Factors affecting the immunoperoxidase demonstration of intracellular immunoglobulins and J chain from cytocentrifuged cell smears.

Immunohistochemical methods were used to study 1) the optimum fixation conditions for the preservation of human J chain and immunoglobulin (Ig) immunoreactivity and 2) the relation of J chain synthesis by plasmablasts and plasma cells to Ig synthesis in cell smears of cultured human peripheral blood lymphocytes stimulated with pokeweed mitogen (PWM). J chain was demonstrated using the indirect immunoperoxidase method, and intracellular Ig was demonstrated with the unlabeled antibody--enzyme method. In the sequential double staining procedure, J chain was demonstrated using the indirect immunoperoxidase method followed by the demonstration of Ig with the direct immunofluorescence method. Optimum preservation of J chain immunoreactivity was obtained with fixation in neutral buffered formalin at 22 degrees C for 5 min followed by immediate immunoperoxidase staining. False negative results were seen when the slides were stained 2 weeks after fixation. In PWM-stimulated smears, J chain appeared on day three, simultaneously with or after the onset of Ig synthesis. In double stained smears most IgG-positive cells also showed immunoreactivity for J chain from the third day on.

Patch test reactions to inhalant allergens in atopic dermatitis.

To study whether inhalant allergens could induce eczematous reactions on normal skin of atopic patients we applied birch pollen and house dust mite antigens at 500 times the concentration used for prick testing as epicutaneous tests. Six out of 17 patients with atopic dermatitis in remission had positive delayed type reactions to birch pollen and three to house dust mite. Only one out of 13 atopic patients without history of atopic dermatitis but with seasonal allergic rhinitis had a positive patch test reaction to birch pollen and no patient had positive test reactions to house dust mite. No positive patch test reactions to birch pollen or house dust mite were seen in the ten healthy control subjects. In patients with positive test reactions biopsies from the test sites revealed epidermal spongiosis and vesiculation. Immunostaining of the epidermis revealed keratinocytes displaying both CD1 and HLA-DR. The present study suggests that inhalant allergens can exacerbate atopic dermatitis.

Cost analysis of an intensive home follow-up program for first-time post-myocardial infarction patients and their families.

OBJECTIVE: The general goal of this research was to determine the effectiveness of a home follow-up program in order to acquire guidance in how to plan the future structure and contents of post-myocardial infarction (MI) patients' care and rehabilitation. The specific aim of this study was to evaluate the cost-effectiveness of the program in reducing the rate of rehospitalization of first-time post-MI patients when measured at six weeks and six months post-discharge. HYPOTHESIS: The supportive-educative home follow-up program will prove to be cost-effective by indicating an inverse correlation with the cost of post-MI patients being rehospitalized for unplanned and preventable diagnoses. DESIGN AND SETTING: Cost analysis, using data from a one year randomized control clinical trial conducted in a small urban hospital in eastern Canada. An experimental post test only control group design, including the process of randomization, was used in this study. SUBJECTS: 62 people admitted with a diagnosis of a first-time acute MI during a one-year period with no co-morbidity likely to affect rehabilitation. MAIN OUTCOME MEASURES: Health care costs. RESULTS: Early supportive home follow-up reduced inpatient rehospitalization by more than half (three rehospitalizations vs seven rehospitalizations) and reduced the average length of stay (five days vs seven days). Cost analysis demonstrated that intense home follow-up in the time immediately following patient discharge could still produce cost savings to the health care system. CONCLUSION: Intensive home follow-up provided a cost-effective alternative to traditional cardiac rehabilitation programs; however, a larger study is required to assess the generalizability of the results and long-term cost effectiveness.

Optimal fixation conditions for the immunoperoxidase identification of human J chain from tissue sections.

J chain can be used as a marker of plasmablasts and plasma cells at an earlier stage than intracellular immunoglobulin. Immunoperoxidase techniques were used to study optimal fixation conditions for the preservation of human J chain antigenicity in paraffin-embedded tissue sections. The most constantly positive staining for J chain combined with good morphological integrity was obtained with Bouin's fluid for 1.5 h at 20 degrees C. All other fixatives studied showed less consistent staining results.

