LTHOUGH allergic reactions to barium sulfate suspensions are estimated to occur at a rate of less than 2 per million, 1,2 the frequency has been reported to be increasing. 3,4 The cause of these reactions is not known, 5-9 but the additives in barium suspensions, 10-13 medications such as glucagon, 3 and exposure to latex 14-17 -for example, through contact with rubber gloves or balloons -have all been implicated.We describe a patient with anaphylaxis induced by the carboxymethylcellulose sodium in barium sulfate suspension. The reaction occurred after an upper gastrointestinal examination. CASE REPORTA 63-year-old woman was admitted to the hospital in May 1994 because of an anaphylactic reaction after a double-contrast upper gastrointestinal examination. Before the examination, she had no abdominal discomfort. She had no history of atopic dermatitis, allergic rhinitis, or asthma and had not had any side effects from earlier barium studies. The examination was performed with a 100 percent (wt/vol) suspension of barium sulfate (Balgin S Solution number 3, Kaigen, Osaka, Japan) and gas-producing granules (Kaigen). No other medications were given. The examination revealed no gastritis or peptic ulcers. About 30 minutes later, the patient reported generalized pruritus and urticarial lesions on her abdomen, arms, and face, as well as mild periorbital edema. Within minutes she lost consciousness briefly and had tonic convulsions.On admission, a complete blood count, blood chemical values, and serologic tests were normal. Chest radiographs revealed no abnormalities. The white-cell count was 6400 per cubic millimeter, with 0.5 percent eosinophils. The patient again had transient loss of consciousness and hypotension. She was resuscitated with A subcutaneous injections of epinephrine (0.5 mg), intravenous infusion of fluids, and two injections of methylprednisolone sodium succinate (250 mg each). The urticarial lesions disappeared after 24 hours. The patient recovered fully and went home eight days later. METHODS Skin TestingAfter obtaining oral informed consent, we studied the patient and three healthy subjects without atopy or allergies. We conducted skin-scratch tests for each of the components of the barium suspension: barium sulfate, carboxymethylcellulose sodium, sodium metaphosphate, sodium benzoate, sodium dehydroacetate, ethyl parahydroxybenzoate, propyl parahydroxybenzoate, glacial acetic acid, saccharin sodium, and flavorings. All substances (purity, more than 98.0 percent) were mixed with petrolatum and liquid paraffin (10 percent wt/wt) and applied to the skin. The response was evaluated 20 minutes later. The patient also underwent skin-scratch testing with barium sulfate suspension that contained 1.2 percent carboxymethylcellulose sodium and with barium suspension free of carboxymethylcellulose. All the components of the suspension as well as the suspension that did not contain carboxymethylcellulose sodium were obtained from Kaigen. Histamine Release from Isolated LeukocytesPeripheral blood was withdrawn fr...

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Fluoropyrimidines (FU) in combination with warfarin (WF) are reported to increase prothrombin time-international normalized ratio (PT-INR) and bleeding. In the present study, we investigated retrospectively the timing of expression of blood coagulation abnormality in 11 patients treated with WF and UFT or S-1 concomitantly in Okayama University Hospital and Ako City Hospital. In 11 patients, 6 were UFT in combination with WF (UFT group), 5 were S-1 in combination with WF (S-1 group). In all patients, PT-INR was significantly increased after combination with UFT or S-1. The PT-INR elevated rate of the S-1 group was 214.5％ and its rate of the UFT group was 178.2％. The PT-INR elevated rate was higher in the S-1 group than in the UFT group. The PT-INR was increased 2.8 times after four months in the UFT group. These results suggest that the careful monitoring of PT-INR elevation and bleeding is necessary in patients receiving UFT in combination with WF as well as S-1 in combination with WF.

To clarify the regulation of central histaminergic (HAergic) activity by cholinergic receptors, the effects of drugs that stimulate the cholinergic system on brain histamine (HA) turnover were examined, in vivo, in mice and rats. The HA turnover was estimated from the accumulation of tele-methylhistamine (t-MH) during the 90-min period after administration of pargyline (65 mg/kg, i.p.). In the whole brain of mice, oxotremorine, at doses higher than 0.05 mg/kg, s.c., significantly inhibited the HA turnover, this effect being completely antagonized by atropine but not by methylatropine. A large dose of nicotine (10 mg/kg, s.c.) also significantly inhibited the HA turnover. This inhibitory effect was antagonized by mecamylamine but not by atropine or hexamethonium. A cholinesterase inhibitor, physostigmine, at doses higher than 0.1 mg/kg, s.c., significantly inhibited the HA turnover. This effect was antagonized by atropine but not at all by mecamylamine. None of these cholinergic antagonists used affected the steady-state t-MH level or HA turnover by themselves. In the rat brain, physostigmine (0.1 and 0.3 mg/kg, s.c.) also decreased the HA turnover. This inhibitory effect of physostigmine was especially marked in the striatum and cerebral cortex where muscarinic receptors are present in high density. Oxotremorine (0.2 mg/kg, s.c.) and nicotine (1 mg/kg, s.c.) also decreased the HA turnover in the rat brain. However, these effects showed no marked regional differences. These results suggest that the stimulation of central muscarinic receptors potently inhibits the HAergic activity in the brain and that strong stimulation of central nicotinic receptors can also induce a similar effect.

The combination of ELISA and histamine release experiment made it possible to identify the high risk group for developing anaphylactic response. The administration of high dose CMC as a suspending agent in barium sulfate or injectable corticosteroids to this group should be avoided to prevent anaphylactic reactions in the clinic.

Background Primary angle closure disease (PACD) is a type of glaucoma in which the intraocular pressure (IOP) is increased because of the blockage of the anterior chamber angle. Medications contraindicated for patients with PACD, such as anticholinergics, cause mydriasis, and can elevate IOP. However, anticholinergics are currently contraindicated only for primary angle closure glaucoma (PACG) in Japanese package inserts. In this study, we investigated the prescription status of medications contraindicated for PACD, such as anticholinergics, in patients with PACD scheduled for eye surgeries. Methods Forty-three Japanese patients diagnosed with PACD at Kobe City Eye Hospital, Japan, and scheduled hospitalization for eye surgeries between December 2017 and July 2018, were included. Data, including sex, age, diagnosis, IOP, anterior chamber depth, and patients’ regular medications prior to hospitalization, were collected for each patient from the electronic medical records. Results The number of patients with chronic primary angle closure (CPAC) and acute primary angle closure (APAC) was 35 (81.4%) and 8 (18.6%), respectively. Among all the 43 patients with PACD, 8 (18.6%) received 15 medications that are potentially contraindicated for PACD by non-ophthalmologist. According to medication categories, benzodiazepine hypnotics were the most commonly prescribed. Among the 8 patients with APAC, 2 (25.0%) had routinely received medications contraindicated for PACD. The median number of all kinds of prescriptions on the day of hospitalization was significantly higher for patients who received medications contraindicated for PACD than for those who did not receive them (p = 0.010). Conclusions About 20% of patients with PACD received medications potentially contraindicated for PACD, such as anticholinergics. Attention should be paid to patients prescribed multiple drugs for adverse events, such as increase in intraocular pressure.

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