Small airway involvement in the late allergic response in asthma.

BACKGROUND: Allergy and asthma are closely linked. Inhalation of allergen induces an early allergic response (EAR) within the airways of allergic asthmatic subjects, which is followed by a late allergic response (LAR) in approximately 50% of the subjects. The LAR is defined as a drop in forced expiratory volume in 1 second (FEV1 ) from baseline usually occurring 4-8 hours after exposure and is believed to affect small airways. However, FEV1 is insensitive to changes in small airway physiology. OBJECTIVE: Our aim was to investigate and compare the pathophysiological processes in large and small airways during the EAR and the LAR and to characterize subjects with both an EAR and a LAR (dual responders) versus those with an EAR only (single responders). METHODS: Thirty-four subjects with allergic asthma underwent an inhaled allergen challenge. Lung physiology was assessed by spirometry, impulse oscillometry (IOS), body plethysmography, inert gas washout, single breath methane dilution carbon monoxide diffusion and exhaled breath temperature (EBT), at baseline and repeatedly for 23 hours post-allergen challenge. RESULTS: Peripheral airway resistance, air trapping and ventilation heterogeneity were significantly increased in dual responders (n = 15) compared to single responders (n = 19) 6-8 hours post-challenge. Parameters of peripheral airway resistance and ventilation heterogeneity, measured with IOS and inert gas washout, respectively, correlated at baseline and during the allergic airway response in all subjects. CONCLUSION: The LAR involves increased resistance and ventilation defects within the peripheral airways. Alternative definitions of the LAR including small airways pathophysiology could be considered. CLINICAL RELEVANCE: Small airway dysfunction during the LAR suggests that dual responders may have more extensive airway pathology and underscores the relevance of small airways assessment in asthma.

Xolair is effective in allergics with a low serum IgE level.

BACKGROUND: Two atopic patients suffering from severe allergy difficult to handle by conventional medication were given Xolair despite an IgE level <30 kU/l. METHODS: Increasing dosages were given and monitored by clinical evaluation and CD-sens to clinically relevant allergens. The patients' IgE antibody fractions were 11-14%. RESULTS: Xolair dosages extrapolated from a recommended dose for IgE of 30-75 kU/l were adapted to the patients' IgE body pool but had very little effect. The double dose resulted in some clinical improvement and a decrease in CD-sens. However, not until the dose was doubled again did the patients become symptom free, although 1 patient needed some additional drugs but no oral steroids. CD-sens turned negative to 5 of the 7 tested allergens. CONCLUSIONS: Xolair is most useful also in atopics with an IgE level <30 kU/l. The dose must be adjusted to the size of the IgE antibody fraction adding all non-cross-reacting, clinically relevant specificities.

After 6 years with Xolair; a 3-year withdrawal follow-up.

BACKGROUND: This study reports the clinical and immunological state of patients 3 years after a 6-year period of Xolair treatment for severe allergic asthma. METHODS: The patient's cat allergen sensitivity, measured as CD-sens, IgE and IgE- and IgG4 antibodies, was analysed and compared with asthma severity evaluated from FEV(1) and a questionnaire. RESULTS: Three years after treatment with Xolair was stopped, 12/18 patients reported improved or unchanged asthma compared with ongoing Xolair treatment. Most of the patients were in a stable clinical condition, 16/18 had not increased nightly asthma attacks and 14/18 little or no increase in medication. The CD-sens to cat was still significantly lower (P < 0.02) than untreated patients with allergic asthma and lower than expected from their serum IgE antibody levels. CONCLUSION: Most of the patients in this study had, still 3 years after closing of 6 years Xolair treatment, a surprisingly mild and stable asthma. Interestingly, the observed, considerable, downregulation of basophil allergen sensitivity, CD-sens, most likely representing mast cell allergen sensitivity, contributed to the clinical results.

The size of the disease relevant IgE antibody fraction in relation to 'total-IgE' predicts the efficacy of anti-IgE (Xolair) treatment.

