Adrenal insufficiency is a contraindication for omalizumab therapy in mast cell activation disease: risk for serum sickness

Omalizumab is an effective therapeutic humanized murine IgE antibody in many cases of primary systemic mast cell activation disease (MCAD). The present study should enable the clinician to recognize when treatment of MCAD with omalizumab is contraindicated because of the potential risk of severe serum sickness and to report our successful therapeutic strategy for such adverse event (AE). Our clinical observations, a review of the literature including the event reports in the FDA AE Reporting System, the European Medicines Agency Eudra-Vigilance databases (preferred search terms: omalizumab, Xolair®, and serum sickness) and information from the manufacturer’s Novartis database were used. Omalizumab therapy may be more likely to cause serum sickness than previously thought. In patients with regular adrenal function, serum sickness can occur after 3 to 10 days which resolves after the antigen and circulating immune complexes are cleared. If the symptoms do not resolve within a week, injection of 20 to 40 mg of prednisolone on two consecutive days could be given. However, in MCAD patients whose adrenal cortical function is completely suppressed by exogenous glucocorticoid therapy, there is a high risk that serum sickness will be masked by the MCAD and evolve in a severe form with pronounced damage of organs and tissues, potentially leading to death. Therefore, before the application of the first omalizumab dose, it is important to ensure that the function of the adrenal cortex is not significantly limited so that any occurring type III allergy can be self-limiting.

[Surgical interventions in patients with systemic mast cell activation disease : Recommendations for perioperative management]

BACKGROUND

Systemic mast cell activation disease (MCAD, prevalence 5-10%) is a multifactorial, polygenic disease with multisystemic symptoms that is characterized by an unregulated increased release of mast cell mediators and an accumulation of activated mast cells potentially in all organs and tissues. Due to the high prevalence of the disease, physicians involved in surgical, anesthesiological and interventional procedures are often unknowingly faced with MCAD patients experiencing unexpected preoperative, intraoperative and postoperative complications, if no mast cell-specific treatment regimens have been applied.

OBJECTIVE

The findings from a literature search, consensus recommendations of the various international expert groups and extensive own experience in the treatment of MCAD patients enable an empirical and evidence-based care of MCAD patients in association with invasive procedures.

RESULTS AND CONCLUSION

Due to the high prevalence of MCAD in the population, it can be assumed that patients with MCAD are correspondingly frequently represented in the surgical patient collective. When MCAD-specific peculiarities are preventively considered in the anesthesiological and surgical procedures in patients with proven or suspected mast cell disease, MCAD patients should not be classified as being at risk.

[Surgical interventions in patients with mast cell activation disease. Aspects relevant for surgery using the example of a cholecystectomy]

BACKGROUND

Systemic mast cell activation disease (MCAD) is characterized by an increased and unregulated release of mast cell mediators which can evoke a multifaceted clinical picture often resembling irritable bowel syndrome or fibromyalgia. Because of the considerable prevalence (~ 17 %) of MCAD surgeons are frequently unwittingly confronted with MCAD patients in whom unexpected intraoperative and postoperative complications may occur. Therefore, knowledge of the particular requirements is of relevance for surgical treatment of MCAD patients.

OBJECTIVE

The present paper outlines a concept of surgical treatment of MCAD patients based on the literature which is illustrated by a case report on emergency laparoscopic cholecystectomy.

CONCLUSIONS

Due to the high prevalence of MCAD in the general population it can be assumed that the frequency in the surgical patient population is similar. If a patient has MCAD, specific characteristics should be taken into account in the surgical procedure to avoid increased operative and complication risks resulting from MCAD.

Establishment of transplantation tolerance via minimal conditioning in aged recipients

Mixed hematopoietic chimerism is a powerful means of generating donor-specific tolerance, allowing long-term graft acceptance without lifelong dependence on immunosuppressive drugs. To avoid the need for whole body irradiation and associated side effects, we utilized a radiation-free minimal conditioning regime to induce long-term tolerance across major histocompatibility barriers. We found that low-dose busulfan, in combination with host T cell depletion and short-term sirolimus-based immunosuppression, facilitated efficient donor engraftment. Tolerance was achieved when mice were transplanted with whole or T cell-depleted bone marrow, or purified progenitor cells. Tolerance induction was associated with an expansion in regulatory T cells and was not abrogated in the absence of a thymus, suggesting a dominant or compensatory peripheral mode of tolerance. Importantly, we were able to generate durable chimerism and tolerance to donor skin grafts in both young and aged mice, despite age-related thymic atrophy and immune senescence. Clinically, this is especially relevant as the majority of transplant recipients are older patients whose immune recovery might be dangerously slow and would benefit from radiation-free minimal conditioning regimes that allow efficient donor engraftment without fully ablating the recipient immune system.

