Practical Guidelines for Perioperative Hypersensitivity Reactions.

Perioperative hypersensitivity reactions constitute a first-line problem for anesthesiologists and allergists. Therefore, hospitals should have a consensus protocol for the diagnosis and management of these reactions. However, this kind of protocol is not present in many hospitals, leading to problems with treatment, reporting of incidents, and subsequent etiological diagnosis. In this document, we present a systematic review of the available scientific evidence and provide general guidelines for the management of acute episodes and for referral of patients with perioperative hypersensitivity reactions to allergy units. Members of the Drug Allergy Committee of the Spanish Society of Allergy and Clinical Immunology (SEAIC) have created this document in collaboration with members of the Spanish Anesthesia Society (SEDAR). A practical algorithm is proposed for the etiologic diagnosis, and recommendations are provided for the management of hypersensitive patients.

Pharmacogenetics of methylphenidate response and tolerability in attention-deficit/hyperactivity disorder.

Methylphenidate (MPH) is the most frequently used pharmacological treatment in children with attention-deficit/hyperactivity disorder. However, a considerable interindividual variability exists in clinical outcome, which may reflect underlying genetic influences. We analyzed 57 single-nucleotide polymorphisms in 9 dopamine-related candidate genes (TH, DBH, COMT, DAT1 and DRD1-5) as potential predictors of MPH efficacy and tolerability, and we considered prenatal and perinatal risk factors as environmental hazards that may influence treatment effects in a gene-by-environment analysis. Our results provide evidence for the contribution of DRD3 (P=0.041; odds ratio (OR)=4.00), DBH (P=0.032; OR=2.85), TH (P=5.5e-03; OR=4.34) and prenatal smoking (P=1.7e-03; OR=5.10) to the clinical efficacy of MPH, with a higher risk for treatment failure in genetically susceptible subjects whose mother smoked during pregnancy. Adverse events after MPH treatment were significantly associated with variation in DBH (P=6.4e-03; OR=0.28) and DRD2 (P=0.047; OR=3.76). This study suggests that the dopaminergic system together with prenatal smoking exposure may moderate MPH treatment effects.

Psychopathology and traffic violations in subjects who have lost their driving license.

BACKGROUND: The persistence of risky behaviors while driving and traffic accidents despite campaigns to increase awareness suggest that there may be underlying causes that maintain proneness to traffic violations. The aim of the current study was to assess: a) the prevalence of psychopathology in a sample of people who have lost their driving license due to former traffic violations and b) the discriminatory capacity of each psychopathological disorder to differentiate among people with high and low proneness to perform risky behaviors while driving. METHODS: 383 participants in a course to recover their driving license after its loss due to previous traffic violations were included. The International Neuropsychiatric Interview (M.I.N.I.) according to DSM-IV was used to assess psychopathology. RESULTS: Between 67% and 76.2% of the participants had been affected by a lifetime psychopathological disorder until the moment of assessment. The most prevalent diagnoses were substance abuse including alcohol (52.5-62.7%), ADHD (19.7-28.5%), depression (7.9-14.4%) and anxiety (3.6-12.4%). Substance abuse and ADHD also showed the strongest set of associations with specific risk behaviors, but ADHD emerged as the most discriminant disorder to distinguish between those people at high and low risk of while driving. CONCLUSIONS: The results of the current study suggest that addressing psychopathology explicitly to prevent risky behaviors and recidivism while driving would provide benefits in this area.

Hypersensitivity reactions to biological drugs.

Strictly speaking, biological drugs are defined as drugs obtained using biotechnology that act on the immune system. They encompass monoclonal antibodies, fusion proteins, and cytokines. Although they are restricted to specific diseases, they have been increasingly used in recent years, with the consequent reporting of adverse reactions, many of which occur during the postmarketing phase. Because of the characteristics of adverse reactions, a new classification has been proposed. Hypersensitivity reactions are beta-type reactions and include infusion reactions and injection site reactions. In some cases, an immune mechanism mediated by IgE, IgG, or T cells is involved. Clinical symptoms vary widely, from skin reactions to anaphylaxis. Diagnostic studies are based on skin tests and in vitro tests (specific IgE, basophil activation test). Most are not standardized and are conducted in small groups of patients, thus making it impossible to obtain sensitivity and specificity values. With some biological drugs, desensitization protocols have proven successful. In this review, we discuss hypersensitivity reactions to biological drugs and the diagnostic tests used to assess these reactions.