BACKGROUND: Some patients with allergic asthma treated with anti-IgE (Xolair) do not become symptom free. Better criteria for response assessment than allergy skin tests or IgE determination are needed. The impact of the size of the disease relevant allergen-specific IgE antibody fraction, i.e. the percentage of IgE antibody of total IgE, was evaluated in cat allergic patients treated with the recommended doses of Xolair. Results were measured as changes in basophil allergen threshold sensitivity (CD-sens). METHODS: In a double-blind placebo controlled trial 20 patients with a high (>3.8%) and 18 with a low (<1%) percentage of IgE antibodies to cat were given Xolair for 16 weeks and the change in CD-sens was compared to 11 and 10 patients, respectively, in each group receiving placebo. RESULTS: The CD-sens dropped significantly in both the high (P < 0.001) and low (P < 0.001) group on Xolair but did not change significantly after placebo. For Xolair-treated patients, at the end of the trial there was a highly significant (P < 0.001) difference in CD-sens between the high group, where no patients, and the low group, where 13/18 patients, had become negative. CONCLUSIONS: The currently recommended doses of Xolair very efficiently eliminate IgE antibodies if the IgE antibody fraction is <1% of total IgE but has not enough effect on allergen sensitivity if the fraction is >3-4%. Further studies will show if increased doses of Xolair would help also these patients, who seem to represent about 1/3 of the patient population.

CD-sens and clinical changes during withdrawal of Xolair after 6 years of treatment.

BACKGROUND: Many clinical trials with omalizumab, Xolair, have been reported but the treatment period has always been short, i.e. <12 months. After withdrawal, the clinical symptoms tend to return. A group of patients who stopped treatment after approx. 6 years allowed studies of the long-term effects of Xolair. METHODS: The patient's cat or mite allergen sensitivity was quantitated as basophil allergen threshold sensitivity, CD-sens, and immunoglobulin E (IgE) and IgE- and IgG4-antibodies were determined before start and during treatment withdrawal. Asthma severity was evaluated from forced expiratory volume (FEV), peak expiratory flow (PEF) and a questionnaire. RESULTS: At 6-14 months without Xolair 13 of the 18 cat and mite allergic asthmatics had either improved or remained the same as on treatment. Most of the patients were in a stable clinical condition reporting high quality of life, no increased nightly asthma attacks, no emergency visits as well as little or no increase in medication. The CD-sens to cat showed a peak 4 months after withdrawal but then decreased to levels below those of untreated patients with allergic asthma and at 12 months six of 14 had nonreactive basophils. Cat IgG4 antibody levels were higher than in cat allergics in general. CONCLUSION: Most of the patients 12-14 months had, after closing of 6-year Xolair treatment, a surprisingly mild asthma. Interestingly, and probably contributing to the clinical results, a downregulation of basophil, and presumably also mast cell, reactivity, was seen.

Basophil allergen threshold sensitivity: a useful approach to anti-IgE treatment efficacy evaluation.

BACKGROUND: Monitoring of the allergen sensitivity of a patient is most important for optimal patient care and a basic prerequisite for immunomodulating treatment. The objective of this study was to investigate how basophil allergen sensitivity can be applied in the monitoring of anti-immunoglobulin E (IgE) treatment. METHODS: Basophils from timothy grass pollen allergic patients were, by flow cytometry, analysed for allergen threshold sensitivity (CD-sens) by measuring CD63 up-regulation on CD203c-identified basophils. The results were compared with maximal percentage CD63 up-regulation at one allergen dose (CD-max), skin prick test end-point allergen titration, (SPT-sens), nasal provocation titration tests (nasal provocation titre) and serum IgE and IgE antibody concentrations. RESULTS: There was a significant correlation (r = 0.50, P = 0.01) between CD-sens and SPT-sens, CD-sens and the IgE antibody concentration in percentage of 'total IgE' (relative IgE antibody concentration) (r = 0.72, P < 0.001) as well as between CD-sens and nasal provocation titre (r = 0.54, P < 0.05) but, in contrast, CD-max did not correlate with any of the sensitization parameters, i.e. SPT-sens, nasal provocation titre, absolute and relative IgE antibody concentration or CD-sens. CD-sens could be used to monitor omalizumab treatment efficacy while, based on CD-max, four of seven symptom-free patients on omalizumab would have been classified as having ongoing allergy. CONCLUSIONS: CD-sens seems to be very useful for the determination of a patient's allergen sensitivity and should be evaluated for the measurement and monitoring of anti-IgE treatment efficacy. CD-max, the conventional approach to basophil allergen challenge, which mirrors cell reactivity, gives incorrect information.

