Increase of high mobility group box chromosomal protein 1 in eosinophilic chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by eosinophil-dominant infiltration in Europe and the United States. However, CRSwNP in Asia has shown different immunopathologic features. High-mobility group protein box 1 (HMGB1) is a DNA-binding protein that has been suggested to be involved in various chronic inflammatory diseases. The objective of this study is to investigate whether HMGB1 is augmented in the Chinese eosinophilic CRSwNP and if non-eosinophilic CRSwNP is associated with interleukin 5 (IL-5), IL-8, and tumor necrosis factor α (TNF-α).

METHODS

Nasal polyps specimens were collected from 41 patients with CRSwNP (20 eosinophilic and 21 non-eosinophilic) undergoing functional endoscopic sinus surgery (FESS). Biopsies of uncinate process, and ethmoidal mucosa from 9 non-CRS patients were used as controls by means of immunohistochemistry (IHC) staining, Western blotting, and quantitative reverse-transcription polymerase chain reaction (qRT-PCR).

RESULTS

HMGB1-positive expression was significantly increased in the epithelium and among the large inflammatory cells infiltration in Eos CRSwNP and non-Eos CRSwNP as compared with controls (p < 0.001). The HMGB1 protein and messenger RNA (mRNA) levels of HMGB1, IL-5, IL-8, and TNF-α were significantly higher in eosinophilic CRSwNP than those from controls and non-eosinophilic CRSwNP, but no significant differences in these markers were found between non-eosinophilic CRSwNP and controls. HMGB1 expression levels correlated significantly and positively with IL-5, IL-8, and TNF-α (rs = 0.665, 0.771, and 0.724, respectively; p < 0.001) and slightly with eosinophil infiltration (rs = 0.149; p = 0.012) and the blood eosinophils count (rs = 0.225; p = 0.001) in all samples.

CONCLUSION

Upregulation of HMGB1 could be a significant marker typically in eosinophilic CRSwNP and it may also contribute to the pathogenesis of CRSwNP along with IL-5, IL-8, and TNF-α.

Nasal Allergy and Otitis Media: A real correlation?

OBJECTIVES

The correlation between middle ear pathology and nasal allergy has been debated for almost 30 years. This study aimed to evaluate the relationship between otitis media with effusion (OME) and persistent allergic rhinitis symptoms versus intermittent rhinitis in children.

METHODS

The study included 100 atopic children (52 boys, 48 girls) aged 5-9 years with otological symptoms who were patients of the University of Siena Hospital, Italy. Ear, nose and throat evaluations, tympanometry, skin prick tests (SPTs), mucociliary transport time (MCTt) and Eustachian tube function tests were performed.

RESULTS

The SPTs revealed 50 children sensitised to Dermatophagoides pteronyssinus, 34 to grass pollen and 16 to Parietaria. Of all patients, mild symptoms were intermittent in 19 children and persistent in 18; moderate/severe symptoms were intermittent in 22 and persistent in 41. Tubal dysfunction was present in 25 children, whereas middle ear effusion was present in 45 children undergoing myringotomy. The MCTt was slower in the persistent group (21 ± 2 mins) versus the intermittent group (16 ± 2 mins) with a significant difference (P <0.01). Mean eosinophil cationic protein (ECP) values in the middle ear effusions of children who had undergone myringotomy were 251 ± 175.2 μg/L, and mean ECP blood values were 25.5 ± 16.3 μg/L, with significant differences (P < 0.001).

CONCLUSION

There was a significant association between OME, delayed MCTt, ECP values in middle ear effusion and persistent symptoms of allergic rhinitis. These results suggest a direct involvement of the middle ear mucosa as a target organ in persistent forms.

The natural course of allergic rhinitis: a 32-year follow-up study

CONCLUSION

Early intervention may change the natural course of allergic rhinitis, preventing the progression to asthma. In particular, immunotherapy guarantees remission of local symptoms and valid protection against local and bronchial complications. Symptomatic treatment represents a valid alternative; it is always to be preferred to abstention from any treatment.

