Increased risk of relapse in multiple sclerosis patients after ovarian stimulation for in vitro fertilization

In this preliminary study we analysed the impact of ovarian stimulations and the different protocols used for in vitro fertilizations (IVF) on the clinical activity of multiple sclerosis (MS). By matching the databases on MS and IVF of the past 10 years at the university hospital of Nantes, six patients have been found and, for five of them MS relapse rate seemed to be increased in the three-month period following IVF as compared to the previous three months and to two other control periods of three months (P<0.05, Friedman test). The increased relapse rate mainly concerned patients treated by GnRH agonists but not the patients treated by GnRH antagonists. This preliminary work suggests a possible impact of the treatments used for IVF on MS relapse rate. Further studies are now underway to validate these results on a larger scale, by including all cases reported in France.     

Beta-2 adrenergic stimulants in the treatment of asthma: myths and realities

In this review paper the authors describe the reasons, sometimes complex, which have given birth to such myths as the abuse of beta 2-stimulants generating status asthmaticus, or patients developing clinical tachyphylaxis to this type of drug. While there is no solid ground to believe that beta 2-stimulants can be blamed for the overmortality due to asthma, and while the indications of beta 2-stimulants delivered by metered-dose aerosols can be extended to chronic asthma, it is still necessary to apply certain safety rules when these drugs are inhaled in high doses or given parenterally. Some patients must be encouraged to use inhaled beta 2-stimulants prophylactically, sometimes combined with cromolyn or inhaled corticosteroids, but these patients, their relatives and their doctor should be taught to evaluate lung function by means of a peak-flow meter. A lack of response to beta 2-stimulants must be taken as a warning that systemic corticosteroids and in some cases admission to hospital are needed.     

Intraoperative anaphylaxis: verba volant, scripta manent!

We describe a case of intraoperative gelatine-induced anaphylaxis whose diagnosis was delayed as the use of gelatine during surgical procedures was omitted for two times in patient's medical records. The subject is a 66-year old woman, with a negative medical history of atopy, food and drug allergy, with arterial hypertension on a course of beta-blockers and with bladder carcinoma requiring surgery. The patient had tolerated both general and local anaesthesia on several previous occasions. On the first occasion she experienced arterial fibrillation secondary to a severe episode of hypotension following local anaesthesia, while on a course of beta-blockers. On the second occasion she developed a very severe episode of hypotension followed by the outbreak of a generalised rash during general anaesthesia. The tryptase sera level was 109 mg/L one hour after the reaction had subsided, while the basal values were normal. On the third occasion the patient redeveloped severe hypotension and a generalised rash during general anaesthesia. The allergological work-up was negative, except for intradermal test with gelatine. A study of the intra-cellular cytokines in blood lymphocytes showed a production of IL4 from CD4+ lymphocytes after stimulation by gelatine. The patient underwent a successive surgical procedure without any adverse event.     

Update on threshold doses of food allergens: implications for patients and the food industry

PURPOSE OF REVIEW: The purpose of this review is to bring the reader up to date on the importance of assessing a food's lowest observed adverse-effect level (LOAEL) with two aims. Firstly, to help industry choose tests with a level of sensitivity capable of detecting food allergens hidden in industrial products. Secondly, to specify protective measures for highly allergic individuals in order to prevent recurrent severe anaphylaxis. The review also seeks to highlight the present issues and unsolved questions. RECENT FINDINGS: Thanks to standardized oral-provocation tests (double-blind placebo-controlled food challenges), LOAELs have been identified for many IgE-dependent food allergies. Most studies concern the pediatric population. Data is available for milk, egg, peanut, wheat flour, and sesame. The LOAELs are commonly in the range of 1-2 mg of natural foods, representing a few hundred micrograms of protein. These minimal reactive doses characterize about 1% of people allergic to milk, egg, or peanut. The level at which no observed adverse effect is seen might be a few tens of micrograms of protein for peanut. At the present time, allergy to oil seems to be restricted to unrefined cold-pressed oils. SUMMARY: Concerning IgE-dependent food allergies, the threshold dose inducing symptoms is now known to vary a great deal according to the individual. A reactive dose of less than 65 mg characterizes 16 and 18% of patients allergic to egg or peanut. Less than 30 mg of milk proteins characterizes 5% of those allergic to milk. For milk, egg, and peanut, 1% of patients have a very low threshold, about 1 mg. Such data emphasize the necessity of using detection tests with a sensitivity better than 10 parts per million. The modifications of allergenicity undergone by protein ingredients that are now commonly introduced into industrially made products are not yet sufficiently known. A better knowledge of the reactive doses of these proteins is needed.