Intrasinus catheter-directed heparin infusion in the treatment of dural venous sinus thrombosis.

BACKGROUND AND PURPOSE: In this small series, local intrasinus catheter-directed heparin infusion with or without balloon thrombectomy was safe in the treatment of dural venous sinus thrombosis (DVST). Although systemic anticoagulation (SAC) is the treatment of choice, there is a lack of consensus regarding the best treatment should SAC fail or be contraindicated. We present our institutional experience with 16 patients in whom failure of, or contraindication to, SAC occurred and who subsequently underwent intrasinus catheter-directed heparin infusion with or without balloon thrombectomy. MATERIALS AND METHODS: A retrospective review of 16 patients ranging in age from 14 days to 77 years who had intrasinus catheter-directed heparin infusion was undertaken with 9 male and 7 female patients identified. Of these 16 patients, 4 (25%) had a contraindication to SAC and SAC failed in 12 (75%). Technically successful intrasinus infusion catheter placement was achieved in all 16 patients (100%). Mean duration of infusion was 3.3 days (range, 1-6 days). Adjunctive balloon thrombectomy was performed in 9 (56.3%) of 16 patients. No procedure-related mortality occurred. RESULTS: Partial and complete sinus recanalization occurred in 10 (62.5%) of 16 patients and 1 (6.3%) of 16 patients, respectively. There were 3 deaths (18.8%) attributed to disease progression. At most recent clinical follow-up (mean, 9.3 months), 11 (84.6%) of 13 surviving patients were independent, with a modified Rankin Scale (mRS) score of 1 or less. CONCLUSIONS: Local intrasinus catheter-directed heparin infusion with or without adjunctive balloon thrombectomy seems to be a safe and effective treatment of DVST in patients in whom SAC failed or in whom there was a contraindication to SAC. In addition, the risk for symptomatic intracranial hemorrhage may be significantly lower than intrasinus infusion of thrombolytics.

Sphenoidal electrode placement using biplane fluoroscopy and rotational flat panel CT imaging.

Assessment of otherwise occult seizure foci arising from the anterior mesial temporal region occasionally necessitates placement of sphenoidal electrodes (SEs). This minimally invasive procedure is often performed without imaging guidance; however, more precise lead positioning with a reduced risk of complications has been described with fluoroscopic guidance. We describe the added value of rotational flat panel CT imaging for precise anatomic localization of the SE tip in relation to the foramen ovale.

Novel intra-arterial strategies in the treatment of acute ischaemic stroke.

Acute ischaemic stroke is among the leading causes of death and disability in developed societies. I.v. and intra-arterial thrombolysis, and mechanical thrombectomy carried out within the appropriate time window can result in superior clinical outcomes compared with traditional therapy consisting of anticoagulation and/or aspirin. In cases where thrombolysis and/or thrombectomy have not been proven effective or have failed to result in rapid clinical and/or angiographic improvement, novel intra-arterial strategies may be applied by experienced interventional neuroradiologists to achieve recanalization of recalcitrant vessel occlusions with good clinical outcomes.

Incidental giant arachnoid granulation.

Arachnoid granulations may expand the dural sinuses or inner table of the skull. Although usually incidental, giant arachnoid granulations that are of sufficient size to fill the lumen of a dural sinus and cause local dilation or filling defects can rarely cause symptoms due to sinus obstruction leading to venous hypertension. This 31-year-old man presented with a 3-month history of progressive bifrontal headaches and a giant arachnoid granulation at the posterior superior sagittal sinus. Intrasinus pressure measurements showed no significant pressure difference across the lesion to explain the headaches, which were then treated medically. Dural sinus pressure measurement, in certain cases of giant arachnoid granulations, can be used to exclude the lesion as the cause of the patient's symptoms.

Prevalence and clinical relevance of specific immunoglobulin E to pollen caused by sting- induced specific immunoglobulin E to cross-reacting carbohydrate determinants in Hymenoptera venoms.

