Biomedical subjects
L C Grammer
Publications and source records attributed to L C Grammer.
Risk factors for immunologically mediated disease in workers with respiratory symptoms when exposed to hexahydrophthalic anhydride.
Occupational immunologic lung diseases caused by exposures to substances such as hexahydrophthalic anhydride are significant health problems. It would be useful to identify risk factors, other than exposure, for occupational immunologic lung diseases such as occupational asthma. Our objective was to identify risk factors for development of immunologically mediated disease in workers with respiratory symptoms associated with exposure to hexahydrophthalic anhydride. A medical and immunologic survey study was conducted of 33 employees with respiratory symptoms associated with hexahydrophthalic anhydride exposure. Of the 33 employees with respiratory symptoms, 20 had no immunologically mediated disease. Seven had both immunoglobulin E-mediated and immunoglobulin G-mediated disease, 5 had immunoglobulin E-mediated disease only, and 1 had immunoglobulin G-mediated disease only. Although larger samples would have rendered atopy a statistically significant risk factor (assuming effect replication), the associated effect strength represents less than a 16% improvement versus chance, which is indicative of marginal clinical significance. However, as expected, elevated levels of specific antibodies were statistically and clinically significant risk factors. Development of one type of immunologically mediated disease was highly predictive of development of the other type. In hexahydrophthalic anhydride-exposed employees with respiratory symptoms, development of immunologically mediated respiratory disease is most closely associated with presence of specific immunoglobulin E or immunoglobulin G antibodies. Neither race, age, smoking status, atopy, nor exposure levels emerged as significant risk factors in this symptomatic study population.
An intervention program to reduce the hospitalization cost of asthmatic patients requiring intubation.
BACKGROUND: Asthma is the single disease that accounts for the largest proportion of total health care cost in the US. OBJECTIVE: To analyze whether an asthma management program affected the cost of subsequent asthma care for patients in whom intubation had been necessary. METHODS: We evaluated patients with asthma who (1) had required intubation for treatment of status asthmaticus; (2) were 45 years old or younger; (3) had regular follow-up visits in our clinic for 1 year after initial evaluation; and (4) had complete medical records 1 year before and 1 year after the intervention for our evaluation. Medical costs of asthma treatment for each patient were determined for 1 year before and 1 year after intervention. The program included patient education, regular outpatient visits, specialist care, and access to the Allergy Immunology emergency call service. The outcome measures were the total cost of care, inpatient hospitalizations, outpatient services, emergency services, and medicine costs. RESULTS: Nine patients [mean age 19.6 years (SD = 9.9)] fulfilled the criteria (six women and three men). The mean duration of asthma was 14.0 years (SD = 9.7). The mean total cost of care decreased from $43,066 to $4,914 (t = -4.53, P < .001) and inpatient hospitalization costs decreased from $40,253 to $1,926 (t = -4.50, P <.001). There was, however, no significant difference in the mean pre-intervention versus post-intervention cost of emergency services, outpatient services, or medicine costs. CONCLUSIONS: The intervention--which included education, specialist care, regular outpatient visits, and access to an emergency call service--significantly reduced the cost of asthma care in our population of patients intubated for asthma.
Total serum IgE in trimellitic anhydride-induced asthma.
The objective of this study was to determine whether total serum IgE levels are elevated in workers with trimellitic anhydride-induced asthma as compared with anhydride-exposed workers without an occupational immunologic syndrome. Sera from 12 highly exposed workers with trimellitic anhydride-induced asthma, and from 31 similarly exposed workers without occupational immunologic disease, were assayed for total immunoglobulin E (IgE) levels by Total IgE II FAST analysis. The mean total IgE levels were 176.74 ng/mL and 34.55 ng/mL respectively. The difference between the two groups was statistically significant, but considerable overlap of IgE levels between groups was seen. In conclusion, although mean total IgE levels are significantly different between TMA-exposed workers with or without occupational asthma, the significant amount of overlap and poor sensitivity of the test preclude the use of this assay in the individual evaluation of these workers.
Study of employees with anhydride-induced respiratory disease after removal from exposure.
The purpose of this study was to determine the clinical and immunologic status of hexahydrophthalic anhydride (HHPA)-exposed employees who had developed an immunologic respiratory disease and who have been removed from exposure for at least 1 year. In a surveillance study spanning 4 years, we identified 28 employees with HHPA-induced immunologic respiratory disease who had been removed from exposure for at least 1 year. Seven had asthma, nine had hemorrhagic rhinitis, four had both, and eight had allergic rhinitis alone. Respiratory symptoms were assessed by physician-administered questionnaires. For each employee, a physical examination, spirometry, and chest roentgenograph were performed. Antibody against HHPA conjugated to human serum albumin (HHP-HSA) was measured using an enzyme-linked immunosorbent assay. Symptoms, signs, and spirometry normalized in all but one employee. There were no chest-roentgenograph findings at follow-up that could be attributed to HHPA. There was a decline in antibody liter for both immunoglobulin E and G against HHP-HSA. In this group of 28 employees, there was only one employee with mild asthma after removal from exposure for at least I year. Although specific antibody was still present in many, the titers were generally lower at follow-up than at presentation.