Factors influencing the patient-provider relationship.

This article analyzes some of the central elements of the patient-provider relationship i.e. continuity of care, communication, compliance, and the various elements of the consultation itself. This analysis is based on the review of relevant literature. The same principles apply to this relationship regardless of the provider category. When aiming at good care the recognition of the real need of care and the sharing of information with the patient in a proper and effective way are important. These skills belong to the professional competence of the provider. Continuity of care is the element facilitating the forming of a good patient-provider relationship. The importance of the patient-provider consultation is very great. The immediate, intermediate and long term outcomes of the consultation have been studied by several researchers. The immediate outcomes such as the patient satisfaction strongly influence the intermediate outcomes and also the long term outcomes all-though the intermediate (i.e. compliance) and long term (i.e. change in health status) is also strongly influenced by the patient's sociocultural environment. On the other hand, the patient's health understanding can be much enhanced through skillful communication by the provider during the consultation in a good patient-provider relationship. This, again, connects the elements of consultation very tightly with the success or failure of the care process and the patient's future use of health services.

Effects of a human urinary mitogen on subpopulations of peripheral blood mononuclear leukocytes.

We have earlier isolated, to apparent homogeneity, a 27-28 kD human basic protein (UM) from the urine of a patient with myelomonocytic leukaemia. UM is a mitogen for resting human peripheral blood mononuclear leukocytes (PBML). We have now further defined the effect of UM on human PBML and their subpopulations in 6-day cultures. Cell proliferation was measured by 3H-thymidine uptake and Ig production by the plaque forming cell (PFC) response. Whole PBML responded to UM with proliferation and an increase in PFC. The PFC response was at best equal to and frequently synergistic with that produced by pokeweed mitogen and occurred in the three major Ig classes. To test the effect of UM on subpopulations of PBML, adherent cells (AC) were isolated by plastic adherence and T and B enriched populations by rosetting with sheep red blood cells. The proliferative response of T cells needed the presence of AC whilst the effect on Ig production by B cells required both T cell help and the presence of AC. Human thymocytes also responded to UM by proliferation. The results show that, in addition to being a T cell mitogen, UM is also a T cell dependent polyclonal B cell activator.

Immunocompetent cells of fixed drug eruption.

The positive provocation test reactions of the skin of six patients with fixed drug eruption (FDE) were studied from timed skin biopsies taken between 2 hours and 9 days after the appearance of FDE. Monoclonal antibodies to the following immunocompetent cell surface epitopes were used: T3, T4, T6, T8, T9, M1, Ia1, Drc, Leu7 and B cell. The dermal infiltrate comprised 60-80% of T lymphocytes at all the times studied. Cells with T4 and T8 epitopes were displayed in similar numbers. A transient decrease in the number of T6+ cells of the epidermis could be detected with a simultaneous and also transient increase of the T6+ cells in the dermis, which suggests a possible traffic of Langerhans' cells from the epidermis to the dermis. The epidermal Ia1+ cells showed changes similar to but less marked than the T6+ cells. The number of the dermal Ia1+ cells increased continuously. In the late biopsies these Ia1+ cells comprised up to 90% of the infiltrating cells. Except for the finding of a reduction of T6+ and Ia1+ epidermal cells, the cellular kinetics of FDE are similar to those seen in both cutaneous immunological and irritant reactions.

Human ferritin: effects of antigen source and fixation on leucocyte staining by immunoperoxidase technique.

The localization of ferritin was studied in peripheral blood cells and variously fixed tissues with the antibodies against ferritins isolated from human heart and spleen. The unlabelled antibody enzyme method (PAP) was used to detect the binding sites of antibodies. In peripheral blood cell smears both antisera gave rise to strong staining of polymorphonuclear (PMN) cell cytoplasm, whereas the monocytes stained relatively weakly. There were no staining differences between the two antisera. In human spleen sections the spleen ferritin antiserum stained the PMN cells and sinusoidal lining cells, whereas the heart ferritin antiserum stained only PMN cells. Neither of the two antisera stained monocytes in the spleen sections. This finding was observed in specimens fixed in Bouin's fixative, Baker's fixative and neutral formalin. However, the immunoreactivity of ferritin was totally destroyed by some other fixatives (Carnoy's fixative, formol sucrose and glutaraldehyde). These results suggest that ferritin is more readily released from monocytes than from PMN cells, and that mature spleen macrophages contain antigenic determinants of ferritin that are recognized only by anti-spleen ferritin antiserum.

