An evaluation of overall effectiveness and treatment satisfaction with intravenous immunoglobulin among patients with immune thrombocytopenia.

BACKGROUND: A global assessment of patient satisfaction that considers therapeutic effect, toxicities, and convenience is needed to evaluate the acceptability of intravenous immunoglobulin (IVIG) as a treatment for patients with immune thrombocytopenia (ITP). STUDY DESIGN AND METHODS: We performed a cross-sectional pilot study to assess the feasibility and usefulness of a treatment satisfaction questionnaire for adult patients with ITP receiving IVIG in an academic hematology clinic. Treatment satisfaction was evaluated by administration of a validated survey-based tool 7 days after IVIG administration. The tool assessed treatment satisfaction across four domains (effectiveness, toxicity, convenience, and global satisfaction); results were summarized with mean scores. RESULTS: Twelve patients were enrolled (nine females; median age, 44 years; interquartile range, 35-69 years). Mean platelet increment after infusion was 54.2 × 10(9) /L (SD, 47.6 × 10(9) /L). Treatment satisfaction scores were highest in the side effect burden domain (88.2/100; SD, 19.3; higher scores indicate a lower burden of side effects). Six participants reported IVIG-associated toxicities; most were "slightly" or "not at all" dissatisfied by the impact of side effects. The domain with the lowest score was convenience (62.0/100; SD, 24.7). CONCLUSION: The assessment of treatment satisfaction using a survey-based assessment tool was feasible for patients receiving IVIG and provided meaningful results that discriminated between domains. Patients found IVIG treatment to be inconvenient, but were satisfied with its tolerability as an ITP treatment. Larger studies are needed to determine the precise impact on each domain and the reproducibility of study results. Patient satisfaction scores can be used to compare different ITP treatments.

Effect of a thrombopoietin receptor agonist on use of intravenous immune globulin in patients with immune thrombocytopenia.

BACKGROUND: Thrombopoietin receptor agonists are new treatments for patients with chronic immune thrombocytopenia (ITP). How one of these agent, romiplostim, has impacted practice patterns, especially the use of intravenous immune globulin (IVIG), has not been evaluated outside of clinical trials. STUDY DESIGN AND METHODS: This was a retrospective cohort study of adult ITP patients treated with romiplostim in four Canadian centers. Patients had primary or secondary ITP and were followed for 1 year before starting weekly romiplostim treatment. We compared IVIG use, clinical outcomes, and cost before and after romiplostim. RESULTS: Twenty-nine patients with ITP received romiplostim. Median age was 54 years (interquartile range [IQR], 45-63 years) and patients had a median of two prior ITP treatments (IQR, 1-4) including splenectomy (n = 7). Median platelet (PLT) count was 23 × 10(9) before and 124 × 10(9) after romiplostim. Median duration of romiplostim treatment was 3.7 months. Patients used a median of two IVIG infusions per year before and 0.7 per year after starting romiplostim (p = 0.16). For patients who received weekly romiplostim for at least 1 month (n = 19), IVIG infusions were three (IQR, 1-5) per year before and 0.7 (IQR, 0.4-1.6) per year after romiplostim. Results were squewed by two high IVIG users. Nineteen (66%) patients discontinued romiplostim treatment during follow-up because of lack of response (n = 8), sustained response (n = 5), toxicities (n = 4), or response to splenectomy (n = 2). Overall health care costs were similar before and after romiplostim when concomitant treatments, nursing resources, and hospitalizations were considered. CONCLUSIONS: Romiplostim was associated with improved PLT counts and fewer IVIG infusions for most ITP patients. In practice, romiplostim was generally not continued long term and was cost neutral for overall ITP management.

A neonatal swine model of allergy induced by the major food allergen chicken ovomucoid (Gal d 1).

BACKGROUND: Food allergy is a serious health problem for which a validated outbred large animal model would be useful in comparative investigations of immunopathogenesis and treatment and in testing hypotheses relevant to complex host-environmental interactions in predisposition to and expression of food allergy. OBJECTIVE: To establish a neonatal swine model of IgE-mediated allergy to the egg protein ovomucoid (Ovm) that may mimic human allergy. METHODS: In order to induce Ovm sensitivity, piglets at days 14, 21 and 35 of age were sensitized by intraperitoneal injection of 100 microg of crude Ovm and cholera toxin (50, 25 or 10 microg). Controls received 50 microg of cholera toxin in phosphate-buffered saline. The animals were challenged orally on day 46 with a mixture of egg white and yoghurt. Outcomes were reported as direct skin tests, clinical signs, IgG-related antibody and passive cutaneous anaphylaxis. RESULTS: Sensitized pigs developed immediate wheal and flare reactions, and after oral challenge, sensitized but not control animals displayed signs of allergic hypersensitivity. Serum IgG-related, Ovm-specific antibodies were detected only in the sensitized pigs and IgE-mediated antibody response to Ovm was confirmed by positive passive cutaneous anaphylaxis reactions induced by sera of sensitized but not by heat-treated sera from Ovm-sensitized pigs or sera of unsensitized control pigs. CONCLUSION: The present results confirm induction of Ovm-specific allergy in pigs and provide opportunity to investigate allergic predisposition and immunopathogenesis of IgE-induced Ovm allergy using outbred neonatal swine. This may better simulate allergic disease in humans and allow investigation of candidate prophylactic and therapeutic approaches.