[Mast cell activation disease: a concise practical guide for diagnostic workup and therapeutic options]

In the present paper clinical phenotypes, pathogenetic relationships, and diagnostic algorithms as well as therapeutic concepts of/for systemic mast cell activation disease are reviewed. The reader should be able to recognize and diagnose a systemic mast cell activation disease, as well as to counsel a personalized drug therapy. In the case of chronic multisystem polymorbidity systemic mast cell activation disease should be considered as a differential diagnosis at an early stage. In most cases, specific, little invasive investigations allow diagnosing the disease and, hence, an appropriate therapy can be initiated.

[Systemic mast cell disease with gastrointestinal symptoms--a diagnostic questionnaire]

Systemic mast cell disease often becomes clinically manifest as a mast cell mediator activation syndrome with episodic or chronic nonspecific abdominal symptoms. As a result of genetic alterations, pathological mast cells have an increased proliferation rate as well as accumulation within different organs with consequential effect on gastrointestinal secretion, absorption, pain perception and motility caused by release of their mediators. These changes may not be detected in routine laboratory or imaging methods. This report describes how the diagnosis systemic mast cell disease can be established with a diagnostic questionnaire based on a synopsis of clinical findings relevant to a mast cell mediator activation syndrome.

Localized lymphoid relapse in the pancreas following allogeneic hematopoietic stem cell transplant for chronic myelogenous leukemia

The incidence of isolated extramedullary disease (EMD) following allogeneic hematopoietic stem cell transplant (allo-HSCT) for chronic myelogenous leukemia (CML) is not fully known. One review found the incidence of isolated myeloid EMD, or granulocytic sarcoma (GS), in an allo-HSCT treated CML/myelodysplastic subgroup to be just 0.22%. The incidence of lymphoid EMD in similar patients is extremely rare with only two cases reported in the literature. While the etiology of EMD in the post-transplant setting is not entirely clear, there may be inefficacy of immune surveillance function outside of the bone marrow cavity. Isolated CML GS following allo-HSCT carries a median interval to bone marrow relapse between 7 and 10 months and a median survival of 12 months. Less is known about lymphoid EMD. The treatment in these cases is ill defined with modalities ranging from involved field radiation to second allo-HSCT. We present a case of isolated pancreatic lymphoid EMD diagnosed 15 months after allo-HSCT for CML. Our patient was also treated with withdrawal of his immunosuppressive regimen. Unfortunately, at just over 4 months following pancreatic resection, he developed systemic relapse and died. While EMD can occur anywhere in the body, CML associated pancreatic EMD is not previously reported.

Stroke knowledge among stroke support group members

BACKGROUND AND PURPOSE

Community stroke education is needed to improve early stroke recognition and reduce delays in the referral of stroke patients. In some regions, stroke support groups are important promoters of regional stroke education. However, there are no data about the level of stroke knowledge among support group members that support this promotional role.

METHODS

We performed a cross-sectional questionnaire survey among 11 German stroke support groups. The questionnaire asked for stroke knowledge and sociodemographic and medical data. Stroke knowledge was excellent if a participant knew (1) at least 2 stroke symptoms (good symptom knowledge) and (2) at least 2 stroke risk factors (good risk factor knowledge), as well as knowing (3) that immediate hospital admission or an emergency call is necessary in case of stroke (good action knowledge).

RESULTS

A total of 133 members (96.2%) of 11 stroke support groups took part in the study. Mean age was 65.3 years (SD 11.2 years). Fifty-four percent of subjects were female, 72.8% were retired, and 69.8% were stroke patients. Of the participants, 80.3% had good symptom knowledge, 64.7% had good risk factor knowledge, and 79.7% had good action knowledge. Stroke knowledge was excellent in 44.0% of subjects. Logistic regression analysis showed that age <70 years and not having had a stroke were significant predictors for excellent stroke knowledge.

CONCLUSIONS

Overall, members of stroke support groups are well informed about all aspects of modern stroke care. Because of their knowledge and personal experience, support groups should be viewed as important partners in community stroke education.

[Knowledge about stroke among the German population]

BACKGROUND AND OBJECTIVE

Modern stroke therapy requires patients to correctly identify stroke symptoms and seek immediate hospital admission. US studies showed that only 57% of the population knew at least one stroke symptom. This is the first study about stroke knowledge among German populations.

