Measurement of left ventricular dimensions and function in patients with dilated cardiomyopathy.

Studies on medical therapy in heart failure are focused on changes of left ventricular (LV) dimensions and function. These changes may be small, requiring a large study group. We measured LV parameters (LV volumes, LV ejection fraction (LV-EF), and left ventricular mass (LVM)) with two-dimensional echocardiography (2D-echo) and magnetic resonance imaging (MRI) in 50 patients. Based on the difference between the measurements, we determined the variance of the results and calculated the sample sizes needed to detect changes of baseline values. For the calculated and measured parameters we found significant differences between the two techniques: LV-EF and LVM were higher in 2D-echo, and LV dimensions were comparable. The sample size to detect relevant changes from baseline with MRI was significantly (P < 0.01) smaller than in 2D-echo. We conclude that MRI is superior in clinical studies on left ventricular dimensional and functional changes, since measurements are more reproducible and the required sample size is substantially smaller, thereby reducing costs.

Immunoblot studies in birch pollen-allergic patients with and without fruit hypersensitivity: part I: antibody pattern for birch pollen extract.

About 40-70% of birch pollen allergic patients show allergic symptoms after ingesting or handling raw fruits. Several investigations have indicated a partial immunological identity between birch pollen and stone fruit. To further clarify this association, we investigated 59 patients with allergic symptoms (conjunctivitis, rhinitis, and asthma during the birch pollen season) and 18 nonatopic controls by skin prick test (SPT) and RAST with birch pollen, fresh apple, cherry, and peach as well as freshly prepared fruit extracts. According to a questionnaire dealing with symptoms after ingestion of raw fruits, the subjects were divided into groups with (35 FH+) and without (24 FH-) fruit hypersensitivity. IgE, IgG, IgG1, IgG4, IgA, and IgM binding patterns to birch pollen extracts were performed with 33 sera (12 FH+, 11 FH-, and 10 nonatopic controls) using the immunoblot-technique. Patients with FH+ expressed a significantly stronger sensitization to birch pollen than patients without FH-, as measured by RAST and SPT. Native fruits induced stronger SPT reactions than fruit extracts, and patients with FH+ showed a significantly higher skin index with all fruits and fruit extracts tested. Specific IgE, IgG, IgG1, IgG4, IgM and IgA to birch pollen extracts could be detected by immunoblot in all groups, albeit with different frequencies and intensities. From this data we conclude that fruit hypersensitivity is related more to the 17 kd and 67-85 kd than to the 26-28 kd or 36 kd protein bands of the birch pollen extract. The relationship of specific IgE > IgG > IgM to a single protein band seems to be associated with the development of symptomatic type I allergy.

Immunoblot studies in birch pollen-allergic patients with and without fruit hypersensitivity: part II: antibody pattern for fruit extracts.

Patients allergic to birch pollen also exhibit more hypersensitivity reactions to fresh fruits and vegetables than do patients allergic to other pollens. Several investigations have indicated a possible partial immunological identity between birch pollen and fruits. To study this, 23 birch pollen-allergic patients 12 with (FH+) and 11 without (FH-) fruit hypersensitivity and 10 nonatopic controls were examined with self-prepared apple-peel, cherry, and peach extracts by immunoblotting. The self-prepared extracts were characterized by histamine release studies with 20 FH+ birch pollen-allergic patients. Specific IgE, IgG, IgG1, IgG4, IgA, and IgM binding patterns of the fruit extracts presented an individual distribution with at least 1-3 IgE bands at varying molecular weight locations. The FH+ group expressed intense IgE binding to the different extracts compared to the FH- group, and even the control group showed all immunoglobulin classes, though different frequencies and intensities compared to the allergic groups. It seemed that the specific IgE > IgG > IgM relation to a single antigen is important for distinguishing between symptomatic and asymptomatic persons. With this hypothesis we found most IgE with less IgG binding to apple-peel in the region of 22-28 kd and 43-56 kd, cherry: 15-25 kd and 72- > 90 kd and peach 35-41 kd and 66-76 kd, suggesting that these proteins might be important for cross-reactivity with birch pollen and developing fruit hypersensitivity.