Circulating eosinophils in asthma, allergic rhinitis, and atopic dermatitis lack morphological signs of degranulation.

BACKGROUND: In allergic diseases, eosinophils in affected tissues release granule proteins with cytotoxic, immunoregulatory, and remodelling-promoting properties. From recent observations, it may be assumed that eosinophils degranulate already in circulating blood. If degranulation occurs in the circulation, this could contribute to widespread systemic effects and provide an important marker of disease. OBJECTIVE: To determine the degranulation status of circulating eosinophils in common allergic diseases. METHODS: Using a novel approach of whole blood fixation and leucocyte preparation, the granule morphology of blood eosinophils from healthy subjects, non-symptomatic patients, symptomatic patients with asthma, asthma and Churg-Strauss syndrome, allergic rhinitis, and atopic dermatitis was evaluated by transmission electron microscopy (TEM) and eosinophil peroxidase (TEM) histochemistry. Plasma and serum levels of eosinophil cationic protein were measured by fluoroenzymeimmunoassay. Selected tissue biopsies were examined by TEM. RESULTS: Regardless of symptoms, circulating eosinophils from allergic patients showed the same granule morphology as cells from healthy subjects. The majority of eosinophil-specific granules had preserved intact electron-density (96%; range: 89-98%), while the remaining granules typically exhibited marginal coarsening or mild lucency of the matrix structure. Abnormalities of the crystalline granule core were rarely detected. Furthermore, granule matrix alterations were not associated with any re-localization of intracellular EPO or increase in plasma eosinophil cationic protein. By contrast, eosinophils in diseased tissues exhibited cytolysis (granule release through membrane rupture) and piecemeal degranulation (loss of granule matrix and core structures). CONCLUSION: In symptomatic eosinophilic diseases, circulating blood eosinophils retain their granule contents until they have reached their target organ.

Protection against cold air and exercise-induced bronchoconstriction while on regular treatment with Oxis.

This study aimed to compare the duration of protection against exercise-induced bronchoconstriction (EIB) after inhalation of formoterol (Oxis) Turbuhaler with that of terbutaline Turbuhaler and placebo Turbuhaler in asthmatic patients treated regularly with formoterol Turbuhaler 9 microg b.i.d. and inhaled steroids. The study. performed at three centres (Göteborg and Lund, Sweden, and Trondheim, Norway), consisted of an open-label part with formoterol Turbuhaler 9 microg b.i.d. and a randomized, double-blind, cross-over part with a single dose (on top of the regular treatment) of either formoterol Turbuhaler 9 microg, terbutaline Turbuhaler 0.5 mg or placebo Turbuhaler. The patients attended the clinic six times: twice for screening visits, three times for randomized treatment and once for a follow-up visit. Patients received regular b.i.d. treatment with formoterol 9 microg for a mean period of 16 days. Formoterol gave a post-exercise fall of 12, 10, 15 and 17% in forced expiratory volume in 1 sec (FEV1) 15 min, 4, 8 and 12 h after inhalation. The differences compared with placebo (falls of 26, 22, 23 and 22%) and terbutaline (falls of 17, 18, 22 and 22%) were all statistically significant (P<0.05 for all comparisons). Patients on regular treatment with formoterol Turbuhaler 9 microg b.i.d. have a significant protection against EIB up to 12 h after inhalation of formoterol 9 microg. The protection was also significantly better than that of terbutaline Turbuhaler 0.5 mg.