METHODS

Using a cross-sectional questionnaire survey, 300 working-age participants of the PROCAM study, the Prospective Cardiovascular Münster Study, and 95 senior citizens of the Augsburg Study, a follow-up project of the MONICA survey 1989/90, were asked about stroke symptoms and what to do if they occur. Good knowledge about stroke was defined as knowing at least two stroke symptoms and calling the emergency medical system or seeking immediate hospital admission in case of symptoms.

RESULTS

Participation rate in the PROCAM study was 90%, while all senior citizens took part. The mean age of the working population was 41.2 years, the mean age of the retired population was 72.8 years. 35% of the working and 24.5% of the retired participants knew at least two stroke symptoms. Urgent hospital admission was selected by 78.2% of the occupational but only 41.5% of the retired participants. Good stroke knowledge was demonstrated by nearly a third of the workers but less than 10% of the elderly. Among the occupational population, being a white-collar worker or knowing someone with a stroke was a significant predictor of good stroke knowledge. Among senior citizens higher age and current smoking status were significant predictors.

CONCLUSION

Our study shows significant information deficits about stroke in our population: education needs to be geared especially towards the elderly.

Potential relevance of agmatine as a virulence factor of Helicobacter pylori

The polyamine agmatine is able to increase gastric acid secretion. Therefore, we investigated whether Helicobacter pylori is able to form and release agmatine in vitro and in the human stomach in vivo, and if so, whether a relationship exists among agmatine concentration in gastric juice, H. pylori infection, and gastroduodenal lesions. Agmatine was determined by means of HPLC. In the supernatant of H. pylori cultures, agmatine concentrations up to 1500 ng/ml (approximately 12 microM) were determined, depending on the number of the bacteria in the individual cultures. Agmatine concentration in gastric juice from H. pylori-positive patients was higher than in that from H. pylori-negative patients. Gastrin in blood was elevated in H. pylori-positive patients compared with H. pylori-negative patients. Agmatine concentration in gastric juice and serum gastrin level appeared to be related. In conclusion, H. pylori is able to form and to release agmatine in vitro and in vivo. This may be assumed to be relevant in vivo, since higher amounts of agmatine are present in gastric juice from H. pylori-positive than from H. pylori-negative patients. Accordingly, agmatine produced by H. pylori may be a virulence factor of this bacterium and may be involved in the pathogenesis of gastroduodenal lesions.

Imidazoline recognition sites and stomach function

Radioligand binding experiments carried out in cell membranes from rat and human stomach revealed the existence of non-adrenoceptor [3H]clonidine and [3H]idazoxan binding sites and of [3H]DTG (1,2-di-(2-tolyl)guanidine) binding sites. In rat stomach, specific binding was inhibited by imidazolines and guanidines and by non-imidazoline sigma-site ligands, respectively, at different rank orders of affinity, suggesting the existence of non-I1/non-I2 [3H]clonidine binding sites, I2-imidazoline binding sites as well as sigma 2-like-sites. These sites are not directly related to a postsynaptic contractile effect on rat gastric smooth muscle or to acid release from isolated gastric glands. Finally, we demonstrated that the gastric pathogen Helicobacter pylori is able to form and to release the endogenous imidazoline receptor ligand agmatine and that considerable amounts of agmatine are present in human gastric juice. The quantities of agmatine were higher in gastric juice from H. pylori-positive than H. pylori-negative patients.

Early detection of amatoxins in human mushroom poisoning

Amatoxins were detected radioimmunologically as early as 90-120 min after ingestion in the gastric fluid and urine of a 15-year-old boy who tried to commit suicide by ingestion of wild mushrooms. This early detection of amatoxins in the urine is proof of rapid absorption from the intestinal tract and subsequent excretion by the kidneys in man.

[Dose comparative study with ranitidine in the therapy and prevention of duodenal ulcer]

The clinical value of ranitidine, 75 b. d. versus 175 mg b. d. in 48 patients with endoscopically proven duodenal ulcer was evaluated in a randomised double-blind study. In the two groups of patients there was no significant difference of ulcer healing. After 4 weeks of treatment in each group healing of 79% and after 6 weeks of 92% of the ulcers was observed. After 8 weeks the healing rate was 96% in patients who received 75 mg b. d. and 100% in those receiving 150 mg of ranitidine b. d. Smoking prolonged ulcer healing in both groups. Upon ulcer healing in 34 patients a ranitidine dosis of 75 mg nocte for prophylaxis of ulcer recurrence was compared with a 150 mg dosis nocte. Within 12 months in the two groups recurrence of duodenal ulcer was found by endoscopy in 21% and 20% of the patients. 7 out of 8 patients with ulcer recurrence were smokers. According to the results of these studies it appears that the recommended standard dosis of ranitidine for treatment of duodenal ulcer could be reduced by one half. To confirm our conclusions, further studies with a greater number of duodenal ulcer cases are necessary.