BACKGROUND: Hymenoptera stings can induce specific IgE (sIgE) to carbohydrate determinants (CD) on venom glycoproteins that cross-react with CD in pollen. sIgE to such cross-reacting CD (CCD) are believed to have little or no biological activity and thus may cause misdiagnosis of pollen sensitization after a sting. OBJECTIVE: To determine the prevalence of multiple false positive CAP results to pollen because of sting induced anti-CCD sIgE in Hymenoptera venom (HV) allergic patients and to investigate the association of such anti-CCD sIgE with features of 'atopy'. METHODS: Skin prick tests (SPT) and CAP tests with grass, tree and weed pollen and with house dust mite (HDM) were carried out prospectively in 259 HV allergic patients and CAP tests with honeybee (HBV) and yellow jacket (YJV) venom were performed. Patients with negative pollen SPT associated with positive CAP tests to all three pollen groups were operationally defined as 'CCD positive'. We investigated in selected 'CCD positive' patients the presence of anti-CCD sIgE by CAP tests with bromelain and studied the identity of CD in HVs and pollen by mutual sIgE inhibition tests with CD from proteinase treated HBV (HBV-CD) and Lolium perenne (Lol-CD) extracts. RESULTS: sIgE to all three pollen groups without positive SPT or history was found in 16% of 259 patients. The presence of anti-CCD sIgE was substantiated by positive CAP tests with bromelain in 14/14 and by inhibition of all pollen CAP tests with HBV-CD in 8/9 and with Lol-CD in 2/2 patients. Double venom (DV) positive CAP tests were present in 93% of 'CCD positive' patients and were in some associated with DV skin test positivity and allergy. The prevalence of 'CCD positivity' was significantly higher among HBV (23%) than among YJV (11%) allergic patients, but was also unexpectedly high among those with DV allergy (47%). 'CCD positive' patients were younger, had a higher total IgE and more sIgE to HDM than 'CCD negative' patients. CONCLUSION: We have shown that the risk in HV allergic patients for misdiagnosis of multivalent pollen sensitization is 16%, and we have confirmed that sting induced anti-pollen sIgE are directed to similar CD in venoms and pollen. We found evidence that the recognition of CCD might be related to the 'atopic' trait. Importantly, a positive bromelain CAP test does not exclude clinical reactivity to both venoms in 'CCD positive' HV allergic patients.

The circulating lymphocyte profiles in patients with discoid lupus erythematosus and systemic lupus erythematosus suggest a pathogenetic relationship.

BACKGROUND: Discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE) are chronic inflammatory diseases of unknown aetiology; the relationship of DLE with SLE has been a subject of debate for many years. OBJECTIVES; To find evidence for systemic immune activation in DLE by analysis of the immunophenotypic profiles of circulating lymphocytes, and to compare these changes with those in patients with SLE. METHODS: The immunophenotypic profile of peripheral blood lymphocyte subsets from 23 DLE patients without clinical or laboratory evidence of systemic disease, 25 SLE patients and 38 healthy donors was characterized by two-colour immunofluorescence flow cytometry analysis. None of the patients was receiving corticosteroid or immunosuppressive treatment. RESULTS: Patients with DLE had increased numbers of circulating HLA-DR+ CD3+ T cells and HLA-DR+ CD4+ T cells, indicating systemic T-cell activation, and an expansion of CD5+ CD19+ B cells. Decreased numbers of T-cell subsets expressing the differentiation markers CD11b and CD16/56, and of CD16/56+ natural killer cells were also found. In SLE, the changes were similar but more pronounced. In addition, a profound CD4+ T-cell lymphopenia and an increase of HLA-DR+ CD8+ T cells were found only in SLE. CONCLUSIONS: Our data provide evidence for systemic activation of the cellular immune system in patients with purely cutaneous DLE. Similarities in the lymphocyte immunophenotypic profiles in patients with DLE compared with SLE suggest that there are common immunopathological processes in these two conditions.

Different circulating lymphocyte profiles in patients with different subtypes of juvenile idiopathic arthritis.