Cardiopulmonary auscultation: duo for strings--Opus 99.

In spite of increasing mechanization in medicine and reliance on "high-tech" diagnostic tools, bedside clinical skills of the attending physician can still identify findings that are missed by the more sophisticated devices. Using a stethoscope, we relied on our skills in inspection, palpation, percussion, auscultation, as well as echocardiography and phonocardiography to diagnose a patient whose murmur was very reminiscent of the D-sharp pizzicato in the Cello Sonata in F, Opus 99, by Johannes Brahms. Initial echocardiography was not helpful. We suspected an anomalous chorda and confirmed this with phonocardiography and a second echocardiography. Although advances in cardiac imaging are extremely helpful, the use of simple clinical skills, in addition to being fun, is not obsolete. Cardiopulmonary auscultation should receive more emphasis in the medical school curriculum and clinical training.

Patch testing with fragrances: results of a multicenter study of the European Environmental and Contact Dermatitis Research Group with 48 frequently used constituents of perfumes.

The objective of this study was to determine the frequency of reactivity to a series of commonly used fragrances in dermatological patients. A total of 48 fragrances (FF) were chosen, based on the publication of Fenn in 1989 in which the top 25 constituents of 3 types (1. perfumes, 2. household products, 3. soaps) of 400 commercial products on the US market had been determined. In a pilot study on a total of 1069 patients in 11 centres, the appropriate test concentration and vehicle were examined. For most fragrances, 1% and 5% were chosen, and petrolatum proved to be the best vehicle in comparison to isopropyl myristate and diethyl phthalate. In the main study, a set of 5 to 10 fragrances at 2 concentrations was patch tested in each centre on a minimum of 100 consecutive patients seen in the patch test clinic. These patients were also patch tested to a standard series with the 8% fragrance mix (FM) and its 8 constituents. In patients with a positive reaction to any of the 48 FF, a careful history with regard to past or present reactions to perfumed products was taken. A total of 1323 patients were tested in 11 centres. The 8% FM was positive in 89 patients (8.3% of 1072 patients). Allergic reactions to the constituents were most frequent to oak moss (24), isoeugenol (20), eugenol (13), cinnamic aldehyde (10) and geraniol (8). Reactions read as allergic on day 3/4 were observed only 10X to 7 materials of the new series (Iso E Super (2), Lyral (3), Cyclacet (1), DMBCA (1), Vertofix (1), citronellol (1) and amyl salicylate (1)). The remaining 41 fragrances were negative. 28 irritant or doubtful reactions on day 3/4 were observed to a total of 19 FF materials (more than 1 reaction: 5% citronellol (2), 1% amyl salicylate (2), 1% isononyl acetate (3), 0.1% musk xylol (2), 1% citral (2), and 1% ionone beta (2)). Clinical relevance of positive reactions to any of the FF series was not proved in a single case. This included the 4 reactions in patients who were negative to the 8% FM. In conclusion, the top 25 fragrances commonly found in various products caused few reactions in dermatological patients and these few appeared to be clinically irrelevant, with the possible exception of Lyral. However, this data should be interpreted in the light of the relatively small number of patients tested (only 100 in most centres).

Testing with fragrance mix. Is the addition of sorbitan sesquioleate to the constituents useful?