OBJECTIVES

Data emerging from various studies on the increase of the prevalence of allergic rhinitis in recent decades appear to be widely dishomogeneous. Another point that needs clarification is the relationship between allergic rhinitis and lower airways pathologies such as asthma or bronchitis.

METHODS

We followed the evolution of allergic rhinitis in a group of patients for the last 30 years to highlight the efficacy of different treatments in the prevention of complications, specifically asthma. After 32 years (1980-2012), 46/73 (63%) patients completed the follow-up.

RESULTS

Symptomatic drugs exhibited maximum efficacy from the third to the eighth year, with 13 of 15 patients reporting an improvement of symptoms; immunotherapy achieved the best efficacy starting from the sixth to the tenth year (8 of 10 patients recovered). Subsequently, improvements decreased in the two groups, to a steady level of 11 of 15 and 6 of 10 recovered patients. Asthma developed in 3 of 46 patients and only among patients that were not treated.

Functional maturation of nasal mucosa: role of secretory immunoglobulin A (SIgA)

Secretory IgA (SIgA) plays an important role in defending the mucous membranes of the upper respiratory airways from common infection. Studying and comparing the values and the daily variation of SIgA in nasal secretion could explain the largest number of upper respiratory infection, especially in children. Moreover, the ELISA dosage of SIgA in nasal secretion, sampled by cotton swabs positioned between septum and middle turbinate for 20 minutes every 4 hours 5 times in a day, can be easily performed and shows significant differences between the healthy child and the healthy adult. Nasal secretion SIgA mean value is lower in the healthy child than in the healthy adult. Circadian variation for healthy child showed the highest value at 7.00 a.m., while in adult the highest value was at 4.00 a.m. These knowledge on SIgA may help to explain the highest number of upper airway infection during childhood and clarify the physiological cycle of production. Thus, in performing a SIgA dosage the time of sample must be considered and preferably it should be made at a standardized time of the day.

Functional maturation of nasal mucosa: role of secretory immunoglobulin A (SIgA)

Secretory IgA (SIgA) plays an important role in defending the mucous membranes of the upper respiratory airways from common infection. Studying and comparing the values and the daily variation of SIgA in nasal secretion could explain the largest number of upper respiratory infection, especially in children.

Moreover, the ELISA dosage of SIgA in nasal secretion, sampled by cotton swabs positioned between septum and middle turbinate for 20 minutes every 4 hours 5 times in a day, can be easily performed and shows significant differences between the healthy child and the healthy adult.

Nasal secretion SIgA mean value is lower in the healthy child than in the healthy adult. Circadian variation for healthy child showed the highest value at 7.00 a.m., while in adult the highest value was at 4.00 a.m.

These knowledge on SIgA may help to explain the highest number of upper airway infection during childhood and clarify the physiological cycle of production. Thus, in performing a SIgA dosage the time of sample must be considered and preferably it should be made at a standardized time of the day.

Are HMGB1 protein expression and secretion markers of upper airways inflammatory diseases?

Taking into account the mechanisms at the origin of the airways inflammatory pathologies, our attention has been recently addressed to the study of HMGB1, a protein belonging to the group of alarmins. Alarmins are those molecules which in homeostatic conditions carry out specific metabolic and/or structural functions; furthermore, after a direct trauma or an infection, these molecules are released in the extracellular milieu becoming there activators of the innate immunity and powerful inflammatory factors. In a previous research we found in patients affected with chronic rhinosinusitis with/without nasal polyposis (CRSwNP) an increased expression of this protein in the nucleus of nasal mucosa epithelial cells. HMGB1 was overexpressed also as focal subepithelial infiltration and in the inflammatory cells of patients in comparison with controls. These results suggested a possible pathogenetic role of HMGB1 in CRSwNP. The aim of the present study was to investigate if the expression and localization (nuclear, cytoplasmic and extracellular) of the HMGB1 protein-cytokine is somehow related to the severity and complexity of the histological and clinical picture. We noticed values which have around statistical significance between nuclear HMGB1 and eosinophils infiltrate (p=0.0607) and between nuclear HMGB1 and inflammatory infiltrate (P=0.0524). Even more significant was the correlation between extra-cellular HMGB1 expression and the presence of allergic-hyper reactive conditions such as asthma, allergic rhinitis, NSADs intolerance, antibiotic allergy. HMGB1 was significantly more expressed in the nucleus (p=0.0499) and in the intercellular space (p=0.0380) in allergic patients than in non-allergic subjects and as extra-cellular infiltrate in patients with NSADs intolerance (p=0.0022). These results confirm the role of HMGB1 in the pathogenesis of chronic rhinosinusitis with/without nasal polyposis; besides the higher extra-cellular expression in patients with a more severe clinical and inflammatory picture and the presence of associated co-morbidities suggests to seek for new compounds: these compounds, decreasing the extra-cellular release of this alarmin through a scavenger mechanism, could keep under control the inflammatory process without interfering with the nuclear transcriptional messengers.

