Investigation of drugs responsible for perioperative anaphylactic reactions using cellular allergen stimulation test

Background Anaphylactic reactions during anesthesia and operation are common and life threatening.Follow-up investigation is necessary for avoiding potential re-exposure of the patients to the offending drugs.The purpose of this study was to assess cellular allergen stimulation test （CAST） as a diagnostic instrument in immunoglobulin E （IgE）-and non-lgE-mediated anaphylactic reactions.Methods This study included 25 patients who developed perioperative anaphylactic reactions and 10 subjects that tolerated anesthetics and other drugs during perioperative period from September 2009 to October 2013 in Peking Union Medical College Hospital.We performed skin tests and flow cytometric analysis of basophil activation-based CAST in all subjects.Results Of the 25 patients,17 had IgE-mediated anaphylactic reactions （causative agent identified by skin tests） and 8 had non-lgE-mediated anaphylactic reactions （negative skin tests）.CAST showed a sensitivity of 42.9％,specificity of 90％,and negative predictive value of 80.6％ for neuromuscular blocking agents.Conclusions CAST may be useful for the diagnosis of anaphylactic reactions during perioperative period.Our findings call for further investigation to increase the sensitivity of the test.

Pancreatic function testing: Here to stay for the 21st century

The diagnosis of Chronic Pancreatitis （CP） is based on the detection of abnormal structure or function of the diseased pancreas. The pancreatic function tests more accurately determine the presence of CP than tests of structure, especially for early stage disease. The function tests can be divided into two categories： non- invasive and invasive. The invasive ＂tube＂ tests can reliably detect mild, early CP, but are only available at a few referral centers and tend to be poorly tolerated by patients. The non-invasive tests are easy to obtain, but tend to perform poorly in patients with early, mild disease. Therefore, no one test is useful in all clinical situations, and a detailed understanding of the rational, pathophysiologic basis, strengths, and limitations of various tests is needed. This review highlights the role of various pancreatic function tests in the diagnosis of CP including fecal fat analysis, fecal elastase, fecal chymotrypsin, serum trypsin, the secretin stimulation test, the cholecystokinin （CCK） stimulation test, the combined secretin-CCK stimulation test, the intraductal and endoscopic secretin stimulation tests, and the functional magnetic resonance imaging of the pancreas after secretin stimulation.

Does a combined intervention program of repetitive transcranial magnetic stimulation and intensive occupational therapy affect cognitive function in patients with post-stroke upper limb hemiparesis?

Low-frequency repetitive transcranial magnetic stimulation（LF-r TMS） to the contralesional hemisphere and intensive occupational therapy（i OT） have been shown to contribute to a significant improvement in upper limb hemiparesis in patients with chronic stroke. However, the effect of the combined intervention program of LF-r TMS and i OT on cognitive function is unknown. We retrospectively investigated whether the combined treatment influence patient＇s Trail-Making Test part B（TMT-B） performance, which is a group of easy and inexpensive neuropsychological tests that evaluate several cognitive functions. Twenty-five patients received 11 sessions of LF-r TMS to the contralesional hemisphere and 2 sessions of i OT per day over 15 successive days. Patients with right- and left-sided hemiparesis demonstrated significant improvements in upper limb motor function following the combined intervention program. Only patients with right-sided hemiparesis exhibited improved TMT-B performance following the combined intervention program, and there was a significant negative correlation between Fugl-Meyer Assessment scale total score change and TMT-B performance. The results indicate the possibility that LF-r TMS to the contralesional hemisphere combined with i OT improves the upper limb motor function and cognitive function of patients with right-sided hemiparesis. However, further studies are necessary to elucidate the mechanism of improved cognitive function.

CAN LONG-TERM POTENTIATION BE INGVCED BY ACUPOINT STIMULATION?

Longterm potentiation (LTP ) is usually induced by direct brain stimulation. An attempt has been made to evoke LTP in dentate granule cells of hippocampus by acupoint stimulation in anesthetized rats. Assuming a gradual increasing course, LTP rose to 146% at the end of one hour. After applying such stimulation to the awake rats for six days (once everyday), their discriminative learning capacity in Y maze test markedly improved as compared with that of the control.

Liver injury after aluminum potassium sulfate and tannic acid treatment of hemorrhoids

We are reporting a rare case of acute liver injury that developed after an internal hemorrhoid treatment with the aluminum potassium sulfate and tannic acid(ALTA) regimen. A 41-year-old man developed a fever and liver injury after undergoing internal hemorrhoid treatment with a submucosal injection of ALTA with lidocaine. The acute liver injury was classified clinically as hepatocellular and pathologically as cholestastic. We could not classify the mechanism of injury. High eosinophil and immunoglobulin E levels characterized the injury,and a drug lymphocyte stimulation test was negative on postoperative day 25. Fluid replacement for two weeks after hospitalization improved the liver injury. ALTA therapy involves injecting chemicals into the submucosa,from the rectum to the anus,and this is the first description of a case that developed a severe liver disorder after this treatment; hence,an analysis of future cases as they accumulate is desirable.

Oxaliplatin-Induced Lung Injury with Allergic Reaction

A 79-year-old man was diagnosed as stage IV colon cancer and treated with a modified FOLFOX6 （mFOLFOX6） regimen.On the 12th cycle,we observed erythema and dyspnea.Radiographs showed ground grass opacities.Blood tests showed elevated levels of eosinophils and immunoglobulin E.We diagnosed this finding as response to drug allergy and administered high-dose methylprednisolone.The treatment was successful and he was discharged.The drug lymphocyte stimulating test against oxaliplatin was positive,indicating a type I and IV allergic reaction due to oxaliplatin.Regimens including oxaliplatin must be carefully monitored and frequent blood tests and chest radiographs are needed.