The Utility of Serum Tryptase in the Diagnosis of Food-Induced Anaphylaxis

Purpose

This study investigates the utility of serum tryptase for the confirmation of shrimp-induced anaphylaxis.

Methods

Patients with a history of shrimp allergy and positive skin prick tests (SPT) to commercial shrimp extract were recruited for shrimp challenges. Serum total tryptase was obtained at baseline and 60 min (peak) after the onset of symptoms.

Results

Thirty-nine patients were challenged. There were 12 patients with anaphylaxis, 20 with mild reactions and 7 without symptoms (control group). Characteristic features and baseline tryptase were not different among the 3 groups. The peak tryptase levels were higher than the baseline in anaphylaxis and mild reaction groups (P<0.05). The delta-tryptase (peak minus baseline) and the tryptase ratio (peak divided by baseline) in the anaphylaxis group were higher than the mild reaction and control groups (P<0.01). The optimum cut-off for peak tryptase to confirm anaphylaxis was 2.99 µg/L with 50% sensitivity, 85% specificity, 3.33 positive likelihood ratio (LR) and 0.59 negative LR. The manufacturer''s cut-off for peak tryptase was >11.4 µg/L with 17% sensitivity, 100% specificity, infinity positive LR and 0.83 negative LR. The best cut-off for delta-tryptase was ≥0.8 µg/L with 83% sensitivity, 93% specificity, 11.86 positive LR and 0.18 negative LR. The best cut-off for tryptase ratio was ≥1.5 with 92% sensitivity, 96% specificity, 23 positive LR and 0.08 negative LR.

Conclusions

The peak tryptase level should be compared with the baseline value to confirm anaphylaxis. The tryptase ratio provide the best sensitivity, specificity, positive and negative LR than a single peak serum tryptase for the confirmation of shrimp-induced anaphylaxis.     

Usefulness of UniCAP‐Tryptase fluoroimmunoassay in the diagnosis of anaphylaxis

BACKGROUND: Serum tryptase level measured by RIA is the main in vitro tool to confirm the diagnosis of anaphylaxis. METHODS: Serum tryptase levels were determined by UniCAP-Tryptase fluoroimmunoassay (Pharmacia & Upjohn, Uppsala, Sweden), in 30 consecutive patients who presented at the emergency room with a clinical allergic reaction of less than 6-h duration to assess the value of this method in the diagnosis of anaphylaxis. Anaphylaxis was established by clinical criteria and by immunoallergic study. Baseline tryptase levels were determined 1 month later in 21 patients. The receiver operating curve (ROC) was used to establish the best cutoff point of tryptase levels to confirm the diagnosis of anaphylaxis. RESULTS: Seventeen patients were diagnosed with anaphylaxis. In this group, tryptase levels were higher than in the nonanaphylaxis group, composed mostly of patients with urticaria or angioedema (P<0.001). ROC established the best cutoff of tryptase levels at 8.23 ng/ml with a 94.12% sensitivity and 92.31% specificity, whereas the 13.5 ng/ml cutoff recommended by the manufacturers showed 35.29% sensitivity and 92.31% specificity. The reaction-tryptase/baseline-tryptase ratio was 2.85 in the anaphylaxis group and 1.29 in the nonanaphylaxis group. CONCLUSIONS: Serum tryptase levels of >8.23 ng/ml by UniCAP-Tryptase fluoroimmunoassay identify anaphylaxis in patients with symptoms of less than 6-h duration. The usefulness of this determination is higher if baseline tryptase levels are available.     

Two-dimensional speckle-tracking echocardiography assessment of left ventricular remodeling in patients after myocardial infarction and primary reperfusion

Introduction

Left ventricular remodeling (LVR) is the most prognostically important consequence of acute myocardial infarction (AMI). The aim of the study was to assess the value of speckle tracking echocardiography in the prediction of left ventricular remodeling in patients after AMI and primary coronary angioplasty (PCI).

Material and methods

Eighty-eight patients (F/M = 31/57 patients; 63.6 ±11 years old) with coronary artery disease (CAD) and successful PCI were enrolled and divided into group I with ST-elevation myocardial infarction or non-ST elevation myocardial infarction and group II with stable angina pectoris. Conventional and speckle tracking echocardiography was performed 3 days (baseline), 30 days and 90 days after PCI. Patients were divided into 2 groups based on the presence of LVR (increase of LV end-diastolic and/or end-systolic volume > 20%) at 3 months follow-up.