Hyperhomocysteinemia and changed plasma thiol redox status in chronic obstructive pulmonary disease.

Reduced and total homocysteine, cysteine, glutathione and cysteinylglycine in plasma were investigated in 19 patients with chronic obstructive pulmonary disease and in 29 healthy subjects. The purpose was to examine the influence of pro-oxidant activity caused by the lung disease on the metabolism of homocysteine and other plasma thiols. We observed a decreased concentration of reduced glutathione and a decreased ratio of reduced/total glutathione in the patients compared to the healthy individuals, which supports the hypothesis of an association between free radicals and pathogenesis in some lung diseases. We also observed an increased total plasma homocysteine. The influence of a possible extracellular pro-oxidant activity on the concentration of total plasma homocysteine is discussed.

Estrogen receptor content in adenovirus type 9-induced rat mammary tumors.

Hormonal factors play an important role in the induction of mammary tumors and tumor-like lesions in adenovirus type 9-inoculated W/Fu rats. Primary Ad 9-induced fibroadenomas contained significantly higher amounts of estrogen receptor (determined by means of enzyme immunoassay) in comparison to normal breast tissue (p = 0.01**) and "spontaneous" fibroadenomas (p = 0.03*), used as control tissues. The receptor content of serially isografted virus-induced fibroadenomas did not differ significantly from the two types of control tissue. The findings suggest that changes in the estrogen receptor level are of importance in the tumor induction process, but also that additional factors are required for the preservation of tumor characteristics as well as for lipoma induction.

Laser-induced fluorescence in malignant and normal tissue of rats injected with benzoporphyrin derivative.

Laser-induced fluorescence was used to characterize the localization of intravenously administered benzoporphyrin derivative-monoacid (BPD-MA) 3 h postinjection in different rat tissue types, including an induced experimental malignant tumor. A comparison of the fluorescence properties and demarcation potential between the newer sensitizer BPD-MA and four other substances, hematoporphyrin (HP), polyhematoporphyrin ester (PHE), tetrasulfonated phthalocyanine (TSPc) and the commercially available Photofrin earlier investigated, is included. The fluorescence light was induced with a nitrogen laser, emitting at 337 nm. The fluorescence spectrum in the region 380-750 nm was analyzed by a polychromator equipped with a diode array detector. The demarcation potential between tumor and surrounding tissue in terms of fluorescence signal for the tumor model used was 2:1 for BPD-MA. In comparison with the other drugs, HP shows about the same demarcation potential, whereas Photofrin and PHE exhibit about 3 times better and TSPc about 1.5 times better demarcation. By also employing the endogenous tissue fluorescence signature the contrast was enhanced by a factor of about 2 for each of the five drugs.

Inhibition of platelet aggregation by granulocytes stimulated during experimental trauma.

The effect of granulocytes, stimulated in vivo by standardized soft tissue trauma, on the aggregation of autologous platelets in vitro, was studied in the pig. Platelet aggregation induced by ADP and arachidonic acid was inhibited when platelets harvested before trauma were incubated with granulocytes obtained 5 min after trauma. The granulocytes were separated from the platelets during the incubation by enclosure in dialysis tubes. Platelet inhibition was evident when the cell cohorts were suspended in cell-free medium as well as in autologous plasma extracted before trauma. In addition, incubation of platelets harvested before trauma with plasma obtained after trauma decreased platelet aggregation. In conclusion, granulocytes stimulated in vivo inhibited platelet function in vitro. Platelet inhibitory activity was shown to be related with the granulocytes per se, but also with factors present in plasma after trauma.

A microcalorimetric vessel for monitoring cytotoxic reactions in the micro-submicrowatt region.

A microcalorimetric vessel for monitoring the initial phases of cytotoxic reactions in the micro-submicrowatt region has been designed and tested. The vessel is intended to be used with a multichannel microcalorimetric system from Thermometric, Järfälla, Sweden and can be built up stepwise in a modular way. The different functions of perfusion, stirring and addition of small amounts of soluble immune reactants can be used separately but also in combination. This is accomplished by the use of a vertical stirring mechanism and a reaction vessel of low volume, 200 microliters. The simplicity of the vessel permits an identical vessel to be used on the reference side, handled in parallel with the measuring vessel. No gas phase is present.

