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75 FEV1 measurement validation scheme
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Abstracts
Eesinophilia and Vasculitis Associated With Montelukast in a Man With Asthma not on Prednisone RC Van De//en. SS Foubion Mayo Clinic, Rochester, MN We present a patient with asthma, a vasculitis, and eosinophilia on montelukast but not on prednisone. An association of a Churg-Strauss-like vasculitis developing in patients with asthma on systemic steroids when given zafirlukast has been reported. The vasculitis became apparent as the systemic steroids were reduced raising the possibility that the vasculitis was present initially and suppressed by systemic steroids (Wechsler et al, JAMA; 1998,279:455-57). A 78-year-old man presented to Mayo Clinic in July 1999 with fatigue, weight loss, a leukocytoclastic vasculitis, and marked eosinophilia. He also had chronic atrial fibrillation, mild aortic stenosis, hypertension, and mild cognitive impairment before his present illness. He had asthma for4-5 years and received several courses of prednisone prior to 1 l/97. Since I l/97 his asthma has been mild both by history and on pulmonary function tests done in I l/97 at Mayo and at the onset of the current illness done elsewhere. In 1997 he was started on zafirlukast. The asthma was controlled on this with salmeterol and fluticasone, 880 mcg daily. He had not required systemic steroids since 1 l/97. His total eosinophil count at Mayo in I l/97 and 1998 was less than lOO/pL. Five months before presentation he was started on montelukast. One month before presentation at Mayo he developed severe fatigue and a total eosinophil count of 54OO/pL. Montelukast was stopped and 4 days later the eosinophil count was 94OO/pL. He was admitted to another hospital. Purpuric lesions of the skin on biopsy showed leukocytoclastic vasculitis. Prednisone was started. A month later he was seen at Mayo Clinic with fatigue, weakness, and weight loss. He looked cachectic. His sedimentation rate was normal and total eosinophil count 238O/pL despite prednisone, IO mg daily. He was admitted to the hospital where he became confused and disoriented. His MRI of the head showed lesions consistent with infarcts or vasculitis. His p-ANCA was positive with anti-MPO antibodies. The neurology consultant thought the findings were consistent with a vasculitis, and a tentative diagnosis of Churg-Strauss vasculitis was made. The dose of prednisone was increased. Liver lesions were found on CT scan. A liver biopsy showed hepatocellular carcinoma with cirrhosis. Serologies to hepatitis B and C were negative, making it unlikely the vasculitis was related to viral hepatitis. Our patient with mild asthma not on prednisone developed a vasculitis associated with a marked peripheral eosinophilia after 2 years of therapy with leukotriene antagonists, most recently montelukast, raising the questions whether montelukast might have caused the vasculitis and eosinophilia or whether this was coincidence. Only further experience with leukotriene antagonists will clarify whether there is a cause and effect relationship with this class of drugs and eosinophilic vasculitis. FEV, Measurement Validation Scheme TR Kofschwar*. CL Curtis*, CC Heath*, WA Colburn*, TJ Lenehan*, CH Piercef. FA Romero#, RG Townky# *MDS Harris, Lincoln, NE tPhoenix International, Cincinatti, OH SCreighton University, Omaha, NE Accuracy and reproducibility of pulmonary function measurements are critical when assessing the effects of therapeutic intervention. For research spirometry, the American Thoracic Society recommends that the highest and second highest forced expiratory volume in I second
J ALLERGY CLIN IMMUNOL JANUARY 2000
(FEV,) measurements on any given patient be within 5% or 100 cc, whichever is greater. In any research setting, instruments and spirometry technicians need to be validated according to GLP/GCP standards. We have implemented processes to ensure that both instruments and technicians are generating accurate and reproducible FEV, data. INSTRUMENT VALIDATION: The pneumotach for each spirometer (KoKo Spirometer. Pulmonary Data Service Instrumentation, Inc. Louisville, CO) is calibrated daily using a certified gas syringe with settings of I .O, 2.0, and 3.0 liters. The accuracy of the syringe has been verified by the manufacturer utilizing reference materials supplied by the National Institute of Standards and Technology (NIST, formerly known as the national Bureau of Standards, NBS). TECHNICIAN VALIDATION: To ensure that all spirometry technicians were properly trained and capable of obtaining accurate and reproducible results, an internal protocol assessing FEV, in 7 normal. healthy patients was conducted with 10 technicians. Each technician performed FEV, maneuvers on 7 patients in accordance with American Thoracic Society Guidelines which dictate less than or equal to 5% difference between the two best efforts. Our goal was to assess the variability between technicians when conducting FEV,s on the same patient. Prior to conducting this validation. we provided intense training for the technicians with emphasis on the importance of uniformity as well as the importance of coaching the patient to give his/her best effort. CONCLUSIONS: By providing technician training and instmment calibration, we were able to match and exceed requirements of the ATS guidelines and demonstrate that the variability between different technicians on the same patient is less than 3%. It is our firm opinion that continual training is the key to minimizing intertechnician variability and that formalized training must occur at least on a quarterly basis to ensure continuing education for current employees and proper training for new employees.