Results

At initial presentation, 2-chamber longitudinal strain (9.4 ±3.5% vs. –11.6 ±3.6%, p < 0.04) and 4-chamber transverse strain (10.4 ±8.2% vs. 15.6 ±8%, p < 0.003) were lower in the LVR+ group compared to the LVR– group. LV wall motion score index did not differ between the two groups. After 30 days, circumferential apical and basal strain (–15.58 ±8.9% vs. –25.53 ±8.8%, p < 0.001; –15.02 ±5.6 vs. –19.78 ±6.3, p < 0.008), radial apical strain (9.96 ±8.4% vs. 14.15 ±5.5%, p < 0.03), 4-chamber longitudinal strain (–8.7 ±5.8% vs. –13.47 ±3.9%, p < 0.005), 4-chamber transverse strain (10.5 ±8.1% vs. 16.7 ±8.3%, p < 0.03), apical rotation (3.84 ±2.5° vs, 5.66 ±3.2°, p < 0.04) and torsion (6.15 ±4.1° vs. 8.98 ±4.6°, p < 0.03) were significantly decreased in the LVR+ group compared to the LVR– group. According to ROC analysis, circumferential apical strain > –15.92% (sensitivity 93%, specificity 59%, positive predictive value 90%) was the most powerful predictor of remodeling after primary PCI in AMI.

Conclusions

Our results suggest that impaired indices of LV deformation detected 3 days and 30 days after AMI may provide important predictive value in LV remodeling and patients’ follow-up.     

Blood monocyte activation in rheumatoid arthritis: increased monocyte adhesiveness, integrin expression, and cytokine release

Infiltration of the synovium by mononuclear cells, namely lymphocytes and monocytes, is one of the main features of rheumatoid arthritis (RA) and is considered to be responsible for the development of the disease. In this study in 31 consecutive patients with RA, we investigated whether peripheral blood monocytes exhibited markers of cellular activation related to cell migration. Using flow cytometry with the respective specific antibodies, we studied the expression of integrins CD11a, CD11b, CD11c, CD49d (VLA-4), and CD49e (VLA-5) on monocytes from patients with RA and from normal (N) subjects. IL-1β, IL-6, and tumour necrosis factor-alpha (TNF-α) production by cultured monocytes was measured by immunoassay. Adhesiveness of monocytes was studied on various surfaces (plastic, human fibronectin, gelatin-coated plasma, subendothelial matrix) and on cultured endothelial cells under basal conditions or after stimulation by IL-1β. An increased number of CD14⁺ monocytes (Mo) from RA patients expressed the CD11b molecule (RA Mo = 90·3%, N Mo = 83·4%, P < 0·005). The expression of CD11b on CD14⁺ monocytes was significantly increased in RA patients (median fluorescence intensity (FI): RA Mo = 145 (range 80–466) units; normal Mo = 95 (range 24–164) units; P < 0·003). Production of extracellular IL-1β and IL-6 by RA monocytes was significantly enhanced compared with monocytes from normal subjects (IL-1β: RA = 2·65 ± 0·91 ng/ml versusN = 1·35 ± 0·85 pg/ml, P < 0·05; IL-6: RA = 4·83 ± 0·90 ng/ml versusN = 2·40 ± 0·95 ng/ml, P < 0·05). Compared with normal monocytes, RA monocytes exhibited increased adhesion to the various surfaces studied (plastic, P < 0·01; fibronectin, P < 0·01; and gelatin-coated normal or RA plasma, P < 0·01) as well as to unstimulated (P < 0·01) and IL-1β-stimulated endothelial cells (IL-1β for 4 h, P < 0·05; IL-1β for 24 h, P < 0·05). In our study, blood monocytes from RA patients exhibited features of activation related to cell adhesion.     

Serum associated leucocyte locomotion inhibition and leucocyte motility in malignant melanoma: effect of BCG treatment

Serum-associated leucocyte locomotion inhibition (SALLI) and leucocyte motility were investigated in patients with malignant melanoma. Ten days after tumour excision twelve out of eighteen patients' sera exhibited a SALLI exceeding the normal range of 15%. The mean SALLI thus reached was 59·2±5·2%. No correlation was observed between SALLI and the level of invasion or the stage of the disease.