Low complication rate of corticosteroid-treated asthmatics undergoing surgical procedures.
OBJECTIVE: To determine the incidence of perioperative complications in asthmatic patients who received preoperative treatment with corticosteroids and whether these could be predicted using any study variables such as age, sex, severity of asthma, or surgery type. METHODS: Using a retrospective cohort design, we studied 71 asthmatic patients who underwent 89 surgical procedures; 86 of 89 patients received preoperative treatment with systemic corticosteroids. The main outcome measures evaluated were incidence of postoperative bronchospasm, infection, clinical evidence of adrenocortical insufficiency, and death. RESULTS: Three patients (4.5%) developed mild postoperative bronchospasm; five (5.6%) developed postoperative infections, two of which were wound infections (2.2%); there were no patients with evidence of adrenocortical insufficiency; there was one death related to a neurosurgical intraoperative complication. Incidence of infection was not statistically different from two comparison surgical groups. None of the complications was predicted using any of the study variables. CONCLUSION: Asthmatic patients who are treated preoperatively with corticosteroids can undergo surgical procedures with a low incidence of complications.
Undifferentiated somatoform idiopathic anaphylaxis: nonorganic symptoms mimicking idiopathic anaphylaxis.
BACKGROUND: Northwestern University's Division of Allergy and Immunology has had experience with the diagnosis and treatment of more than 350 patients with idiopathic anaphylaxis (IA). In 1992 we reported a group of patients with IA whose presentations mimicked IA, but IA and other organic causes were later excluded. Psychologic factors were suspected as the underlying problem. These patients were classified as IA-variant. Management of these cases was extremely difficult. There was significant morbidity and high and unnecessary costs. OBJECTIVE: We aim to distinguish the nature of this disease and to highlight the evaluation and treatment of this group of patients. METHODS: Their cases are reviewed and reported. RESULTS: Common features included (1) presenting symptoms mimicking IA, (2) no objective findings that correlated with 1, (3) no response to the therapeutic regimen for IA, (4) meeting the Diagnostic and Statistical Manual of Mental Disorders criteria for undifferentiated somatoform disorder, and (5) significant wasted health care expenditure. CONCLUSIONS: This group of patients were better defined as having undifferentiated somatoform-IA. An algorithm was proposed to expedite the diagnosis of the disease so that with early recognition of the disease, unwarranted repetitive consultations, tests, and inappropriate therapy can be avoided.
Study of employees with anhydride-induced respiratory disease after removal from exposure.
The purpose of this study was to determine clinical and immunologic status of hexahydrophthalic anhydride (HHPA) employees who have had immunologic respiratory disease and who have been removed from exposure for at least 1 year. In a retrospective study, 16 consecutive employees with HHPA-induced immunologic respiratory disease who had been removed from exposure for more than 1 year were evaluated. Eleven had asthma, allergic rhinitis, or both; five had hemorrhagic rhinitis. Respiratory symptoms were obtained by physician-administered questionnaire. Physical examination, spirometry, and chest film were obtained. Antibody against HHPA conjugated to human serum albumin (HHP-HSA) was determined by enzyme-linked immunosorbant assay. Symptoms, signs, and pulmonary functions were normalized in all employees. There was a decline in antibody titers for both IgE and IgG against HHP-HSA. There were no chest film findings attributable to HHPA. In this group, there appeared to be no evidence of permanent anatomic sequelae after removal from exposure for at least 1 year. Specific antibody was still present, but titers were lower at follow-up than at presentation for a substantial proportion of the sample.
Direct laryngoscopy with provocation: a useful method to distinguish acute laryngeal edema from nonorganic disease.