Adenovirus type 9-induced tumorigenesis in the rat mammary gland related to sex hormonal state.

Adenovirus type 9 was inoculated sc into newborn Wistar/Furth rats, divided into four groups: (1) six male rats, not treated further; (2) 11 male rats, castrated at 4 weeks of age; (3) 12 male rats, castrated at 4 weeks of age and subsequently treated repeatedly with estrogen; and (4) 12 female rats, not treated further. All of the rats in group 3 developed mammary hyperplasia and tumors (fibroadenomas and lipomas), in some cases with malignant histologic structure. Rats in group 4 developed similar mammary tumors, but with later appearance and significantly slower growth. A fifth group of rats, not virus inoculated but castrated and estrogen treated as in group 3, did not develop any demonstrable mammary lesions. The results show that the effects of the virus on the mammary gland are dependent upon an estrogenic background, which by itself cannot cause tumor development in males. It is suggested that viral DNA is incorporated into the cellular DNA in such a way that it influences the synthesis and/or activity of steroid receptors, triggering tumor development.

Inhibition of platelet aggregation by myeloid leukaemic cells demonstrated in vitro.

The effect of myeloid leukaemic cells, cells of the promyelocytic cell line HL-60 and normal polymorphonuclear granulocytes (PMN), enclosed in dialysis tubes, on the aggregation of allogeneic normal platelets after induction with arachidonic acid (AA) and with adenosine diphosphate (ADP) was investigated in vitro. Inhibition of aggregation was seen after preincubation of the platelets with leukaemic blood or bone marrow cells from 7/14 patients belonging to various FAB groups and with HL-60 cells, but not with normal PMN (14/14 cases). A dose-dependent inhibition was seen after lysis of some leukaemic cells with anti-human rabbit antiserum and active complement. Lysis of normal PMN inhibited platelet aggregation slightly and inconstantly and only at higher cell concentrations. Platelet inhibitory activity was not related to a higher rate of metabolism of the leukaemic cells which inhibited platelet aggregation since they did not differ from the cells not inhibiting aggregation with respect to heat production. Neither was a non-specifically increased cell membrane permeability the cause of the release of platelet inhibitory factor(s) since the release of 51Cr-labelled leukaemic cells was not related to the inhibition of platelet aggregation.

Abnormal granulocyte functions in autoimmune disorders demonstrated by microcalorimetry.

Heat production by polymorphonuclear granulocytes (PMN) was assayed in 14 patients suffering from diseases known to be associated with circulating immune complexes (CIC) and in 10 healthy blood donors. The patients' PMN produced significantly more heat than the normal PMN when the cells were suspended in autologous plasma (23.8 +/- 3.9 pW/cell vs. 18.1 +/- 1.9 pW/cell, p less than 0.0005), but not when the cells were suspended in tissue culture medium (5.6 +/- 1.2 pW/cell vs. 5.6 +/- 0.8 pW/cell, p greater than 0.05). After mixing with IgG-coated latex particles the heat production by patients' PMN were significantly less stimulated than that of normal PMN when the cells were suspended in autologous plasma (42 +/- 13% vs. 75 +/- 22%, p less than 0.0005), but not when the cells were suspended in tissue culture medium (82 +/- 24% vs. 83 +/- 22%, p greater than 0.05). The increase of heat production by normal PMN after stimulation with IgG-coated latex particles was significantly lower when the cells were preincubated with heat aggregated human gammaglobulin compared to that obtained when the cells were preincubated in saline (11 +/- 10% vs. 51 +/- 11%, p less than 0.001). This finding shows that the increased PMN heat production which occurs after binding of the IgG-coated particles is mediated via Fc receptors. A plasma factor(s), possibly circulating immune complexes, can explain the abnormal PMN functions in the patients.