Six patients selected at random who had a mean SALLI of 71·5±5·8% after tumour excision were further treated by BCG immunotherapy and presented after 8·2±2·9 months of therapy with a significantly (P<0·01) lower SALLI of 32·6±8·1%. In eight patients treated exclusively by surgical excision, SALLI remained basically unchanged in the course of 10±2·8 months (29·0±8·0% vs 30·4±12·9%).

The mean index of leucocyte locomotion (LL) of eight melanoma patients who had received BCG for 11·2±2·3 months was 5·9±0·9 cells/field and thus significantly (P<0·01) higher in comparison with the mean index of LL (2·8±0·5) found in eight patients treated by surgical excision only 12·4±2·1 months before testing.

In addition, patients receiving BCG had a significantly higher (P<0·05) mean value of LL than fifteen healthy controls who presented with a mean index of LL of 3·4±0·3 cells/field. Our results permit the suggestion that BCG decreases SALLI and increases LL in melanoma patients.

     

Circulating complexes in leprosy studied by the platelet aggregation test. The platelet aggregation test and its relation to the rubino test and other sero-immunological parameters in 135 patients with leprosy

Sera from 135 patients with leprosy were tested by the platelet aggregation test (PAT), by the Rubino test and by other sero-immunological assays. PAT positivity (titre≥10) was 53% in the lepromatous subgroups and 5% in the tuberculoid subgroups (P<0·005). The higher PAT titres and Rubino titres clustered significantly (P<0·0005) toward the lepromatous end of the disease spectrum. A statistically significant correlation was found between the PAT and the Rubino titres (0·05>P>0·025). Removal of the effect of the disease spectrum, however, resulted in a partial correlation between the PAT and the Rubino titres that was not significant (P>0·1), suggesting different basic mechanisms for the platelet aggregation (PA) and the Rubino activity of the lepromatous sera. The correlation between the PAT titres and twenty-nine other sero-immunological parameters was calculated, and a highly significant correlation was found between the PAT and the IgG level (P<0·005) and between the PAT and the antistaphylolysin-α titre (P<0·005).

The PA activity in most lepromatous sera studied sedimented in the heavy (>19S) fractions and was inhibitable by IgM rheumatoid factor. It thus fulfilled the criteria for IgG complexes as defined in previous studies with known model Ag/Ab complexes and with sera from patients with immune complex states. The addition of an excess of soluble mycobacterial antigens affected the PA activity of some lepromatous sera, which suggests that the putative complexes were composed of mycobacterial antigens complexed with corresponding IgG antibody.

It was concluded that the PAT is a sensitive detector of IgG complexes peculiar to the lepromatous leprosy. In leprosy the discriminatory power of the PAT seems to be superior to that of other immune complex tests recently applied for the analysis of leprosy series.

     

Increased numbers of CD5+ B cells and T cell receptor (TCR) γδ+ T cells are associated with younger age of onset in rheumatoid arthritis (RA)

Patients presenting with RA before the age of 45 years (younger onset) are known to have more aggressive disease compared with patients presenting after the age of 65 years (older onset). Coordinated expansion of circulating CD5⁺ B cell and TCR γδ⁺ T cell levels has been reported in patients with RA. This study assesses the peripheral blood levels of these two cell types in RA patients with younger and older onset of disease. CD5⁺ B cell levels were significantly elevated in the younger onset RA group (26·6 ± 4·5%) compared with the older onset RA group (14·2 ± 1·2%; P <0·01). TCR γδ⁺ T cell levels were also significantly raised in the young patients (4·0 ± 0·9%) compared with elderly patients (1·6 ± 0·2%; P <0·01). T cell levels (CD3⁺) were similar in both groups (young 66·4 ± 3·3%; old 74·3 ± 3·4% (mean ± s.e.m.); NS). Total B cell levels (CD19⁺) were also similar in these groups (7·7 ± 0·7% versus 8·9 ± 1·8%; NS). A significant positive correlation was observed between the CD5⁻ B and TCR γδ⁺ T cell types in the patients (r = 0·72, P <0.05). Compared with age-matched normal controls, the younger onset patients had similar CD5⁺ B cell and TCR γδ⁺ T cell levels to the elderly controls (CD5⁺ B cells 30·2 ± 3·0%; TCR γδ⁺ T cells 3·0 ± 0·8%). Conversely, older onset RA patients had CD5⁺ B cell levels similar to the young controls (12·3 ± 1·9%). Spontaneous in vitro synthesis of immunoglobulins (IgM, IgA and IgG) and rheumatoid factors (IgM and IgA isotypes) were not significantly different in both patient groups. The coordinate expansion of circulating CD5⁺ B cells and γδ⁺ T cells seen in patients with RA presenting before 45 years of age and not after 65 years of age may suggest a potential role for these cells in more aggressive disease states.     