76 Posttranscriptional
Control of Gene Expression in Activated T Cells U Amsoy C Song. J Keene Duke University Medical Center Many genes involved in mediating important events inTcell activation are predominantly regulated at the posttranscriptional level. Three broad categories of genes known to be involved in T cell function and regulated at the posttranscriptional level include (I) protooncogenes, (2) cytokines and (3) cell surface receptors. Many cytokines are also regulated at the level of mRNA stability including, IL-2. GM-CSF, TNF. IFN. IL- I, IL-4. IL-3 as well as vascular endothelial growth factor (VEGF). In certain systems, IL-2 steady state mRNA levels increase by as much as 20 to 40-fold after stimulation resulting in 80 to IOO-fold increases in IL-2 protein production. These events are posttranscriptionally mediated. In addition, cytokine cell surface receptors such as IL-2 gamma and alpha chains, IL-4R, IFN-gamma receptor are posttranscriptionally regulated. Hence, posttranscriptional gene regulation is a very important control mechanism that the activated cell uses to greatly increase the amounts of cytokines. Many of these genes have in common the AUUUA motif in their 3’ untranslated regions (UTR) of the mRNA transcripts. The AU-rich motifs are thought to play a central role in determining the mRNA stabilities of these genes since they interact with trans-acting mRNA binding proteins. We have previously described the cloning of one such mRNA binding protein, HuR. This nuclear shuttling protein binds to the AU-rich motifs and helps stabilize the mRNAs of its targets. We have studied the role of
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75
Abstracts
Eesinophilia and Vasculitis Associated With Montelukast in a Man With Asthma not on Prednisone RC Van De//en. SS Foubion Mayo Clinic, Rochester, MN We present a patient with asthma, a vasculitis, and eosinophilia on montelukast but not on prednisone. An association of a Churg-Strauss-like vasculitis developing in patients with asthma on systemic steroids when given zafirlukast has been reported. The vasculitis became apparent as the systemic steroids were reduced raising the possibility that the vasculitis was present initially and suppressed by systemic steroids (Wechsler et al, JAMA; 1998,279:455-57). A 78-year-old man presented to Mayo Clinic in July 1999 with fatigue, weight loss, a leukocytoclastic vasculitis, and marked eosinophilia. He also had chronic atrial fibrillation, mild aortic stenosis, hypertension, and mild cognitive impairment before his present illness. He had asthma for4-5 years and received several courses of prednisone prior to 1 l/97. Since I l/97 his asthma has been mild both by history and on pulmonary function tests done in I l/97 at Mayo and at the onset of the current illness done elsewhere. In 1997 he was started on zafirlukast. The asthma was controlled on this with salmeterol and fluticasone, 880 mcg daily. He had not required systemic steroids since 1 l/97. His total eosinophil count at Mayo in I l/97 and 1998 was less than lOO/pL. Five months before presentation he was started on montelukast. One month before presentation at Mayo he developed severe fatigue and a total eosinophil count of 54OO/pL. Montelukast was stopped and 4 days later the eosinophil count was 94OO/pL. He was admitted to another hospital. Purpuric lesions of the skin on biopsy showed leukocytoclastic vasculitis. Prednisone was started. A month later he was seen at Mayo Clinic with fatigue, weakness, and weight loss. He looked cachectic. His sedimentation rate was normal and total eosinophil count 238O/pL despite prednisone, IO mg daily. He was admitted to the hospital where he became confused and disoriented. His MRI of the head showed lesions consistent with infarcts or vasculitis. His p-ANCA was positive with anti-MPO antibodies. The neurology consultant thought the findings were consistent with a vasculitis, and a tentative diagnosis of Churg-Strauss vasculitis was made. The dose of prednisone was increased. Liver lesions were found on CT scan. A liver biopsy showed hepatocellular carcinoma with cirrhosis. Serologies to hepatitis B and C were negative, making it unlikely the vasculitis was related to viral hepatitis. Our patient with mild asthma not on prednisone developed a vasculitis associated with a marked peripheral eosinophilia after 2 years of therapy with leukotriene antagonists, most recently montelukast, raising the questions