OBJECTIVE: To determine the immunophenotypic profiles of circulating lymphocytes in patients with different disease types of Juvenile Idiopathic Arthritis (JIA). METHODS: Peripheral blood lymphocyte subsets from 19 patients with oligoarticular JIA (o-JIA), 10 patients with polyarticular JIA (p-JIA), 12 patients with systemic JIA (s-JlA) andfrom 41 age-matched healthy controls were characterized by two color immunofluorescence flow cytometry analysis. RESULTS: Patients with o-JIA and p-JIA had increased numbers of HLA-DR+ Tcells and Tcells co-expressing CD57 and CD16/56, indicating T cell activation and terminal differentiation of CD8+ T cells respectively. By contrast, in patients with s-JIA there was no increase in the activation or differentiation markers on T cells, but a profound decrease in circulating NK cells. All patients had hypergammaglobulinemia consistent with B cell hyperactivity, but increased numbers of CD5+ B cells were found only in o-JIA and p-JIA. CONCLUSION: Distinct immunophenotypic lymphocyte profiles in patients with o-JIA and p-JIA compared to patients with s-JIA as demonstrated in this study, are consistent with afundamental heterogeneity of the disease.

Haptoglobin interacts with the human mast cell line HMC-1 and inhibits its spontaneous proliferation.

Haptoglobin (Hp) is an acute phase reactant produced by hepatocytes. There is evidence for an immunomodulatory potential of Hp, though there is no clear evidence yet about the mechanisms of this action. We have previously shown that Hp interacts with the beta2-integrin CD11b/CD18. In addition, other investigators reported the binding of Hp to B lymphocytes through the CD22 receptor, and to neutrophils through two different receptors. In the present study, we investigated the interaction of haptoglobin with the human mast cell line HMC-1. We report that fluorescein isothiocyanate (FITC)-labelled haptoglobin binds to this cell line and that binding is increased by calcium in a dose- and time-dependent manner. Hp binding sites on HMC-1 were upregulated upon stimulation with phorbol myristate acetate (PMA)/A23187 and after treatment with anti-CD43 and anti-CD44 monoclonal antibodies (MoAbs). HMC-1 cells do not express either CD11b/CD18 or CD22 receptors, indicating that the haptoglobin-binding receptor on this cell line is different from the known receptors. Assessment of cell function showed that Hp inhibits the spontaneous growth of HMC-1 up till 40% at higher Hp concentrations, but it did not exhibit any effect on the expression of CD54 on the release of either tryptase or IL-1ra. In conclusion, haptoglobin binds specifically to human mast cells via a receptor different from CD11b/CD18 and CD22, and may play a role in the modulation of mast cell functions. Exploration of Hp effects in mast cell-dependent diseases such as allergic rhinitis and urticaria seems warranted.

Comparative study of two cytofluorometric methods of analysis.

Cytofluorometry of lymphocytes is an important technique in experimental biology and clinical medicine. One source of variability in the results with this technique stems from the difficulty of delineating cell subpopulations on a visual basis. We have evaluated the performance of a novel software method (Attractor), which introduces cluster analysis for the more precise definition of cell populations. Using 115 blood samples from patients with various immunological diseases, we compared the results obtained for 19 lymphocyte cell populations employing either the Attractor program or a conventional program (Cellquest). The analysis focused on inter-observer and inter-method variability and comparability. Inter-observer variability was significantly lower with the Attractor software, particularly when quantifying small cell populations such as activated subsets. The results obtained with both methods showed high correlation coefficients except for some cell populations that were either very small or which had to be calculated from the sum of other counts. The performance of the novel flow cytometric software is similar to software programs currently in use, but it offers an advantage for the definition of small and/or activated lymphocyte subpopulations. Moreover, the consistency of the measurements is better. A major disadvantage for statistical analysis, however, is that the Attractor program has not been adapted for non-parametric data.

Purification and characterization of an 18-kd allergen of birch (Betula verrucosa) pollen: identification as a cyclophilin.