Validation of international consensus equation for acute serum total tryptase in mast cell activation: A perioperative perspective

There is no standardized method for assessing serum total mast cell tryptase (MCT) in anaphylaxis. The consensus equation (peak MCT should be>1.2× baseline tryptase+2 mg/L) has been proposed to interpret acute MCT in mast cell activation syndrome (MCAS). To validate consensus equation in a perioperative setting analyses of cases of suspected perioperative anaphylaxis during general anaesthesia (GA) were performed. Anaphylaxis was defined as per World Allergy Organisation (WAO) criteria. Timed serial MCT measurements were mapped against the consensus equation and receiver operating characteristic (ROC) curves produced. A total of 82 patients (60 females, mean age 56.5 years±SD17.2) underwent investigation. Sixty (73%) patients fulfilled WAO criteria for anaphylaxis, and 22 patients did not. Aetiology included 59% IgE‐mediated anaphylaxis, 2% non‐IgE‐mediated anaphylaxis, 12% anaphylaxis of unknown cause and 27% deemed non‐anaphylaxis. IgE‐mediated anaphylaxis included the following: NMBA (35%), antibiotics (46%), chlorhexidine (8%), patent blue dye (8%) and others (8%). An acute MCT with a comparable baseline was available in 71 of 82 (87%) patients (60 anaphylaxis and 11 controls). The median interquartile range (IQR) time from reaction to peak MCT was 1.34 (0.82‐2.51) hours. Analyses confirmed that a rise in acute MCT greater than that defined by the equation had a sensitivity, specificity, positive predictive value (PPV) and negative (N) PV of 78%, 91%, 98% and 44%, respectively. The magnitude of increase in acute MCT above the threshold predicted by consensus equation was higher in the anaphylaxis group compared to controls (P=.0001). This equation has a high specificity, PPV with a moderate NPV and sensitivity in perioperative anaphylaxis.     

Threshold for Positivity and Optimal Dipyrone Concentration in Flow Cytometry-Assisted Basophil Activation Test

Purpose

Basophil activation occurs both in patients with immediate hypersensitivity reactions to anti-inflammatory drugs and in healthy controls in a dose-dependent manner. Our aims were to define the optimal basophil activation test (BAT) concentration and the threshold for BAT positivity for dipyrone.

Methods

From 45 patients with a positive history of an immediate hypersensitivity reaction to dipyrone, we found 20 patients with dipyrone-induced anaphylaxis demonstrating positive skin tests. All selected patients, as well as 10 healthy controls, were tested in vivo and in vitro. BAT was performed using Flow 2CAST technique with three low dipyrone concentrations: 25 µg/mL (c1), 2.5 µg/mL (c2) and 0.25 µg/mL (c3). The threshold for BAT positivity was established using receiver operating characteristics (ROC) curve analysis.

Results

Using ROC curve analysis the highest area under curve, 0.79 (0.63-0.95) (P<0.01), was found for c3. When the highest stimulation indexes from the three concentrations for each patient were used, ROC curve analysis revealed an area under curve of 0.81 (0.65-0.96) (P<0.01), sensitivity and specificity were 0.70 and 1 and the optimal threshold value for BAT positivity was 1.71. Thirteen patients had a positive BAT for at least one of the tested dipyrone concentrations. All healthy controls presented negative BAT.

Conclusions

BAT might be a useful technique to diagnose dipyrone allergy, provided all three low dipyrone concentrations are used together. With an assay-specific threshold of 1.71, ROC curve analysis yields 70% sensitivity and 100% specificity.     