Sleep apnea, sleep disturbance, and fasting glucose variability: a pilot study

BACKGROUND

Disturbed sleep and nocturnal altered breathing are related to disturbances of glucose metabolism. The present uncontrolled observational study explores the role of these factors on the variability of fasting glycemia.

METHODS

The number and duration of nocturnal awakenings and the fasting glycemia of 97 patients with type 2 diabetes treated with diet, metformin, or gliptins were recorded over seven consecutive days. During the same time period, the main respiratory indexes-oxygen disturbance index, apnea/hypopnea index, and respiratory disturbance index-were recorded for one night.

RESULTS

The three respiratory indexes and the number of nocturnal awakenings are highly correlated with the coefficient of variation of the fasting blood glucose recorded over the 7-day period at p < .005 level. A multiple regression analysis showed that the variables in the model explained 86% of the variability.

DISCUSSION

Respiratory/sleep disturbances appear to be modulators superimposed on blood glucose levels determined by other factors.

Inhaled foreign bodies in children: a global perspective on their epidemiological, clinical, and preventive aspects

CONTEXT

While several articles describe clinical management of foreign bodies injuries in the upper air tract, little epidemiological evidence is available from injury databases.

OBJECTIVE

This article aims to understand the burden of airway FB injuries in high-, low-, and middle-income countries as emerging from scientific literature.

DATA SOURCES

One thousand six hundred ninety-nine published articles 1978-2008.

STUDY SELECTION

A free text search on PubMed database ((foreign bodies) or (foreign body)) and ((aspiration) or (airways) or (tracheobronchial) or (nasal) or (inhalation) or (obstruction) or (choking) or (inhaled) or (aspirations) or (nose) or (throat) or (asphyxiation)) and ((children) or (child)).

DATA EXTRACTION

Information on reported injuries according to country, time period, children sex and age, FB type, site of obstruction, symptoms, signs, diagnostic and therapeutic procedures, delay at the diagnosis, complications, number of deaths.

RESULTS

Serious complications occur both in high-income and low-middle income countries in a considerable proportion of cases (10% and 20%, respectively). Similarly, death is not infrequent (5-7% of cases).

CONCLUSIONS

Few countries have good systematic data collection and there's a lack of sensibility in parents and clinicians in terms of acknowledge of the choking risk. On the contrary, international surveillance systems able to collect information in a standardized way need to be implemented.

The role of High Mobility Group Box 1 chromosomal protein in the pathogenesis of chronic sinusitis and nasal polyposis