BACKGROUND: Five birch pollen allergens have been identified so far. In a previous study we detected new birch pollen allergens with an isoelectric point in the range 9.0 to 9.3, present only in extracts prepared at controlled basic pH. OBJECTIVE: The purpose of the current study was to purify and characterize those allergens. METHODS: The target allergens were purified by ion exchange and hydrophobic interaction chromatography. Analyses were carried out by SDS-PAGE, isoelectric focusing, immunoblotting, and amino acid sequencing. The in vivo reactivity of the allergens was evaluated by skin testing. RESULTS: An 18-kd protein, which we named Bet v 7, was purified. This 18-kd protein corresponded to 3 bands on isoelectric-focusing immunoblots that probably represent isoforms. On immunoblots up to 20.8% of birch pollen-allergic patients recognized those allergens. The clinical relevance of Bet v 7 was demonstrated by positive immediate-type skin testing on a patient allergic to birch pollen. Sequencing of an internal peptide yielded an amino acid sequence showing high homology with various plant cyclophilins. The rotamase activity of the protein, inhibited by cyclosporin A, further confirmed that Bet v 7 belongs to the group of cyclophilins. CONCLUSION: We have purified a novel allergen of birch pollen, Bet v 7, belonging to the cyclophilin family. Because cyclophilins are highly conserved proteins over the phylogeny, we may postulate that Bet v 7 is a member of a new family of panallergens.

Composition and stability of allergenic extracts made from gamma-irradiated rye grass (Lolium perenne) pollen.

BACKGROUND: Phenol is commonly added to allergenic extracts as a bacteriostatic agent, but it is poisonous and also detrimental to proteins, which accelerates extract degradation. Sterilization by gamma-irradiation of the source material could be an alternative to the use of phenol. OBJECTIVE: To analyse the potential effects of gamma-irradiation of pollen on the composition, potency, and stability of the resulting extract, and compare them with those of phenol. METHODS: Ryegrass (Lolium perenne) pollen was sterilized by gamma-irradiation at a dose of 25 kGy. Extracts prepared from the irradiated pollen were then compared by electrophoresis techniques and RAST inhibition to extracts, without or with 0.5% phenol, from nonirradiated pollen. In addition, proteolytic activity was compared in extracts from irradiated and nonirradiated pollen. To evaluate the stability of extracts on storage, they were analysed after forced degradation for up to 7 days at 37 degrees C. RESULTS: When fresh extracts were analysed, there were no noticeable differences between the three types, as judged by immunoblotting and RAST inhibition experiments. However, on storage, extracts from irradiated pollen appeared to be superior to extracts from nonirradiated pollen, as some proteins were more stable in the former. This could be related to the lower proteolytic activity we have also observed in extracts from irradiated pollen. In contrast, extracts containing phenol degraded much faster, as proven by all our methods of investigation. CONCLUSION: Gamma-irradiation of pollen did not influence the IgE-binding capacity of the resulting extracts, but did yield extracts with somewhat improved stability, probably by reducing the proteolytic activity. It may be concluded that gamma-irradiation of the source material represents a good alternative to the use of phenol for the preparation of allergenic extracts.

Allergenic and antigenic activity of peptide fragments in a whey hydrolysate formula.

BACKGROUND: Milk hydrolysates, although frequently used as substitutes in cases of cow's milk allergy, show a reduced but never a complete abolishment of antigenicity and allergenicity. OBJECTIVE: Our purpose was to determine the lower molecular weight limit of peptides to elicit skin reactions and to bind IgE antibodies in vitro. METHODS: Using FPLC, an ultrafiltrated whey hydrolysate, was fractionated in different molecular weight fractions. Skin-prick tests were performed with the hydrolysate and its fractions in five cow's milk allergic children, and RAST inhibition tests were done using the serum of these children. RESULTS: On the basis of the lowest extinction values between two peaks of the chromatogram, seven fractions with molecular weights between 15000 and 125 Da were obtained. Peptides of > 2600 Da elicited a clearly positive skin reaction and inhibited IgE-binding, while peptides of < 1400 Da did not give any positive skin reaction but were still able to inhibit to a small extent IgE-binding to the hydrolysate. CONCLUSION: Our findings suggest that for skin reactivity peptides of > 1400 Da are needed. The minimal molecular mass for IgE binding in vitro appears to be situated between 1400 and 970 Da. Such peptides might be used to develop a safe formula for patients reacting to milk hydrolysates or even for tolerance induction.

Allergenic proteins in different brands of latex and synthetic medical examination gloves.