The Impact of Asthma Control on Salivary Cortisol Level in Adult Asthmatics

Asthma is a chronic disease causing psychological stress which leads to the activation of hypothalamus-pituitary-adrenal axis. The purpose of this study is to compare morning salivary cortisol levels in persistent asthma patients according to their disease severities and control status. Total 206 adult asthma patients were recruited from four university hospitals. Spirometry, questionnaire of Asthma Quality of Life (AQOL) and Asthma Control Test (ACT) were completed, and saliva samples were collected prospectively to measure morning cortisol level. The mean patient age was 56.5±15.3 years with mean asthma duration of 9.1±11.1 years. Sixty five patents (31.6%) were classified as mild persistent asthma, and 141 patients (68.4%) were classified as moderate persistent asthma according to the Expert Panel Report 3. The mean predicted FEV1 was 88.8%±18.4%, and the methacholine PC20 was 9.6±8.5 mg/mL in all study population. The mean ACT score for all patients was 19.9±3.6, and there were 71 (34.5%) patients in poorly controlled and 135 (65.5%) in well controlled asthma. The poorly controlled asthma patients were characterized by significantly lower FEV1 (84.6%±17.6% vs 91.1%±18.5%, P=0.018), lower AQOL scores (46.0±13.9 vs 73.8±26.3, P<0.001), and lower salivary cortisol levels (0.14±0.08 vs 0.18±0.11 µg/dL, P=0.04) compared to well controlled asthma. The ACT score was significantly related to salivary cortisol levels (P=0.034) after adjusting for age. There was no significant difference in salivary cortisol levels (0.17±0.12 vs 0.16±0.08, P=0.725) when analyzed according to the dose of used corticosteroid and lung function. Asthma control status affects morning salivary cortisol level. Measuring the morning salivary cortisol level might be a simple and new way to assess asthma control status.     

Evaluation of renal function in sickle cell disease patients in Brazil

The objective of this study was to investigate renal function in a cohort of 98 patients with sickle cell disease (SCD) followed up at a tertiary hospital in Brazil. Clinical and laboratory characteristics at the time of the most recent medical examination were analyzed. Renal function was evaluated by the estimation of glomerular filtration rate (GFR) by the criteria of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). We compared patients with normal GFR to patients with decreased GFR (<60 mL·min⁻¹·(1.73 m²)⁻¹) and hyperfiltration (>120 mL·min⁻¹·(1.73 m²)⁻¹). Comparison between patients according to the use of hydroxyurea and comparison of clinical and laboratory parameters according to GFR were also carried out. Average patient age was 33.8 ± 13.3 years (range 19-67 years), and 57 (58.1%) patients were females. The comparison of patients according to GFR showed that patients with decreased GFR (<60 mL·min⁻¹·(1.73 m²)⁻¹) were older, had lower levels of hematocrit, hemoglobin and platelets and higher levels of urea and creatinine. Independent risk factors for decreased GFR were advanced age (OR = 21.6, P < 0.0001) and anemia (OR = 39.6, P < 0.0001). Patients with glomerular hyperfiltration tended to be younger, had higher levels of hematocrit, hemoglobin and platelets and lower levels of urea and creatinine, with less frequent urinary abnormalities. Hydroxyurea, at the dosage of 500-1000 mg/day, was being administered to 28.5% of the patients, and there was no significant difference regarding renal function between the two groups. Further studies are required to establish the best therapeutic approach to renal abnormalities in SCD.     

Trace elements in type 2 diabetes mellitus and their association with glycemic control