whether montelukast might have caused the vasculitis and eosinophilia or whether this was coincidence. Only further experience with leukotriene antagonists will clarify whether there is a cause and effect relationship with this class of drugs and eosinophilic vasculitis. FEV, Measurement Validation Scheme TR Kofschwar*. CL Curtis*, CC Heath*, WA Colburn*, TJ Lenehan*, CH Piercef. FA Romero#, RG Townky# *MDS Harris, Lincoln, NE tPhoenix International, Cincinatti, OH SCreighton University, Omaha, NE Accuracy and reproducibility of pulmonary function measurements are critical when assessing the effects of therapeutic intervention. For research spirometry, the American Thoracic Society recommends that the highest and second highest forced expiratory volume in I second
J ALLERGY CLIN IMMUNOL JANUARY 2000
(FEV,) measurements on any given patient be within 5% or 100 cc, whichever is greater. In any research setting, instruments and spirometry technicians need to be validated according to GLP/GCP standards. We have implemented processes to ensure that both instruments and technicians are generating accurate and reproducible FEV, data. INSTRUMENT VALIDATION: The pneumotach for each spirometer (KoKo Spirometer. Pulmonary Data Service Instrumentation, Inc. Louisville, CO) is calibrated daily using a certified gas syringe with settings of I .O, 2.0, and 3.0 liters. The accuracy of the syringe has been verified by the manufacturer utilizing reference materials supplied by the National Institute of Standards and Technology (NIST, formerly known as the national Bureau of Standards, NBS). TECHNICIAN VALIDATION: To ensure that all spirometry technicians were properly trained and capable of obtaining accurate and reproducible results, an internal protocol assessing FEV, in 7 normal. healthy patients was conducted with 10 technicians. Each technician performed FEV, maneuvers on 7 patients in accordance with American Thoracic Society Guidelines which dictate less than or equal to 5% difference between the two best efforts. Our goal was to assess the variability between technicians when conducting FEV,s on the same patient. Prior to conducting this validation. we provided intense training for the technicians with emphasis on the importance of uniformity as well as the importance of coaching the patient to give his/her best effort. CONCLUSIONS: By providing technician training and instmment calibration, we were able to match and exceed requirements of the ATS guidelines and demonstrate that the variability between different technicians on the same patient is less than 3%. It is our firm opinion that continual training is the key to minimizing intertechnician variability and that formalized training must occur at least on a quarterly basis to ensure continuing education for current employees and proper training for new employees.
76 Posttranscriptional
Control of Gene Expression in Activated T Cells U Amsoy C Song. J Keene Duke University Medical Center Many genes involved in mediating important events inTcell activation are predominantly regulated at the posttranscriptional level. Three broad categories of genes known to be involved in T cell function and regulated at the posttranscriptional level include (I) protooncogenes, (2) cytokines and (3) cell surface receptors. Many cytokines are also regulated at the level of mRNA stability including, IL-2. GM-CSF, TNF. IFN. IL- I, IL-4. IL-3 as well as vascular endothelial growth factor (VEGF). In certain systems, IL-2 steady state mRNA levels increase by as much as 20 to 40-fold after stimulation resulting in 80 to IOO-fold increases in IL-2 protein production. These events are posttranscriptionally mediated. In addition, cytokine cell surface receptors such as IL-2 gamma and alpha chains, IL-4R, IFN-gamma receptor are posttranscriptionally regulated. Hence, posttranscriptional gene regulation is a very important control mechanism that the activated cell uses to greatly increase the amounts of cytokines. Many of these genes have in common the AUUUA motif in their 3’ untranslated regions (UTR) of the mRNA transcripts. The AU-rich motifs are thought to play a central role in determining the mRNA stabilities of these genes since they interact with trans-acting mRNA binding proteins. We have previously described the cloning of one such mRNA binding protein, HuR. This nuclear shuttling protein binds to the AU-rich motifs and helps stabilize the mRNAs of its targets. We have studied the role of