Remittance or persistence of attention deficit-hyperactivity disorder (ADHD) and its impact on recidivism in risky driving behaviors.

OBJECTIVE: Recent data regarding the persistence or remittance of attention deficit-hyperactivity disorder (ADHD) diagnosis into adulthood raise the question of its possible role in crucial public health issues, including road safety, especially when neurocognitive capacities are challenged. METHODS: The study included 611 participants with serious traffic violations. The Spanish version of the Mini International Neuropsychiatric Interview (M.I.N.I.) was used to assess psychopathology. They were grouped into 3 diagnostic conditions: non-ADHD, persistent ADHD (ADHD-P), and remittent ADHD (ADHD-R). Several risky driving behaviors were analyzed. RESULTS: Although participants with ADHD have more driving violations relative to non-ADHD, ADHD-R, and ADHD-P drivers have similar profiles. ADHD-R and ADHD-P drivers are more prone to perform risky and recidivistic behaviors relative to non-ADHD counterparts (P = .044 and P = .047, respectively); ADHD-R and ADHD-P participants are statistically comparable in this proneness (P = .772). CONCLUSION: These results suggest that the underlying core deficits of ADHD-attention and other executive disabilities-persist despite the fact that some people no longer reach the threshold for clinical diagnosis.

Differential expression of the normal and mutated K-ras alleles in chemically induced thymic lymphomas.

The presence of point mutations in the K-ras gene was examined in murine thymic lymphomas induced by a single dose of N-methylnitrosourea by the RNase A mismatch cleavage method and by allelic-specific oligonucleotide hybridization of in vitro amplified DNA by polymerase chain reaction. The results show that the frequency of mutations is lower than that of tumors induced by multiple N-methylnitrosourea treatments. Four mutations identified were the aspartic acid at codon 12, a G:C to A:T transition in its second position. A G:C to T:A transversion in codon 146 was also found in one thymic lymphoma, changing the amino acid alanine to serine. The use of the RNase A assay allowed an estimation of the relative expression levels of both normal and mutant K-ras alleles. The results show that in approximately one half of the tumors the mutant allele is predominantly expressed, suggesting that the normal allele has been lost or that the mutant allele has been amplified relative to the normal. Altogether, these findings are consistent with ras mutations occurring in some instances during tumor development and with a ras effect being not strictly dominant but favoring selection for increasing levels of expression from the oncogenic allele.

Oncogene involvement in tumor regression: H-ras activation in the rabbit keratoacanthoma model.

Activated H-ras genes are present in a number of skin tumors induced in animals by carcinogen treatment. The involvement of the ras oncogenes in tumorigenesis was investigated in keratoacanthomas, benign and self-regressing tumors, as well as malignant squamous cell carcinomas. Both tumors were induced in rabbit ears by repeated applications of 7,12 dimethylbenz(a)anthracene (DMBA). The rabbit H-ras gene was cloned and sequenced. PCR analysis revealed that approximately 82% of the keratoacanthoma DNAs contained an A:T to T:A transversion in codon 61. The relative levels of H-ras transcript were increased in keratoacanthomas compared to normal skin and the activated allele was expressed in tumors, even during the regressing phase. Although a G:C to A:T mutation in codon 12 of the H-ras and an activated N-ras gene were found in two squamous cell carcinomas, the frequency of H-ras activation in codon 61 was much lower (40%) in the malignant tumours induced by the same carcinogen treatment. Therefore, DMBA induced at least two types of genetic lesions in this system: H-ras activation, present in most regressing keratoacanthomas, and activation of other unidentified oncogenes which may result in the development of malignant tumors. Our observations indicate that expression of an activated H-ras gene, in this system, is neither sufficient to induce a malignant phenotype nor even capable of maintaining the growth of a benign tumor and suggest that it could be involved in tumor regression.

The novel gene glaikit, is expressed during neurogenesis in the Drosophila melanogaster embryo.