BackgroundAlterations in serum levels of trace elements reported in type 2 diabetes mellitus (T2DM) have been linked with induction of T2DM and associated complications.ObjectivesTo assess serum levels of copper (Cu), zinc (Zn) and selenium (Se) in T2DM patients with adequate and poor glycemic control.Patients and methodsThis study was performed at King Khalid University Hospital, Riyadh. A total of 100 consenting T2DM patients comprising of 50 patients with glycated hemoglobin (HbA1c) less than 6.5% and 50 patients with HbA1c more than 6.5% along with a group of 50 normal healthy individuals were included in the study. Serum levels of Cu, Zn and Se were measured by inductively coupled plasma-mass spectrometry (ICP-MS) instrument.ResultsAmong T2DM patients with HbA1c <6.5%, mean serum Cu levels (13.4+4.3µmol/L) were not different from the controls (14.5+1.92µmol/L) whereas Zn (9.9+2.7µmol/Lvs15+3.2µmol/L;p<0.0001) and Se levels (1+0.2µmol/Lvs1.62+0.2µmol/L; p<0.0004) were lower than the controls. Among T2DM patients with HbA1c >6.5% mean serum Cu (18.1+4.1µmol/Lvs14.5+1.9µmol/L; p<0.0001), Zn (15+3.2µmol/Lvs13.5+1.9µmol/L; p<0.009) and Se (1.62+0.2µmol/Lvs1.17+0.16µmol/L;p<0.0001) were significantly higher than the controls. HbA1c% negatively correlated with HbA1c >6.5% (r = -0.302; p<0.03).ConclusionCu, Zn and Se homeostasis was altered in T2DM patients and varied with glycemic control.     

The metabolism of C9 in normal subjects and in patients with autoimmune disease

The metabolism of the ninth component of complement (C9) was studied in eight healthy subjects and nine patients with autoimmune disease, including seven with systemic lupus erythematosus (SLE) and one each with mesangial IgA nephropathy and mixed essential cryoglobulinaemia. In normal subjects the metabolic parameters (mean ± s.d.) were: fractional catabolic rate (FCR): 2.92 ± 0.36%/h, plasma half-life (T_1/2): 42.5 ± 6.7 h, and extravascular/intravascular distribution ratio (EV/IV): 0.56 ± 0.12. In patients the FCR was 3.38 ± 0.70%/h, the T_1/2 was 37.6 ± 10.2 h, and the EV/IV was 0.55 ± 0.19. Patients with reduced total serum haemolytic activity (i.e. CH₅₀ < 68% of normal human serum (NHS), n = 7) had significantly higher FCR (3.57 ± 0.67%/h) and shorter T_1/2 (33.5 ± 6.8 h) than the control group (both P< 0.05). The plasma concentration of the terminal complement complex (i.e. soluble TCC or SC5b-9) was higher in patients (median (range): 515 (300–1879 μg/l)) than in normal subjects (313 (229–402 μg/l); P< 0.01) and showed a positive correlation with the FCR of C9 (r =0.61, P< 0.01). Plasma C9 production rate was also greater in patients (0.11 ± 0.05 mg/kg per h) compared with control subjects (0.07 ± 0.03 mg/kg per h, P< 0.05), and was associated with a higher C9 concentration in patients’ sera (76 ± 13 mg/lversus 61 ± 14 mg/l, P< 0.05). These results demonstrate that C9 is rapidly metabolized in normal humans and that hypercatabolism occurs in patients with autoimmune disease and complement activation. This was despite the presence of normal or elevated serum C9 levels and normal compartmental distribution.     

Expression of annexin A7 and its clinical significance in differentiation and metastasis of gastric carcinoma

Objective: To investigate the expression and clinical significance of annexin A7 in the differentiation and lymphatic metastasis of gastric cancer (GC). Methods: The clinical and pathological data were recorded for analysis. Immunohistochemical staining and Western blot were performed to analyze the expression of ANXA 7 in primary GC tissues. Logistic regression analyses were conducted to evaluate the associations between annexin A7 expression levels and differentiations of GC. Analyses of the ROC were conducted to determine the cut-off value of the ratio of pixel density of annexin A7 for predicting lymphatic metastasis of GC. Results: A total of 162 GC patients were enrolled in this study, and expression rate of annexin A7 was 65.4% in GC. The survival rate of patients with positive expression of annexin A7 was lower than that in patients with negative expression (P=0.000). The results of COX regression showed that the positive expression of annexin A7, submucosal confinement and pathological stage of GC were associated with poor clinical outcomes. The ratio of pixel density value of primary GC tissues with PN 1-3 lymphatic spread was significantly higher than those in tissues with PN 0 lymphatic spread (0.56±0.09 vs. 0.42±0.07, P < 0.05). ROC analysis showed a high area under the curve for the ratio of pixel density value of annexin A7 in primary GC tissues. At a cut-off level of > 0.505, the ratio of pixel density value of annexin A7 exhibited 76.7% sensitivity and 88.3% specificity for detecting lymphatic metastasis of GC. Conclusion: High annexin A7 expression is associated with poor differentiation in GC patients, and it may be a predictor for lymphatic metastasis of GC.     