Chronic rhinosinusitis with nasal polyposis is considered to be a multifactorial disease where different stimuli (mechanical, viral, bacterial, fungal infection, immunological disorders or dysreactivity, environmental pollution), acting on the mucosa of nasal cavities and paranasal sinuses, lead to epithelial damage and mucosal inflammation. Inflammatory cell infiltration (predominantly eosinophils, but also neutrophils, mast cells, macrophages and lymphocytes), cytokine release and sub-epithelial oedema are the histological pictures that are associated, from the clinical point of view, with nasal congestion, secretion and/or post-nasal drip and facial pain/headache. Recently, the importance of the HMG B-1 protein in the pathogenesis of several inflammatory diseases has been demonstrated. This protein is released from necrotic/damaged cells or immune-activated cells, and by acting on specific membrane receptors causes the release of pro-inflammatory mediators, endothelial activation and the survival of inflammatory cells. The objective of the present study was: i) to determine whether HMG B1 is augmented in chronic rhinosinusitis with nasal polyps; ii) if its expression is associated with eosinophils, TNF-α, IL 5 and IL 8 cytokines typically present in chronic inflammation of the nose and paranasal sinuses; iii) to investigate a hypothetical role of this protein in the pathogenesis of nasal polyposis. Nasal polyps tissue from 21 patients affected by CRSwNP and nasal mucosa from 8 controls was collected at the ENT Department of the Chinese PLA General Hospital and underwent immunohistological staining for detection of HMG B1 protein and IL -5, IL -8 and TNF-α inflammatory cytokines. The degree of HMG B1 protein expression was evaluated by dividing the stained sections in 4 portions: 1) nucleus of epithelial cells, 2) cytoplasm of epithelial cells, 3) focal extracellular infiltration, 4) inflammatory cells. HMG B1 was more expressed in the nucleus of epithelial cells of patients compared with controls. In contrast, epithelial cytoplasm HMG B1 staining was significant lower in patients. Sub-epithelial focal infiltration of HMG B1 protein expression was lower in controls, whereas the expression of HMG B1 in the inflammatory cells in patients was significantly increased in comparison with controls. These data, together with the correlation we found between HMG B1 protein expression in different portions and the number of eosinophils infiltrating cells, or IL -5, IL -8 and TNF-α positive cells in patients, suggest that HMG B1 may play a crucial role in the pathogenesis of chronic rhinosinusitis with nasal polyps.

Penetration of prulifloxacin into sinus mucosa of patients undergoing paranasal sinus elective endoscopic surgery

The aim of this study was to assess the concentration of ulifloxacin, the active metabolite of prulifloxacin, in sinuses mucosa and plasma of patients with chronic rhinosinusitis, requiring sinus elective endoscopic surgery. Thirty-nine patients (30 males, 9 females; age range 22-77 years) with chronic sinusitis were enrolled, 35 were treated with the investigational medication. Samples from four untreated patients were used to validate the analytical method, while four treated patients dropped out before surgery. One 600 mg prulifloxacin tablet once daily was administered for 5 days before surgery. The last dosing was scheduled from 2 to 12 hours from tissue and plasma sampling. In each patient, two samples of paranasal sinus mucosa (from ethmoid and turbinate, respectively) and one blood sample were collected. Concentrations of ulifloxacin in plasma and sinuses mucosa were measured using validated bioanalytical LC/MS/MS methods. Individual and mean ulifloxacin concentrations in tissues were always higher than the relevant plasma levels. The highest concentrations were observed between 2.5 and 4.5 hours after the last dosing in all districts. The mean tissue/plasma ratios were 2.5 and 3.0 for ethmoid and turbinate, respectively. Data expressed as Area Under the Curves (AUC±SD) showed that ulifloxacin concentrations in the ethmoid were slightly higher (18.68±6.48 μg/g*h) than in turbinate (15.00±2.89 μg/g*h), and definitely higher than in plasma (6.32±1.14 μg/ml*h). The AUC ratios between tissues and plasma were 3.0 for ethmoides and 2.4 for turbinates. One patient reported two treatment-related episodes of diarrhea, which spontaneously resolved after the drug suspension. Results from this study seem to suggest that prulifloxacin showed good distribution in sinus tissues, where it reaches concentrations significantly higher than in plasma. These findings strongly call for confirmatory clinical trials in patients with bacterial rhinosinusitis.

Risk posed to children by stationery items in the upper airways

AIM

The aim of the present study is to characterize the risk of complications and prolonged hospitalization due to stationery items according to age and gender of patients, FB characteristics and foreign body (FB) location, circumstances of the accident, as emerging from the ESFBI study.