The steady increase in anaphylactic reactions to latex medical gloves has raised increasing awareness in the medical community. Even gloves claimed to be hypo-allergenic still may contain substantial amounts of IgE-binding proteins. We have studied non-powdered latex and synthetic examination glove extracts for their allergenicity using the immunoblot technique. Protein levels varied considerably among glove extracts and the amount did not always correlate with the presence of allergenic proteins. IgE binding proteins were found in 2 of the 7 powder-free latex glove brands. Synthetic glove extracts did not contain allergens. The study demonstrates that immunoblot analysis is a useful technique in order to select gloves with a minimal risk to raise IgE antibodies.

Determination of independent risk factors and comparative analysis of diagnostic methods for immediate type latex allergy in spina bifida patients.

BACKGROUND: Development of allergy to natural rubber latex in spina bifida patients is determined by several risk factors, such as age, number of interventions and atopic disease that are, however, interdependent. Furthermore, several diagnostic procedures have been analysed, but a comprehensive analysis of their diagnostic significance is lacking. OBJECTIVE: To determine the independent major risk factor(s) for development of natural rubber latex allergy and the most valuable diagnostic procedure. METHODS: In aselectively collected spina bifida patients, we correlated existing natural rubber latex allergy with age, sex, atopy and the number of hospitalizations and of surgical interventions in appropriately matched subgroups. Allergy to natural rubber latex was established by application of a latex glove fragment on the skin. Skin-prick tests with glove eluate, a natural latex extract and a commercial latex extract were carried out as were specific IgE measurements by radioimmuno assay (RAST-CAP). The results of the latex application test are compared with the other diagnostic methods. RESULTS: Out of 74 fully evaluated patients, 17 had a positive application test. The number of surgical interventions correlates strongly with the presence of natural rubber latex allergy (P<0.0002), independent of age, sex and presence of atopy. Skin-prick tests with unstandardized allergens made from known high allergenic latex gloves represent the most sensitive diagnostic method, with the highest negative predictive value and a specificity of 0.95. RAST-CAP was the next best method with a specificity of 0.93, a sensitivity of 0.89 and a negative predictive value of 0.97. CONCLUSION: The number of surgical interventions is the major independent determining factor for allergy to natural rubber latex in spina bifida patients. Unstandardized skin-prick tests are the most sensitive and specific diagnostic tool, but RAST-CAP is almost equally performant and therefore a valid alternative.

Inhalative occupational and ingestive immediate-type allergy caused by chicory (Cichorium intybus).

We report a first case of occupational allergy to chicory (Cichorium intybus) in a vegetable wholesaler. Symptoms occurred after oral, cutaneous or inhalatory exposure. The patient also reported reactions after ingestion of botanically related endive (Cichorium endivia) and lettuce (Lactuca sativa). We identified the responsible allergen by SDS-PAGE and immunoblot to be a 48-kDa protein, confined to the non-illuminated parts of the plants. No cross-reactivity was found with mugwort (Artemisia vulgaris), ryegrass (Lolium perenne), and birch (Betula verrucosa) pollen, which suggests that the vegetable is the primary allergenic material.

Identification of haptoglobin as an alternative ligand for CD11b/CD18.

Haptoglobin is an acute phase protein with presumed anti-inflammatory activities. We report that purified fluorescein-labeled haptoglobin 1-1 binds to THP1 and U937 promonocytic cell lines, to monocytes, to granulocytes, and to a subset of CD8+ T cells and to NK cells. Studies with radioiodinated haptoglobin on THP1 cells were consistent with specific binding to one class of receptors with a density of 1.7 x 10(5) binding sites per cell and a low affinity of 6.5 x 10(-6) Kd. Binding was increased by Ca2+ and by Ca2+ and ADP. Binding to THP1 and U937 cells could be inhibited by preincubation with nonfluoresceinated haptoglobin and by fibrinogen, but not by albumin, transferrin, or alpha1-acid glycoprotein. Fibrinogen binds to the CD11b/CD18 integrin. We therefore examined whether haptoglobin has the same receptor. The anti-CD11b mAb44 indeed inhibited the binding of fluoresceinated haptoglobin to THP1 and U937 cell lines, and haptoglobin inhibited the binding of the anti-CD11b mAb anti-Leu15 and mAb44 to both cell lines. An anti-CD18 mAb partly inhibited the binding of fluoresceinated haptoglobin to THP1 and U937, indicating that the beta-chain of MAC-1 is also involved in haptoglobin binding. There was no interference between the binding of anti-CD4, anti-CD11a, or anti-CD11c mAb and haptoglobin binding to THP1 cells. Binding of haptoglobin to purified CD11b/CD18 indicates that it binds directly to the receptor. Haptoglobin is an alternative low affinity ligand for the CD11b/CD18 integrin, suggesting that this acute phase protein might regulate MAC-1-dependent cell function in vivo.