BACKGROUND: Acute laryngeal edema is a manifestation of anaphylaxis, is frequently sudden in onset and requires immediate treatment to prevent further airway compromise. Nonorganic disease such as globus hystericus may present with symptoms similar to acute laryngeal edema. Distinguishing life-threatening acute laryngeal edema from non-life-threatening disease may be difficult. OBJECTIVE: We present a patient in which direct laryngoscopy was used to distinguish acute laryngeal edema from nonorganic disease. METHODS: A case report of a woman who had presented to numerous emergency rooms with symptoms of cough, sensation of throat closing, and hoarseness when exposed to odors such as nail polish remover and musk cologne. She was treated repeatedly with subcutaneous epinephrine, oral diphenhydramine and intravenous methylprednisolone. Her history was not classic for IgE-mediated anaphylaxis and we challenged her with nail polish remover while visualizing her vocal cords with direct laryngoscopy. RESULTS: Upon challenge with an offending agent, her symptoms were again suggestive of life-threatening laryngeal edema. Direct laryngoscopy, however, revealed no objective evidence of airway obstruction. CONCLUSION: Direct laryngoscopy with provocation is useful in distinguishing acute laryngeal edema from nonorganic disease.
Value of antibody level in diagnosing anhydride-induced immunologic respiratory disease.
The objective of this study was to determine whether immunologic anhydride-induced respiratory disease could be predicted on the basis of the level of specific immunoglobulin E (IgE) or immunoglobulin G (IgG) antibody. Eight-one anhydride-exposed employees in one plant were studied. Fourteen had disease and 67 did not. Immunologic studies were performed by enzyme-linked immunosorbent assay and expressed as titers. When optimal discriminant analysis was used, IgE < 1:5 and IgG < or = 1:10 were found to be the optimal titers for separating employees with and without immunologic respiratory disease caused by anhydrides. When IgG < or = 1:10 was used, 62 of 81 workers were correctly classified; the sensitivity was 100%, the positive predictive value was 45%, the specificity was 75%, and the negative predictive value was 100%. When IgE < 1:5 was used, 73 of 81 workers were correctly classified; the sensitivity was 86%, the positive predictive value was 67%, the specificity was 91%, and the negative predictive value was 97%. In conclusion, anhydride disease status can be predicted on the basis of specific IgG or IgE antibody level.
A cluster of anaphylactic reactions in children with spina bifida during general anesthesia: epidemiologic features, risk factors, and latex hypersensitivity.
BACKGROUND: Anaphylactic reactions (ARs) in high-risk pediatric patients undergoing general anesthesia, especially those with spina bifida, have been attributed to anesthetics, muscle relaxants, antimicrobials, ethylene oxide, and latex. METHODS: To identify risk factors for AR during general anesthesia and to investigate the role of latex allergy, we studied epidemiologic and immunologic characteristics of patients with ARs during general anesthesia during a 13-month cluster of such reactions at Children's Hospital of Wisconsin (case patients). Patients with AR were compared with patients with spina bifida undergoing uneventful general anesthesia during the same period (control patients). For each case patient and control patient, we conducted a chart review; a parental interview; skin prick testing with latex, anesthetics, aeroallergens, and banana extract; ELISA and RAST for latex-specific IgE; a total serum IgE; and an ELISA for IgE antibody to ethylene oxide. RESULTS: Anaphylactic reactions occurred exclusively in patients with spina bifida (n = 10) or patients with a congenital urinary tract anomaly (n = 1). Case-patients were more likely than control patients to have a history of asthma (p = 0.002), rubber contact allergy (p = 0.001), food allergy (p = 0.001), rash caused by adhesive tape (p = 0.05), daily rectal disimpaction (p < 0.001), nine or more prior surgical procedures (p < 0.002), latex-specific IgE (p = 0.027), or elevated total serum IgE levels (p = 0.002). Multivariate analysis identified non-white race, rubber contact allergy, history of food allergy, and nine or more surgical procedures as significant independent risk factors. Logistic model equation identified the predicted probability of AR with a sensitivity, specificity, and positive predictive value of 82%, 97%, and 82%, respectively. CONCLUSIONS: These findings demonstrate that atopy, especially symptomatic latex allergy, is associated with AR during anesthesia in patients with spina bifida. Until a standardized latex test is available, a medical history of immediate rubber contact allergy, non-white race, food allergy, or nine or more prior surgical procedures can identify patients with spina bifida at highest risk for ARs. A complete history, including rubber contact and food allergy, should be compiled on all patients with spina bifida before surgery.
Gutta-percha allergy in a health care worker with latex allergy.
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Respiratory and systemic reaction following exposure to heated electrostatic polyester paint.