METHODS

A retrospective study in major hospitals of 19 European countries was realized on children aged 0-14 having inhaled/aspired or ingested a stationery item. In the years 2000-2003 a total of 2094 FB injuries occurred in children aged 0-14 years. The characteristics of the child, the FB consistency and the occurrence of complications were analyzed.

RESULTS

Among FB injuries, 62 (3%) were due to a stationery item: 32 were due to objects insertion in the ears while 30 occurred in the upper and lower respiratory tract. Objects most frequently involved are parts of pens in children younger than 3 years and eraser in older. 39% of children needed hospitalization. The most documented complication was inflammation of external ear. Almost 24% of injuries happened under adults' supervision.

CONCLUSION

Injuries are events that in many cases can be prevented with appropriate strategies. Passive environmental strategies, including product modification by manufacturers, are the most effective. Our study testifies that stationary is involved in a non negligible percentage of FB injuries. This results confirm the fact that when passive preventive strategies are not practical, active strategies that promote behaviour change are necessary and information about this issue should be included in all visits to family pediatricians.

Spa therapy of upper respiratory tract inflammations

The upper airway respiratory diseases (i.e. common cold, allergic rhinitis, nonallergic/vasomotor rhinitis, acute and chronic rhinosinusitis and nasal polyposis) in which nasal congestion is a common symptom are often undertreated due to the frequent inadequate efficacy and safety concern with current therapies. In scientific literature, few studies seem to support the hypothesis that nasal inhalatory treatment with thermal water promotes the improvement of nasal symptoms, even if the mechanisms by which the improvement from SPA therapy can be expected remain debated. A prospective comparative study with a pre-post design has been performed consecutively enrolling 33 (males 70 %) patients of both genders older than 12 years of age, affected by chronic sinonasal inflammation. All patients underwent a 14-days course of radioactive water warm vapour inhalations followed by nasal aerosol of the same thermal water 10 min each once/day at Merano Therme. At the beginning and end of the study, in all the subjects, nasal function evaluation by active anterior rhinomanometry, mucociliary transport time (MCTt) determination and nasal cytology were performed. After the inhalatory treatment, the mucociliary function was improved and the pathologic mucociliary transport times recorded at the beginning of the study being significantly reduced to physiologic ones. Besides, before treatment, the cytologic picture showed an inflammatory cell infiltration (eosinophils, neutrophils with/without bacteria, mast cells) in 37 % of patients; after therapy in 66 % of these patients, the rhinocytogram was normal. Our results suggest, according to the literature data, that SPA therapy with radioactive water could represent an alternative choice in chronic inflammatory diseases of the upper airways, nonresponsive to pharmacological therapy.

Modeling the risk: innovative approaches to understand and quantify the risk of severe FB injury

OBJECTIVES

The entry of a small item into the respiratory or digestive tract is still one of the leading causes of injuries in children up to 14 years old. The aim of the paper is to provide a quantitative risk assessment analysis for identifying consumer product features which contribute to increase the risk of sustaining a severe injury.

METHODS

Data on foreign body injuries were collected in 28 European countries and one Pakistani hospital. A total of 7296 cases were classified according to ICD-9CM 931-935. Information about injuries included age and gender of the injured child, circumstances of the accident and foreign body features. A classification tree was set up in order to analyze the impact of the item features like volume shape and rigidity on the severity of the injury.

RESULTS

Males are involved in severe injuries more often than females. Most severe injuries when the foreign body is localized in the ears were due to objects with volume lesser than 49 mm(3). Volume cut-off is slightly higher for foreign bodies that have been found in the nose (55 mm(3)). Objects with conforming rigidity pose children to higher risk of severe injury.

CONCLUSIONS

The presence and supervision of an adult is crucial in reducing the risk for severe injuries both in pharynx and laryhnx and in mouth.

Retrospective study on Romanian foreign bodies injuries in children

BACKGROUND

Foreign bodies (FB) injuries are an issue that has been recognized and investigated since many years; despite that, the impact of this subject in literature and research is still small. Such kind of injuries identifies all incidents due to ingestion, inhalation, insertion and aspiration of an object into the aero digestive tract. FBs injuries located in the upper airways can be a very serious event, sometimes resulting in fatal outcome.

