to describe functional changes correlated with clinical symptomatology, even 3-5 days earlier. Thus, EEG power and center frequency mapping can be used very efficiently to estimate the optimal time between sequential neuroleptic depot injections.

Role of ERCP and therapeutic biliary endoscopy in association with laparoscopic cholecystectomy

Laparoscopic removal is rapidly becoming the preferred method of cholecystectomy; however, choledocholithiasis cannot usually be managed with a laparoscopic approach. Combined endoscopic sphincterotomy and laparoscopic cholecystectomy is a potential solution to this problem. To determine the feasibility of this combined procedure we studied 41 patients who had both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy. Indications for ERCP included jaundice, gallstone pancreatitis, dilated ducts on sonography, elevated liver enzymes, or stones seen on operative cholangiography. Twenty-eight patients had ERCP preoperatively. Nine patients had common duct stones; these were successfully removed from eight patients after sphincterotomy. Two patients had unexpected strictures requiring a change in surgical approach. Thirteen patients had ERCP postoperatively. Eight of those patients had common duct stones, and all were successfully removed following endoscopic sphincterotomy. Three patients had postoperative strictures, one of which was treated by endoscopic stent placement. No complications as a result of ERCP or sphincterotomy were encountered. ERCP and endoscopic sphincterotomy can be safely performed both preoperatively and as early as 1 day postoperatively. If indicators of choledocholithiasis are present, preoperative ERCP is preferred, because stone removal occasionally is unsuccessful, and cholangiographic findings may change the operative approach. Postoperative ERCP can define and, in some instances, treat biliary tract injuries resulting from laparoscopic cholecystectomy.

[Left hemispheric site of EEG findings in patients with schizophrenic psychoses]

It was the aim of our study to examine the interhemispherical and extrahemispherical integration that is possibly disturbed in patients suffering from schizophrenic psychoses, using an easy method of EEG performance spectral analysis. For this purpose, the EEG at rest and the functional EEG were determined in 69 schizophrenic patients (ICD) and 22 healthy subjects and the EEG reactivity was calculated. Differences especially in alpha-2 reactivity were seen both intrahemispherically and interhemispherically. This supports the concept of left hemispheric dysfunction in patients suffering from schizophrenic psychoses.

[EEG performance spectral mapping during drug therapy in a patient with schizophrenic psychosis]

In a paranoid-hallucinatoric patient with chronic course and acute exacerbation a EEG mapping study during neuroleptic treatment was carried out. The typical changes of the alpha power spectra in schizophrenic psychoses as well the normalization after neuroleptic treatment could be found in the alpha map. The changes were in correlation to the clinical state.

Nasopharyngeally and vertex recorded P300's in normal subjects

The P300 waveform has been associated with cognitive activity during information processing, and the hippocampus has been discussed as a possible generator of this waveform. This being the case some would argue that it should be possible to record the P300 with a shorter latency and greater amplitude from an electrode placed as near the hippocampus as possible. Under local anaesthesia we inserted a specially constructed needle electrode through the left nostril in the recessus pharyngeus close to the hippocampus. The results did not support the hippocampal hypothesis. Nasopharyngeally recorded P300's were found to have significantly decreased amplitudes and extended latencies when compared to vertex recordings.

Multivariate EEG power spectral analysis in acute schizophrenics

The electroencephalogram (EEG) during information processing is influenced by specific changes in brain electrical activity. Based on the theory of disturbed information processing in schizophrenics, we analysed auditory stimulus induced EEG changes by Fast Fourier Transformation. The most important of the significant stimulation-dependent EEG power changes were measured in the 0.5-3.5 Hz and 10-13.5 Hz frequency bands in the left frontoparietal lead. In a multivariate analysis the separation of the subjects examined into acute schizophrenics and normals was incorrect in only 21% of the cases (resubstitution rate); using pi-method an error of 31% was estimated.

[Pathophysiologic aspects of schizophrenic psychoses--a review]

The aim of research in the field of "Biological Psychiatry" is the phenomenological description of several aspects of psychiatric diseases and the exploration of their pathological mechanisms. The most used methods are biochemical, morphological, genetical, social psychiatric, neuro- and psychophysiological ones. From the pathophysiological view the most discussed hypothesis is that of a disturbed central information processing. In this paper a short introduction should be given on psychosocial influence on the development of psychotic symptomatology and on the periphere vegetative and electroencephalographic parameters in psychiatric patients.

Repeated acoustic stimulation of acute schizophrenic patients and the habituation of EEG power changes

Habituation in psychiatric patients to repeated stimuli has typically been described in connection with the measurement of the skin conductance orienting response. Here EEG power spectra of acute schizophrenic patients and normals to 4 trials of an acoustic stimulation were examined for evidence of habituation. In response to stimulation the alpha EEG reactivity was less distinct in schizophrenics than in normals. This is in agreement with the theory of hypovariability or hyperstability of the EEG in schizophrenics. Signs of habituation in acute schizophrenics were clearer in fast beta frequencies of the parietal leads.

[Multivariate discriminant analysis of EEG power spectra in acute schizophrenic patients and healthy probands]

The electroencephalogram (EEG) during information processing is influenced by specific changes in brain electrical activity. Based on the theory of a disturbed information processing in schizophrenics we analysed auditory stimulus induced EEG changes by Fast Fourier Transformation. The most important of the significant stimulation dependent EEG power changes were measured in the 0.5-3.5 Hz and 10-13.5 Hz frequency bands in the left parietal lead. In a multivariate analysis the separation of the subjects examined into acute schizophrenics and normals was incorrect in only 21% of the cases (resubstitution rate): using the pi-method an error of 31% was estimated.