The effect of sucrose on the quality of ryegrass (Lolium perenne) pollen extracts.

We studied the protein-stabilizing properties of sucrose, in the extraction medium, on the composition and stability of ryegrass (Lolium perenne) pollen extracts. The effect of 0.5 M and 1 M sucrose was assessed in the presence and absence of 0.5% phenol, which is commonly used as a disinfectant in industrially prepared allergenic extracts. In the absence of phenol, sucrose improves the stability of extracts during storage, but it has little influence on the extraction process. In the presence of 0.5% phenol, however, both the quality of fresh extracts and the stability are greatly improved by 0.5 M and by 1 M sucrose, as shown by electrophoresis, immunoblotting, and RAST-inhibition experiments. The protection afforded by sucrose against the degrading effect of phenol is particularly evident for the major allergen Lol p 1 and for a set of basic allergens. In this respect, sucrose has been found to be superior to glycerol, on an equimolar basis. One may envisage the use of 0.5 M sucrose in allergenic extracts for intradermal testing and immunotherapy.

Influence of the pH of the extraction medium on the composition of birch (Betula verrucosa) pollen extracts.

Extracts from birch (Betula verrucosa) pollen were prepared at different pH, with constant pH monitoring and adjustment to preset values in the range 5.5-8.5. The total protein content of these extracts was directly correlated with the pH. Coomassie brilliant blue-stained isoelectric focusing and SDS-PAGE gels and immunoblot analysis demonstrated qualitative differences: some proteins were lost while others appeared when pH was changed. At pH 8.5, formerly unknown birch pollen allergens were detected with pI 9, 9.10, and 9.30 by about 30% of birch pollen-sensitive sera. Birch pollen extracts prepared at a pH close to neutrality, namely, 6.5 and 7.5, showed the greatest protein and different allergen diversity. Thus, extraction pH values are necessary to analyze the whole pattern of allergenic components in an extract.

Safety and efficacy of a 12-week maintenance interval in patients treated with Hymenoptera venom immunotherapy.

It is currently recommended to administer a maintenance dose of 100 micrograms of venom at 4-6 week intervals for Hymenoptera venom immunotherapy (VIT). Because the optimal duration of therapy is not known, we decided to progressively prolong the interval between maintenance injections instead of accepting the risk of anaphylactic reactions when VIT is discontinued after a predetermined period. We report here on the results of a first phase of this interval extension programme, covering the gradual increase of the interval from 1-12 weeks over 19 months in 178 patients. A 12-week interval maintenance VIT could be achieved in 117/128 (91%) of yellow jacket venom (YJV) and in 35/50 (70%) of honeybee venom (HBV) allergic patients. At the time of the interview these 152 patients had been treated with 12-weekly 100 microgram venom injections for an average period of 2 years without any untoward reaction to VIT. During this period 48 YJV allergy sufferers experienced 77 field re-stings without systemic reaction (SR), and 17 HBV allergic subjects were restung at least 213 times in total, with one patient developing a very large local reaction and one a mild systemic reaction. In 26 of the 178 patients the interval of 12 weeks was not reached for various reasons, with a higher failure rate among the HBV allergic patients. Most Hymenoptera venom allergic patients can thus be safely and effectively treated with 12-weekly injections of 100 micrograms venom.

Occupational allergy to bumble bee venom.

The clinical profile of anaphylactic reactions to bumble bees is described and successful immunotherapy with honey bee venom in seven bumble bee allergic patients is reported. The cause of the high frequency of sensitization to pollen in these patients is discussed.