In a multicentre study, the value of adding sorbitan sesquioleate (SSO) to the constituents of the 8% fragrance mix (FM) was investigated. In 7 centres, 709 consecutive patients were tested with 2 types of FM from different sources, its 8 constituents with 1% SSO, its 8 constituents without SSO, and 20% SSO. 5 patients (0.71%) reacted to the emulsifier SSO itself, read as definitely allergic on day 3/4. 53 patients reacted to either one of the mixes with an allergic type of reaction. When tested with the constituents without SSO, 41.5% showed an allergic reaction versus 54.7% with SSO. If both types of reactions were considered (allergic and irritant) 38.3% of 73 patients showed a positive "breakdown" result without SSO, versus 54.8% with SSO. The differences were statistically significant. Reactivity to FM constituents was changed in a specific pattern by addition of SSO--irritant reactions increased, particularly for cinnamic alcohol, eugenol, geraniol, oak moss and hydroxycitronellal, whereas others showed only a slight change. Allergic reactions were also increased by SSO, but the rank order of the top 3 sensitizers (isoeugenol, oak moss and eugenol) did not change. Cinnamic alcohol was the only constituent with decreased reactivity after addition of SSO. A positive history of fragrance sensitivity (HFS) was clearly associated with a positive allergic reaction to either the mix or 1 of its constituents (51% versus 28.6% with a negative HFS). Irritant reactions were linked to a negative HFS in a high proportion (64.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Contact allergies in medical occupations]. / Kontaktallergien in medizinischen Berufen.

Based on reports in the literature, data from the information network of German dermatology centres (Informationsverbund Dermatologischer Kliniken) and the authors own findings, a review is presented on prevalence, clinical picture and causative agents of contact allergic dermatoses in health care professions. In 1991 the proportion of suspected occupational diseases in the health care professions (including hairdressers) represented by cases of dermatitis, as reported to the responsible insurance institution, reached 72% of the total for the year (7287 out of 10127). Every 20th to 40th case was recognized as an occupational dermatosis according to German law. Accurate figures on incidence are scarce; for dentists an incidence of 0.11% has been calculated. The risk of developing occupational hand eczema has been shown to be at least three times higher for nurses than for other so-called dry professions. For persons engaged in the personal care of the ill and the elderly, relevant occupational allergens were found to be benzalkonium chloride and aldehydes in disinfectants, as well as rubber accelerators such as thiuram mix. Latex contact urticaria has increasing significance for medical personnel, with prevalence rates of sensitization between 4.5% and 10.7%. Among physicians, contact allergies to thiuram mix were found to be dominant (12.9%). For surgeons and orthopaedic surgeons, methyl methacrylate as a constituent of bone cement is of great importance. Various esters of acrylic acid and methacrylic acid are important sensitizers in the dental professions, particularly in heavily exposed dental laboratory technicians. Only a few gloves protect against these types of sensitizers. Sensitizations by medicaments can be avoided in most cases by reducing direct skin contact, as practiced with penicillin or ispaghula powder. Strategies of prevention include information of atopics regarding the increase in occupational dermatitis, the regular use of barrier creams, intensive skin care after work and avoidance of irritants and allergens wherever possible.

Reproducibility of patch tests. A multicenter study of synchronous left-versus right-sided patch tests by the German Contact Dermatitis Research Group.

BACKGROUND: The efficiency and reproducibility of patch tests remain controversial. OBJECTIVE: Our purpose was to determine the efficiency and reproducibility of patch tests and to identify factors influencing these features. METHODS: We double-tested 1285 patients concomitantly with 10 standard allergens by manually filled test chambers. Additional information was obtained from all patients with a standardized protocol. RESULTS: Patch test efficiency was good (> or = 0.94) with all 10 allergens. In contrast, nonreproducibility of patch tests was strongly allergen dependent, ranging from 0.2 for nickel sulfate to 0.6 for formaldehyde. The likelihood of nonreproducible allergic reactions increased when more than four positive reactions were seen at the same time, and with another positive reaction located in close proximity to an allergic reaction. Sex and age of patients, atopy, dermatitis at distant sites, sleeping habits, and the time of allergen exposure (24 or 48 hours) did not affect the rate of nonreproducible results. CONCLUSION: To increase patch test reproducibility, specific preparations of patch test allergens need to be improved. Furthermore, amplification effects by synchronous neighboring positive reactions should be excluded.

Efficacy of skin barrier creams (III). The repetitive irritation test (RIT) in humans.