METHODS

A retrospective study was performed on FB injuries in the aerodigestive tract in paediatric patients 1-17 years old, recorded from the ENT Department of the M. S. Curie Hospital in Bucharest.

RESULTS

455 cases were reported from the M. S. Curie Hospital, ENT Department. Prevalence in female patients is higher than the males (225 males and 230 females). Mean age observed was 4.12 years. The distribution of injuries according to the retrieval location showed a higher prevalence in the nose (44.62% of cases), with a higher occurrence in females (50.74%) followed by the digestive system (24.28% of cases) were the distribution between males and females is equal. The highest prevalence was represented by nuts and seed (23.96%), followed by marble and coins (respectively 12.75% and 12.53%).

CONCLUSIONS

As generally described in scientific literature, injuries usually concerned toddlers and preschoolers, while school-aged children less often place foreign objects in their noses. Our results confirm the fact that when passive preventive strategies are not practical, active strategies that promote behaviour change are necessary. Active strategies require that a caregiver changes his or her behaviour each time the child begins an activity that has the potential to cause injury. Education is critical to these active strategies and plays a complementary role to environmental changes and legal mandates.

Toys in the upper aerodigestive tract: new evidence on their risk as emerging from the Susy Safe Study

Foreign body (FB) inhalation, aspiration or ingestion are relatively common events in children. Despite many efforts made in several countries to achieve acceptable safety levels for consumer products devoted to children, small toys or toy parts are still frequently mentioned among risky foreign bodies. The aim of the present study is to characterize the risk of complications and prolonged hospitalization due to toys inhalation, aspiration or ingestion according to age and gender of patients, FB characteristics, circumstances of the accident, as emerging from the Susy Safe Registry. The Susy Safe Registry started in the 2005 to collect data to serve as a basis for a knowledge-based consumer protection activity. It is actually one of the wider databases collecting foreign body injuries in the upper aero-digestive tract in pediatric patients. It is distinguished by a deep characterization of objects which caused the injuries and a multi-step quality control procedure which assures its reliability. Preventive strategies imposing a regulation of industrial production, even if fundamental, are not sufficient and need to be integrated along with other intervention addressed to make aware caregivers toward a proper surveillance of children.

Foreign bodies injuries in children: analysis of Thailand data

OBJECTIVES

Suffocation due to foreign bodies (FB) is a leading cause of death in children aged 0-3 and it is common also in older ages, up to 14 years old. Based on the RPA report the estimated number of incidents per year in children aged 0-14 is in European Union (EU) of approximately 50,000, 10% of which are fatal. The need of an improvement of knowledge led to the development of the pan European study ESFBI (European Survey on Foreign Bodies Injuries) that collected data on FB injuries in the aerodigestive tract in paediatric patients from 19 European Hospitals (Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Finland, Germany, Greece, Italy, Poland, Romania, Slovakia, Slovenia, Spain, Sweden, Swiss, Turkey and United Kingdom). Recognizing that the rapid management is one of the main goals in the presence of such injury the aim of this paper is to confront data coming from 4 ESFBI case series with a Thailand's case series, in order to broaden the knowledge on FBs injuries characteristics, knowing that features like shape, dimension, consistency are fundamental in determine the consequences that might occur.

METHODS

Data coming from the Siriraj Hospital, Thailand from June 2006 to 2010 were collected and compared with 4 case series chosen amongst the ESFBI study cases (Finland, Slovenia, Sweden and Turkey).