A novel gene glaikit (gkt) has been identified which is expressed in the delaminating neuroblasts of the D. melanogaster embryonic central nervous system. At the earliest stages of embryonic development the expression of glaikit was ubiquitous, but by the time the neuroblasts are delaminating gkt expression became restricted to neuroblasts and a few ganglion mother cells. The gkt gene has no characterized homologues and encodes no previously described protein motifs. There are, however, evolutionary conserved predicted genes present in S. pombe, S. cerevisiae and C. elegans. Ectopic neuroblasts induced in either Notch or Delta mutant backgrounds also showed expression of glaikit.

Allergy to ailanthus altissima pollen: a local allergen to consider

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Lymphocyte immunophenotyping by flow cytometry in normal adults. Comparison of fresh whole blood lysis technique, Ficoll-Paque separation and cryopreservation.

In the present report we have assessed the extent to which Ficoll-Paque separation and cryopreservation of mononuclear cells alter the measurement of lymphocyte subsets by flow cytometry. Standard Ficoll-Paque separation increased the percentage of CD4+, CD19+ and CD4+CD45RA+ cells, as well as decreasing that of CD8+, and CD4+CD29+ cells, compared to the fresh whole blood lysis technique. Moreover, cryopreservation caused a depletion of CD4+ p80+ cells, but normal whole blood values were restored following a short incubation.

Radiation and chemical activation of ras oncogenes in different mouse strains.

A survey of a large series of radiation- or chemically induced thymic lymphomas in (AKR X RF)F1, RF/J, 129/J, and C57BL/6J mouse strains for activated ras oncogenes showed that of the tumors containing transforming activity, in more than 75% of the cases this activity segregated with either K-ras or the N-ras gene. H-ras activity was never detected. The genetic background of the host influenced susceptibility to tumor induction and oncogene activation. The K-ras gene was preferentially activated over the N-ras gene (approximately 2:1) whether the inducing agent was radiation or the chemical N-nitrosomethylurea. The activating mutation for the K-ras gene was consistently identified as a GGT to GAT transition in codon 12. In contrast, several different mutations of the N-ras gene were identified and localized to codons 12, 13, or 61. Assessment of the allelic composition of the ras locus shows that some proportion of the tumors lost the normal ras allele.

ras activation in human tumors and in animal model systems.

Environmental agents such as radiation and chemicals are known to cause genetic damage. Alterations in a limited set of cellular genes called proto-oncogenes lead to unregulated proliferation and differentiation. We have studied the role of the ras gene family in carcinogenesis using two different animal models. In one case, thymic lymphomas were induced in mice by either gamma or neutron radiation, and in the other, keratoacanthomas were induced in rabbit skin with dimethylbezanthracene. Human keratoacanthomas similar to the ones induced in rabbits were also analyzed. We found that different types of radiation such as gamma rays and neutrons, induced different point mutations in ras genes. A novel K-ras mutation in codon 146 has been found in thymic lymphomas induced by neutrons. Keratoacanthomas induced in rabbit skin by dimethylbenzanthracene show a high frequency of H-ras-activated genes carrying a mutation in codon 61. The same is observed in human keratoacanthomas, although mutations are in both the 12th and the 61st codons of the H-ras gene. H-ras activation is less frequent in human squamous cell carcinomas than in keratoacanthomas, suggesting that ras genes could play a role in vivo in differentiation as well as in proliferation.

A method to extract DNA for molecular studies from cells fixed in Carnoy.

We describe a simple method for isolation of high-molecular-weight DNA from cells fixed in Carnoy's solution for cytogenetic studies. DNA samples were extracted from NIH3T3 cells, and no apparent degradation was noticed. This method should be useful for molecular analysis of cells fixed for cytogenetic studies.

B-lymphocytes and co-stimulatory molecules in Mycobacterium tuberculosis infection.