The impact of paracentesis flow rate in patients with liver cirrhosis on the development of paracentesis induced circulatory dysfunction

Background/Aims

Ascites is a dreadful complication of liver cirrhosis associated with short survival. Large volume paracentesis (LVP) is used to treat tense or refractory ascites. Paracentesis induced circulatory dysfunction (PICD) develops if no plasma expanders are given with ominous complications. To study the effect of ascites flow rate on PICD development.

Methods

Sixty patients with cirrhosis and tense ascites underwent LVP of 8 L were randomized into 3 equal groups of different flow rate extraction; group I (80 mL/minute), group II (180 mL/minute) and group III (270 mL/minute). Plasma renin activity (PRA) was measured baseline and on day six. PICD was defined as increase in PRA >50% of the pretreatment value.

Results

In group I through 3; the mean age was (52.5±9.4 vs. 56.4±8.5 vs. 55.8±7.1 years; P>0.05), mean arterial pressure (81.4±5.6 vs. 81.5±7 vs. 79.5±7.2 mmHg; P>0.05), MELD (17.6±4.1 vs. 15.8±4.1 vs. 14.7±4.5). Baseline PRA was comparable (1,366.0±1244.9 vs. 1,151.3±1,444.8 vs. 951.9±1,088 pg/mL; P>0.05). There was no statistically significant (P>0.05) flow mediated changes (Δ) of creatinine (0.23±0.27 vs. 0.38±0.33 vs. 0.26±0.18 mg/dL), MELD (1.25±5.72 vs. 1.70±2.18 vs. 1.45±2.21) or PRA (450.93±614.10 vs. 394.61±954.64 vs. 629.51±1,116.46 pg/mL). PICD was detected in a similar frequency in the three groups (P>0.05). On univariate logistic analysis only female sex was a fairly significant PICD predictor (Wald 3.85, odds ratio 3.14; P=0.05).

Conclusions

The ascites flow rate does not correlate with PICD development.     

Reduction of serum cholesterol and blood pressure in hypertensive patients by behaviour modification

In a pilot study, 14 pharmacologically treated hypertensive patients were given training in psychophysical relaxation exercises, reinforced by biofeedback instruments, for six weeks. The patients were asked to practise twice a day and also incorporate the exercises into everyday activities. In spite of their unchanged drug schedule, their mean blood pressure (B.P.) was reduced from 170·6/102·5 to 147·9/89·14 (P = < ·001) while their mean (± S.D.) serum cholesterol level was reduced from 241·6 ± 39·19 to 217·1 ± 38·12 mg/100 ml (P = < ·001). I believe the possibility of one therapy which can reduce two risk factors at the same time should be explored further in a controlled study.     

Can Fecal Calprotectin Level Be Used as a Markers of Inflammation in the Diagnosis and Follow-Up of Cow's Milk Protein Allergy?

Purpose

Calprotectin is a cytosolic protein with immunomodulatory, antimicrobial, and antiproliferative actions. The concentration of calprotectin increases in infection, inflammation, and malignancy. We determined if calprotectin can be used as a marker for the diagnosis and follow-up of bowel inflammation in cow''s milk protein allergy (CMPA).

Methods

In total, 32 patients newly diagnosed with CMPA were included (24 IgE-mediated, 8 non-IgE-mediated). In all subjects, a complete blood count, total IgE, cow''s milk-specific IgE, and fecal calprotectin (FC) were assessed before and after a cow''s milk protein (CMP) elimination diet was started. The results were compared with those of 39 healthy children.

Results

The mean FC value before the CMP elimination diet was 516±311 µg/g in the 32 patients with CMPA and 296±94 µg/g in the control group (P=0.011). The mean FC value after the diet in these patients was 254±169 µg/g, which was significantly different from the mean value before the CMP elimination diet (P<0.001). When we compared FC levels before the CMP elimination diet in the IgE-mediated group with the control group, we found no significant statistical difference (P=0.142). The mean FC value before the CMP elimination diet was 886±278 µg/g in the non-IgE-mediated group and 296±94 µg/g in the control group; this difference was statistically significant (P<0.001). In the IgE-mediated and non-IgE-mediated groups, FC values after CMP elimination diet were 218±90 µg/g and 359±288 µg/g, respectively, and FC values before CMP elimination diet were 392±209 µg/g and 886±278 µg/g, respectively; these differences were statistically significant (P=0.001 and P=0.025, respectively).