Fluorescence studies of hematoporphyrin derivative in normal and malignant rat tissue.

Laser-induced fluorescence in rat tissue was studied during the uptake and clearing period of i.v.-injected hematoporphyrin derivative. A malignant rat tumor and normal tissue of 20 different kinds from the tumor-bearing animals were investigated. A pulsed nitrogen laser (337 nm) was used in conjunction with an optical multichannel analyzer system, in which the whole fluorescence light distribution was captured for each laser pulse. Several of the organs exhibited an initial and a delayed intensity peak in the characteristic hematoporphyrin derivative laser-induced fluorescence intensity (630 nm) that might be interpreted as due to intracellular transformations of different chemical components of the hematoporphyrin derivative preparation. By dividing the background-free 630-nm signal by the blue fluorescence intensity, a dimensionless quantity is obtained that could have many advantages in practical endoscopic laser-induced fluorescence work. This ratio was also shown to exhibit a larger contrast between tumor and surrounding tissue. The ratio between the two red fluorescence peaks was also found to be useful for discriminating tumor from normal tissue. A combination of the two ratios was shown to be particularly valuable for tumor discrimination.

Demonstration of antibodies binding to autologous and allogeneic leukemic cells in childhood ALL. Evidence for a common ALL antigen(s).

The humoral immune response to autologous leukemic cells was investigated in childhood ALL using a 125I protein A binding assay. In 5/7 patients antibodies were demonstrated at diagnosis and in 3/7 cases also after chemotherapy. Sera from 2/3 patients, which bound significantly to autologous leukemic cells, did not bind significantly to autologous remission cells. In allogeneic experiments sera bound significantly to ALL leukemic cells (6/7 positive combinations), but not to AML leukemic cells (8/8 negative combinations). We propose that ALL sera contain antibodies binding to autologous leukemic cells and that they are directed against a common ALL antigen(s).

Use of microcalorimetry in analysing the kinetics of ADCC.

Microcalorimetry was found to be a useful technique for the demonstration of antibody-dependent cellular cytotoxicity (ADCC) against human melanoma cells mediated by a heterologous rabbit antiserum and two monoclonal antibodies in combination with human peripheral blood lymphocytes as effector cells. The rabbit antiserum and the monoclonal IgG3 antibody 2B2 directed against the GD3 ganglioside expressed cell-inhibitory effects resulting in a decreased heat production rate over 2-18 h of incubation. The 4.2 monoclonal IgM antibody to GD3 had no similar cell-inhibitory effect. In contrast, the 4.2 antibody expressed a much stronger effect than 2B2 in tests for complement-dependent cytotoxicity. The kinetics of these effects were quite reproducible. It is concluded that microcalorimetry is a sensitive and particularly suitable method for the analysis of cytotoxicity kinetics.

Differentiation of myeloid leukemic cells in vitro demonstrated by microcalorimetry: stimulation of leukemic and remission cells by IgG-binding Fc receptors.

Interaction of immunoglobulin G (IgG)-coated latex particles with Fc receptors on myeloid leukemic blood cells and on polymorphonuclear granulocytes (PMN) from remission patients and healthy blood donors was investigated using microcalorimetry. The induced heat production by leukemic cells from 13 patients with the M2, M4 and M5 FAB groups (French-American-British classification) of acute myeloid leukemia (AML) was significantly higher than that of leukemic cells from 7 patients with the M1 FAB group (p less than 0.005) and mononuclear blood cells from 10 healthy individuals (p less than 0.005). The values were similar for PMN from 10 remission patients and 10 healthy blood donors. After incubation of M1 cells in vitro for 24-30 h at 37 degrees C the heat production induced by IgG-coated latex particles by the cells increased significantly, indicating the appearance of Fc receptors for IgG. In addition, the heat production by unstimulated M2, M4 and M5 cells was significantly higher than that by unstimulated M1 cells (p less than 0.005) and normal mononuclear cells (p less than 0.0005). The heat production by unstimulated PMN suspended in tissue culture medium was similar in remission patients and healthy blood donors.