Porcine IgE in the context of experimental food allergy: purification and isotype-specific antibodies.

Measurement of allergen-specific immunoglobulin E (IgE) is a common practice in the investigation of allergy. It has not been possible to measure porcine IgE due to unavailability of anti-porcine IgE. This study was undertaken to purify and characterize porcine IgE from sera of allergic pigs, identify heterologous anti-IgE reactive with pig IgE and to use purified heavy (H) chain of porcine IgE to generate rabbit anti-IgE. A four-step process for the purification of porcine IgE is reported using ammonium sulphate precipitation, Protein G affinity chromatography, DEAE cellulose anion-exchange chromatography and sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) to obtain IgE H chain. The resultant IgE was evaluated for purity using SDS-PAGE and immunoreactivity was detected by Prausnitz-Küstner (PK) tests and passive cutaneous anaphylaxis with the allergen, crude peanut extract, used to induce experimental allergy. Cross-reactivity with anti-mouse and anti-human IgE antibodies were confirmed in western blot and enzyme-linked immunosorbent assays (ELISA). The H chain of IgE was excised from SDS-PAGE gels and used to develop rabbit anti-porcine IgE antisera. Antiserum obtained from rabbits immunized with porcine IgE, as well as heterologous murine and human-specific anti-IgE, induced reverse cutaneous anaphylaxis in pig skin and detected allergen-specific IgE in ELISA but did not react with IgG H chain in western blots. These results confirm allergy-associated bioactivity of porcine IgE and describe both homologous and heterologous anti-pig IgE suitable for use in allergen-specific and other assays. This will enhance utility of pig allergy models and provide an additional measure of type-2 immune response in pigs.

Immunoglobulin isotypes of lactating Holstein cows classified as high, average, and low type-1 or -2 immune responders.

Infectious diseases are detrimental to the health and economy of the livestock industry. Observations of cattle resistant to natural infections have implied the feasibility of breeding livestock for disease resistance. Studies of pigs selected for antibody (AMIR)- and cell (CMIR)-mediated immune responses have demonstrated increased immune responsiveness suggesting enhanced protection by both type 2 and type 1 responses, respectively. Additionally, natural or artificial infections of cattle suggest that the production of particular immunoglobulin (Ig) M, IgG1 and IgG2 isotypes are important for protecting against pathogens. In fact, IgG1/IgG2 ratios are often used to establish whether type 1 (CMIR) or type 2 (AMIR) responses predominate following immunization or infection. The objectives of this study were therefore; (1) to evaluate the Ig isotype bias responses to Candida albicans and hen-egg white lysozyme (HEWL) in cows classified as high responders (HR), average responders (AR) or low responders (LR) based on AMIR or CMIR; (2) to determine if ranking based on IFN-γ (a type 1 cytokine) and DTH responses were analogous in terms of ranking; and (3) to estimate IFN-γ, Ig isotypes, and DTH correlations. Antibody responses to HEWL and DTH to C. albicans were detected such that cows were phenotypically classified as HR, AR and LR for AMIR or CMIR with significant differences (p ≤ 0.05) among classified groups. C. albicans-induced IFN-γ allowed classification of cows, some of which had the same ranking as that of DTH response. The lowest IgG1/IgG2 ratio was to the C. albicans purified antigen (candin), but no differences were observed in anti-HEWL or anti-candin IgG1/IgG2 ratios between classified groups. Anti-HEWL IgG1 and IgG2 responses at day 21 post-immunization were negatively and significantly correlated with DTH to candin at 24h. There were no significant correlations between anti-HEWL or anti-candin IgG1 or IgG2 responses with IFN-γ. Based on Ig isotype bias, IFN-γ and DTH responses, it was concluded that immunization with C. albicans can be used to classify CMIR responder cows based on DTH read-out.