2 barrier creams (BC) were evaluated against the anionic detergent sodium lauryl sulphate (SLS) using a new human test model. In the repetitive irritation test (RIT) on human skin, the irritant SLS is applied to the ventral forearm of healthy volunteers daily for 2 weeks. 1%, 5%, and 10% SLS is exposed to the skin for 30 min, using a glass cup 2.5 cm in diameter. The BC is applied 30 min before the irritant. Cutaneous irritation is assessed on a score for erythema (0 to 5+), and quantified by various biophysical techniques: transepidermal water loss (TEWL) by evaporimetry, skin blood flow volume (BFV) by laser-Doppler velocimetry, and skin colour by colorimetry (La* value). 10 subjects were tested with SLS on one forearm without pretreatment (control) and with Taktosan Salbe as BC on the other forearm. A 2nd panel of 10 subjects was tested in the same way with SLS and Marly skin as BC. Taktosan Salbe was extremely effective in reducing the irritation by SLS: there were significant differences regarding all test parameters for 10% SLS in the 2nd week. The most differentiating parameter was TEWL, revealing statistical differences as early as the 1st week for 10% SLS and Taktosan Salbe, while the least differentiating sensitivity was found for La*. In contrast, there was no significant suppression of irritancy in any parameter with Marly skin, either in the 1st week or in the 2nd week with any concentration of SLS.(ABSTRACT TRUNCATED AT 250 WORDS)

[Contact allergy to topical glucocorticoids]. / Kontaktallergie auf topische Glukokortikoide.

Three women with suspected contact allergies to topical corticosteroids had positive patch test reactions to amcinonide, triamcinolone acetonide and budesonide, two of them also reacted to tixocortol pivalate. Doubtful patch test results were seen on hydrocortisone and Alfasone cream. On performing a ROAT (repeated open application test) with amcinonide in all women we saw massive erythematous reactions and spreading urticaria. ROAT with Betnesol-V cream was negative. Two of the women, who were older, had multiple sensitization owing to long-term treatment of venous ulcers over many years. The third woman was young and had acquired the allergy through short-term treatment of prurigo with various topical corticosteroids. Contact allergy to topical corticosteroids is frequent and should be borne in mind in daily practice. Especially when chronic dermatitis is difficult to manage, cross reactions between chemically related corticosteroids should be considered.

Basophil histamine release in patients with birch pollen hypersensitivity with and without allergic symptoms to fruits.

Histamine release (HR) studies were performed in 40 birch pollen-allergic patients (positive case history, positive SPT, positive birch pollen-specific serum IgE: RAST > or = 3) with (n = 20, A) and without (n = 20, B) fruit hypersensitivity, and 10 nonatopic volunteers (C). Several fruit allergens were used and characterized by protein determination and immunoblot techniques. Dose-dependent HR (apple peel = apple pulp > peach = cherry) was demonstrated in both allergic groups, but to a higher extent in patients with fruit allergy (P < 0.01). Increased basophil sensitivity to birch pollen was found in the group with fruit allergy (P < 0.001). Strong correlations between the mediator response induced by several fruits indicate common allergens within the extracts. We conclude that fruit-related symptoms require not only high specific serum IgE, but a strong cellular sensitization to birch pollen allergens together with an increased cellular reactivity to fruit allergens.

The role of GABA in detecting visual motion.

The basic computations underlying the extraction of motion from the visual environment have been characterized in great detail. A non-linear interaction, such as a multiplication, between neighbouring visual elements was shown to be the core of biological motion detectors in different species ranging from insects to man. GABA (gamma-aminobutyric acid)-ergic inhibitory synapses suppressing the responses to motion in one direction but not in the other are widely accepted to be the cellular basis for this non-linear interaction. Based on model predictions we can show in combined pharmacological and electrophysiological experiments that in the fly motion detection system GABAergic synapses do not play this role but rather are involved in another important step of motion computation. This makes a reconsideration of the role of inhibition in other motion detection systems necessary.