SETTING: The immunological mechanisms that lead to the control of Mycobacterium tuberculosis infection are not well known. OBJECTIVE: To study the role of lymphocyte subsets and co-stimulatory molecules in M. tuberculosis infection. DESIGN: In 35 patients with pulmonary tuberculosis (PTB) and their contacts, 29 persons with tuberculin skin test conversion (TSTC) and 20 healthy individuals with negative tuberculin skin test (NTST), we studied T-lymphocyte subsets (CD3, CD4, CD8, alphabetaTCR and gammadeltaTCR), B-cells, monocytes and co-stimulatory molecules CD28 and CD86 in peripheral blood. The results were analysed at univariate and multivariate level through discriminant analysis. RESULTS: At univariate level, compared with TSTC and NTST, PTB patients presented a decrease in CD4+ T-cells (P = 0.002), and B-cells (P = 0.02 and 0.001, respectively). With regard to NTST subjects, PTB patients also showed a decrease in the percentage of CD86+ monocytes (P = 0.02) and an increase in the percentage of CD86+ B-lymphocytes (P = 0.02). At multivariate level, CD4+ T-lymphocytes showed statistical differences between PTB and TSTC subjects (P = 0.001). B-lymphocytes were discriminant between PTB and NTST (P < 0.001) and between TSTC and NTST individuals (P = 0.01). CONCLUSION: The number of total CD4+ T-cells is the best discriminant parameter for distinguishing between disease and infection, whereas the B-cell count is the best between healthy and infected individuals.

Multistage carcinogenesis in murine thymocytes: involvement of oncogenes, chromosomal imbalances and T cell growth factor receptor.

An animal model of carcinogenesis has been exploited to analyze the various events involved in carcinogen-induced T cell lymphomagenesis. Two carcinogenic agents, the alkylating agent N-methylnitrosourea (NMU) and ionizing gamma-radiation, induce tumors in C57BL/6J mice that are phenotypically and histologically identical. Are the genetic events similar or different in the T cell tumors produced by these two carcinogenic agents? NMU treatment produced a different spectrum of activated oncogenes from gamma-irradiation. The K-ras oncogene was preferentially activated in all of the NMU-induced tumors, most frequently by a GGT to GAT transition in codon 12. Ionizing gamma-radiation produced two different transforming activities. Approximately half of the radiation-induced tumors contained activated N-ras genes and half contained a novel non-ras transforming activity. Analysis of NMU- and gamma-irradiated treated animals for chromosomal abnormalities showed anomalies early in the disease. Although both agents produce tumors containing trisomy of chromosome 15, the timing of this event appears to be different occurring early in NMU-induced tumors and later in gamma-radiation induced tumors. In addition, a unique marker chromosome consisting of a translocation between chromosomes one and five appears to be involved in the early stages of radiation-induced disease and may be associated with the novel transforming activity detected in these same tumors. Expression of receptors for the T cell growth factor (IL-2R) is similar in both NMU- and gamma-irradiation induced tumors. Changes in the expression of IL-2R on different T cell populations with disease progression may account for thymus dependent and thymus independent phases of malignant T cell growth.

Rhinosinusitis and atopy in patients infected with HIV.

HYPOTHESIS: Rhinosinusitis is common during HIV infection; its prevalence is uncertain and could probably be related to clinical features, immunoallergological status, and diagnostic criteria METHODS: Seventy-four patients hospitalized with HIV infection were prospectively evaluated for the presence of rhinosinusitis based on clinical findings, nasal endoscopy, or paranasal sinus computed tomography (CT). Immune status, nasal smear, features of atopy (based on the prick test), and its contribution to sinusal inflammatory pathology were also evaluated. RESULTS: Most patients were severely immunosuppressed: CD4+ 155+/-201 cells/mL and 12+/-11% (mean +/- SD). Thirty-five percent of the patients presented at least two criteria of rhinosinusitis (clinical findings, nasal endoscopy, and CT: 35%; clinical findings and CT: 50%; nasal endoscopy and CT: 15%). CT scan showed multiple sinus involvement, opacification over 25% of the total volume of the maxillary sinus in 50% of patients, and opacification of the sphenoidal sinus in 40% of cases. Atopy was present in 18% of patients, a figure which reflects the expected prevalence in our geographic area. Two independent predictors were associated with a higher probability of rhinosinusitis: bilateral absence of maxillary infundibular patency (odds ratio, 7.5; 95% CI = 2.03-27.9) and low total count (odds ratio, 0.99; 95% CI = 0.99-1.00) or percentage of CD4+ (odds ratio, 0.93; 95% CI = 0.88-1.00). CONCLUSIONS: There is a high prevalence of rhinosinusitis in HIV-infected individuals. This finding is related to a decreased cellular immunity, but it does not appear to be related to IgE-related immediate hypersensitivity. Nasal endoscopy should be the first-step diagnostic test. However, when clinical suspicion exists and endoscopy fails to explain symptoms, CT scan is a valuable adjunct to establish this diagnosis.