Eczematous reactions in atopic patients caused by epicutaneous testing with inhalant allergens.

To determine whether inhalant allergens could induce eczematous lesions we studied 17 patients with atopic eczema (with or without allergic rhinitis), 13 patients with allergic rhinitis without atopic eczema and 10 healthy control subjects. The allergens, birch pollen (Betula verrucosa) and house dust mite (Dermatophagoides pteronyssinus), were applied in aluminium chambers for 48 h on clinically normal skin. In 17 patients with atopic eczema, six epicutaneous test reactions of the delayed type to birch pollen and three to house dust mite were seen at 48 or 72 h. In 13 patients with allergic rhinitis without eczema there was one delayed reaction to birch pollen and none to house dust mite. No delayed type test reactions to either allergen were seen in the controls. Biopsies of the positive test sites revealed an eczematous reaction with epidermal spongiosis and microvesiculation. Immunostaining of cryostat sections showed dermal cell infiltrates consisting of mainly T lymphocytes (ratio of T4:T8, 2-6:I) and to a lesser degree Langerhans and indeterminate T6+ cells. 50-90% of the cells were Ia+. The numbers of basophils and mast cells did not exceed 10-15%.

Delayed hypersensitivity to topical corticosteroids.

Topical hypersensitivity to corticosteroids was studied by epicutaneous testing using the Finn Chamber technic. The steroids were tested in both ethanol and white petrolatum and, in certain cases, in dimethyl sulfoxide. Additionally, commercial preparations were tested. Three groups of patients were studied: (1) patients with a history of hypersensitivity to at least two topical preparations (five of ten patients studied showed a positive patch test reaction for corticosteroids), (2) patients in whom topical corticosteroid hypersensitivity was suspected because of treatment-resistant eczema (seven of twenty-five patients showed a positive patch test reaction), and (3) dermatologic inpatients and outpatients undergoing epicutaneous testing for suspected topical hypersensitivity. Hydrocortisone-17-butyrate (H-17-B) was included in the standard patch test series; of 450 patients tested, two showed a positive patch test reaction. All the patients with corticosteroid hypersensitivity had a positive reaction to H-17-B. In six patients, additional hypersensitivities to one or several other steroid preparations were seen. Use testing was performed as an open test, with 0.1% or 1% H-17-B in ethanol on normal skin of the flexor side of the upper extremities. A positive test reaction was seen in only one of nine patients. Results of use testing with the commercial 0.1% H-17-B (Locoid) ointment were always negative. Our study suggests that the sensitivity of patch tests for corticosteroid hypersensitivity can be increased by using ethanol as vehicle.

Allergic and toxic contact dermatitis: inflammatory cell subtypes in epicutaneous test reactions.

Histochemical and immunohistochemical techniques were used to identify T lymphocytes, mononuclear phagocytes and plasma cells in situ from allergic and toxic epicutaneous test reactions. Intracellular alpha-naphthyl acetate esterase (ANAE), endogenous peroxidase and immunoglobulin were used as markers for inflammatory cells. In allergic contact dermatitis 76 +/- 7% of all cells were ANAE-positive T lymphocytes, 13 +/- 6% mononuclear phagocytes and 12 +/- 6% ANAE-negative cells. In toxic skin lesions the corresponding values were 64 +/- 20%, 18 +/- 15% and 18 +/- 6%, respectively. There were no statistically significant differences between the allergic and toxic skin reactions. The basic reaction type in allergic and toxic contact dermatitis seems to be similar, with possibly some qualitative and quantitative differences.