A 39 year old nonatopic man developed episodes of cough, dyspnoea, sweating and shivers within 2-3 weeks of starting a new job in a factory where metallic boards were treated with an electrostatic powder paint, made of an epoxy resin and a carboxylated polyester containing polyethylene terephthalate and polybutylene terephthalate. The subject sprayed the metallic boards which were then heated in 200 degrees C ovens. The subject was first seen in an emergency room after being at work for 4 h. The physical examination revealed bilateral wheezing with fever (39 degrees C), hypoxaemia (arterial oxygen tension (PaO2) 58 torr (7.7 kPa), leucocytosis (white blood count cells.mm-3 17,000 (17 x 10(9) cells.l-1) and severe airway obstruction (forced expiratory volume in one second (FEV1)/forced vital capacity, (FVC) 1.3/2.4 l, improving to 2.2/3.8 l after bronchodilator; predicted values = 3.4/4.1 l). The subjects condition improved after being treated with oral steroids. His spirometry was normal two weeks later, although he showed mild bronchial hyperresponsiveness to methacholine with the (provocative concentration producing a 20% fall in FEV1 (PC20) being 1.7 mg.ml-1). The subject underwent specific inhalation challenges at the workplace 4 months later. After being exposed at work for 4 h, he developed a significant fall in FEV1 (-40%), fever, leucocytosis, and a fall in diffusing capacity. Lung function tests were back to normal two weeks later. Exposing the subject to heated granulated polyester for one hour in a hospital laboratory produced a fall in FEV1 of 41%, fever, leucocytosis and a fall in diffusing capacity.(ABSTRACT TRUNCATED AT 250 WORDS)
Effectiveness of early therapy with corticosteroids in Stevens-Johnson syndrome: experience with 41 cases and a hypothesis regarding pathogenesis.
Evaluation of therapy for Stevens-Johnson syndrome was initiated as a retrospective analysis and then extended to a prospective series of patients treated with corticosteroids. This report extends the initial prospective study of patients with Stevens-Johnson syndrome treated with corticosteroids and evaluates the total series of 41 patients relative to outcome and the presumptive etiology. We propose that management of Stevens-Johnson syndrome requires corticosteroid therapy and that the survival of patients with Stevens-Johnson syndrome may depend on this therapy. No fatalities or adverse effects due to corticosteroids were noted. Stevens-Johnson syndrome due to a drug, a drug metabolite or viral infection may mimic a graft-versus-host reaction in which the patient rejects skin, mucous membrane, kidney or liver cells to which the drug, drug metabolite, or virus has bound. Corticosteroids suppress the inflammatory rejection until the activating agent has been eliminated.
Hypersensitivity.
Anaphylaxis is a syndrome including one or more of the following life-threatening responses: hypotension, bronchospasm, upper airway angio-oedema. Other manifestations such as urticaria or rhinitis may also occur. Anaphylaxis is due to release of mediators such as histamine or leukotrienes; this mediator release may be due to immunological or non-immunological mechanisms. Ethylene oxide (ETO) is used to sterilize haemodialysers and other medical equipment that cannot with-stand heat sterilization. There is significant scientific evidence that ETO can haptenize human proteins such as human serum albumin (HSA), thus rendering the allergen ETO-HSA. Approximately two-thirds of patients who experience dialysis anaphylaxis have IgE against ETO-HSA, whereas only about 5% of those without anaphylaxis have IgE against ETO-HSA. No other allergens or mechanisms have been described to account for a significant number of anaphylaxis reactions.
Risk factors for immunologically mediated respiratory disease from hexahydrophthalic anhydride.
Our objective was to identify risk factors for development of immunologically mediated respiratory disease in workers exposed to hexahydrophthalic anhydride. We performed a medical and immunologic survey study of 57 workers in a workplace molding operation utilizing hexahydrophthalic anhydride. The main outcome measurements were the development of a respiratory disease due to specific IgE antibody (asthma and/or rhinitis) or specific IgG antibody (hypersensitivity pneumonitis or hemorrhagic rhinitis). Of the 57 workers, 7 had both IgE- and IgG-mediated disease, whereas 9 had only IgE-mediated disease. Although neither smoking, age, nor race were risk factors for development of immunologically mediated disease, exposure level and specific antibody were. In conclusion, development of immunologically mediated respiratory disease due to hexahydrophthalic anhydride is most closely associated with exposure level and development of specific IgE or IgG antibodies.
Rhinitis.
Rhinitis is a problem causing significant morbidity. The etiology of rhinitis is varied. The pathophysiology of rhinitis is just beginning to be elucidated. Allergic rhinitis is primarily understood as an inflammatory disease with a neurogenic component. Disease states such as responses to cold dry air are primarily considered to be neurogenic in origin, but inflammatory cells and mediators play a significant role in the development of symptoms in these patients. Our understanding of these complex interactions is reflected in the pharmacologic interventions currently available. Most rhinitis therapy addresses the symptoms of rhinitis not the underlying disease state. Future research in the field of rhinitis should increase our knowledge of the pathophysiology and therefore assist in new drug development.