Conclusions

FC levels may be a useful marker for follow-up treatment and recurrence determination in CMPA.     

Serum IgD concentrations in sarcoidosis and tuberculosis

Studies of the serum level of IgD in patients with tuberculosis and sarcoidosis reveal evidence of a difference in humoral immunity. Radial diffusion measurements were done of IgD in serums from fifty patients with active tuberculosis, fifty-three patients with sarcoidosis and 103 age, race and sex matched healthy controls. IgD was detected in serums from 20% more tuberculosis patients (P<0·0250) and 20·7% fewer sarcoidosis patients than respective controls (P<0·0005). Multivariate statistical analysis of log_e transformed IgD serum levels revealed significantly lower geometric mean IgD levels in sarcoidosis patients (P=0·0018). The age dependence of serum IgD was highly significant (P<0·0001). Age dependent disease effects were detected. High levels of IgD occurred predominantly in older tuberculosis patients while depression of IgD occurred in middle-aged sarcoidosis patients. It is suggested that the elevated levels of serum IgM in patients with sarcoidosis may represent a compensatory change associated with low levels of serum IgD.     

Activating killer immunoglobulin-like receptors genes are associated with increased susceptibility to ankylosing spondylitis

The aim of this study was to analyse the association of specific killer cell immunoglobulin-like receptors (KIR) genes and haplotypes with susceptibility to ankylosing spondylitis (AS) and its different clinical manifestations in a Spanish population. The presence or absence of all KIR genes was studied for their association with AS. A total of 176 patients with AS and 435 healthy control subjects were selected for this study based on clinical criteria. The commercial KIR-sequence-specific oligonucleotides (SSO) typing kit was used to investigate KIR typing. Frequencies of KIR2DS1 and KIR3DS1 genes were increased significantly in patients compared with healthy controls [52·8 versus 38·2%, P_Bonf < 0·01, odds ratio (OR) = 1·81 (1·28–2·59); 51·7 versus 37·5%, P_Bonf < 0·01, OR = 1·79 (1·25–2·54)]. Moreover, the frequency of activating genotypes in the AS patient group was significantly higher than in the healthy control group (P < 0·05). KIR2DS1 and KIR3DS1, in addition to human leucocyte antigen (HLA)-B27, may play an important role in the pathogenesis of AS. However, we show that the contribution of the KIR genes to AS susceptibility extends beyond the association with individual KIRs, with an imbalance between activating and inhibitory KIR genes seeming to influence the susceptibility to AS.     

Assessment of Hepatic Fibrosis Regression by Transient Elastography in Patients with Chronic Hepatitis B Treated with Oral Antiviral Agents

Transient elastography (TE) has been used as a non-invasive method for liver stiffness measurement (LSM) in patients with chronic liver disease. This study was performed to assess the change of LSM by TE and to assess its clinical usefulness during long-term oral antiviral therapy in patients with chronic hepatitis B (CHB). We retrospectively reviewed 83 CHB patients. The mean interval between two LSM was 411.5 ± 149.5 days. Initial and follow-up LSM was 16.15 ± 12.41 kPa and 11.26 ± 7.36 kPa, respectively (P < 0.001). The degree of regression of liver stiffness was -2.03 ± 0.36% per month. The fibrosis stage classified by LSM value improved in 37 (44.6%) patients during oral antiviral therapy. Of the 30 (36.1%) patients with LSM ≥ 14.1 kPa (cirrhosis) at 1st LSM, 12 (40%) proved to no longer have cirrhosis (≥ 1 decrease in fibrosis stage) at 2nd LSM. LSM significantly decreased in both baseline high (> upper limit of normal [ULN] × 2) and low (≤ ULN × 2) alanine aminotransferase groups during antiviral therapy (P < 0.001; P = 0.001, respectively). Long-term oral antiviral therapy resulted in the improvement of liver stiffness in a substantial portion of patients with CHB. TE may be used a useful clinical tool to assess disease progression in CHB patients.

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