Parathion-provoked lethality in rats is reduced by diethyldithiocarbamate

Intoxication of male rats with 5 mg/kg parathion reduces survival to 15%. Diethyldithiocarbamate (DDC), known to inhibit mixed-function oxidase activity, has no effect on survival rate when this compound is used in a dosage of 300 mg/kg 45 min before or 10 min after parathion intoxication. However, when DDC and parathion are administered simultaneously, the rate of survival rises to 53%.

Comparative studies on isolated rat hepatocytes and AS-30D hepatoma cells with leucocidin from Pseudomonas aeruginosa

Leucocidin, one of the cytotoxic principles of Pseudomonas aeruginosa induces potassium loss and swelling in isolated hepatocytes and in AS-30D ascites hepatoma cells in a dose and time dependent manner. Hepatoma cells are more sensitive than normal hepatocytes. As shown by scanning electron microscopy the volume increase of both types of cells is accompanied by disappearance of microvilli. In contrast to phalloidin poisoning no protrusions were formed when the cells were exposed to leucocidin under isotonic conditions.

[Inhibition by diethyldithiocarbamate (DEDTC) of acute hepatotoxic effects induced by polyhalogenated hydrocarbons (PHHC)]

Hemoglobin-free perfused rat livers were treated with carbon tetrachloride, chloroform, trichloroethylene and halothane by equilibrium of the perfusion medium with the varorous PHHCs. The resulting swelling of liver tissue, the potassium loss and the decrease of the perfusion rates were reduced by DEDTC to a different degree: The decrease of swelling, potassium loss and of the microcirculatory alteration by DEDTC was dose dependent in the case of carbon tetrachloride and halothane, whereas the effects of chloroform and trichloroethylene were not markedly influenced. Glutathione was mostly ineffective when given in similar doses. Pretreatment of rats with phenobarbital for 3 days increased itself swelling, K+-loss and reduction of perfusion rates, when the livers were perfused in absence of PHHCs. The effects of PHHCs in livers from pretreated rats were seldom greater but often lower than additive ones. Chiefly the effects of halothane were not markedly influenced by treatment of rats with phenobarbital. Isolated parenchymal liver cells were exposed to gas mixtures of O2, CO2 and PHHCs under controled conditions. Changes of the shape and staining of the cells were used for additional information. In view of these latter effects chloroform appeared as the most toxic and halothane as a nontoxic agent. DEDTC inhibits all effects of PHHCs demonstrated in isolated hepatocytes.

A clinical decision-making model for child psychiatric intervention selection

This paper describes a four-component procedure of clinical decision-making, developed by a group of senior child clinicians in an urban child mental health center. The major goal of the paper is to give readers a basic understanding of the theory underlying the formulation of our disposition-oriented clinical decision-making system, that can be eventually translated into questionnaire format, and made useful and usable in general clinical application. The four-component procedure is described in a step-wise fashion and then linked to clinical dispositional options to be chosen from the clinical services available in a clinic. A child mental health data system will ultimately be developed.

[Phalloidin antagonists. 2. Protective effect of disilybine in phalloidin poisoning of isolated hepatocytes]

Phalloidin produces marked protrusions on the surface of isolated hepatocytes prepared from rat livers. This typical in-vitro effect of the mushroom toxin is prevented or inhibited by preincubation with disilybin. The antagonistic effect depends on the concentration of disilybin and might be caused by an inhibition of phalloidin binding.

Glucose-6-phosphatase (EC 3.1.3.9) and esterase (EC 3.1.1.1) activities of microsomes prepared from perfused rat livers after partial outflow block or phalloidin poisoning

Microsomes were prepared from perfused rat livers after different perfusion procedures. The yield of microsomal protein and the kinetic data (Km, Vmax) of glucose-6-phosphatase (3.1.3.9) and esterase (3.1.1.1) activities were analysed in each preparation. No marked differences were detected between conventionally prepared liver microsomes and those from livers perfused 1 hr with an erythrocytes-free medium under the conditions of open outflow. If the outflow pressure was increased artificially, the yield of microsomal protein decreased. The Vmax of both enzymes was markedly increased, whereas the Km values remained unchanged. The same microsomal alterations occurred when perfused rat livers were poisoned with phalloidin in vitro under the condition of open outflow. Our findings indicate that microsomal alterations in livers from poisoned animals might be due to microcirculatory disturbances, and not primary effects of the toxin on the endoplasmatic reticulum.