RESULTS

172 cases were collected from the Siriraj Hospital in Bangkok, Thailand. The chosen ESFBI members were Finland, Sweden, Slovenia and Turkey, with a sample numerosity respectively of 307, 235, 104 and 196 cases. All countries showed a male prevalence higher than the female one, and injuries occurred most frequently in children younger than 3 years old. The most frequent retrieval location was the digestive system (oesophagus) in Thailand data (97 cases, 56.40% of cases), whilst European cases involved more frequently the nose in Slovenia (58.65%), Finland (37.79% of cases) and Sweden (54.47%). In Turkey's case series, the highest prevalence of cases interested the airways. In Thailand and Finland case series, the main FB's type were represented by bones (respectively 66 case, 38.37% and 48 cases, 15.64%), whilst pearl, ball and marble were the most frequent FB both in Slovenia (16, 15.38%) and Sweden (83, 35.32%). Turkey case series had nuts, seeds and grain as most prevalent FB (126, 64.29%).

CONCLUSIONS

The nature of foreign bodies varies from country to country and is dependent on diverse cultural, social, religious and economic factors that include parental attitudes, eating habits, availability and types of potentially threatening objects, and prevention strategies. The need to study in more depth specific characteristics of foreign bodies associated with increased hazard, such as nature, size, shape, hardness or firmness, lubricity, pliability and elasticity, in order to better identify risky foods and to describe more precisely the pathogenetic pathway is therefore a necessity.

Proper packaging for food and no-food products to avoid injuries

OBJECTIVES

This paper aims to present data on proper packaging for food and no-food products to avoid injuries.

METHODS

Data collection was made from the Susy Safe data base and the results of the literature research.

RESULTS

Fatal and near fatal foreign bodies injuries may occur at any age, however it is a particular problem for infants and young children due to a variety of predisposing factors. Safety packaging is therefore a landmark and a model for accident prevention.

CONCLUSIONS

Taken the lack of researches and specificity on this subject, it is warmly suggested that a broader and deeper exploration, both at customer's and public health levels, has to be made, highlighting major risks and complications. Packaging classes are extremely composite, therefore accuracy in data registry must be achieved, since from a preventive point of view it is basilar not only knowing the nature of the foreign body but also having information on its origin.

Stationery injuries in the upper aerodigestive system: results from the Susy Safe Project

RATIONALE AND AIM

Foreign body (FB) injuries are a relatively frequent event in young children. Clinical picture can be evidently affected from different variables. Among those size, shape, type and FB location cover an important issue. Increased attempts have been made in order to encourage normative interventions for products devoted to children's care and entertainment, reaching acceptable safety level; on the contrary, fewer efforts have been devoted to investigate the risk associated to objects that--even if not expressly created for children--are easy accessed by children, like stationery. The aim of the present study is to characterize the risk of complications and prolonged hospitalization due to stationery items according to age and gender of patients, FB characteristics and FB location, circumstances of the accident, as emerging from the Susy Safe Registry.

METHODS

From 2005 to 2010 case were collected from 70 centers in 32 different countries. Details on the injuries, identified by means of the International Classification of Diseases, Ninth Revision (ICD-9) codes listed on hospital discharge records, were gathered through a standardized case report form, that provides a full set of information on injuries, with specific details on age and gender of the child, location, shape, volume, consistency and ellipticity of the foreign body, behavioral aspects linked to the injury, like the supervision of the parents or the activity concomitant to the accident, any complication occurred, length of hospitalization.

RESULTS

In the years 2005-2010 a total of 17,205 FB injuries in children aged 0-14 years were registered in Susy Safe Database. Among them 425 (2.5%) were due to a stationery item. The majority of FBs were retrieved in the nose (179, meaning 42.1%) and in the ears (176, 41.4%) only 5 cases were observed in children younger than 1 year, while most of the cases, 80.6%, were recorded in children older than 3 years. 193 patients (45.4%) were female, while 232 (54.6%) were male. Adult supervision was indicated in 212 cases. In 143 of these accidents the adult was present (33.6% of the whole group). The most frequent stationery retrieved was rubber, counting for 209 cases (49.2%). According to the FBs types, mostly all cases reported a 3D volume and a rigid or semirigid consistency (49.3%). Looking to the outcomes, 31 (7%) children needed hospitalization and complications were seen in 38 children (8.9%). No significant associations were seen between the outcomes and the FBs' characteristics, excluded those between the consistency of the FB (rigid) and the necessity of hospitalization and the shape (2D) and the presence of complication.

CONCLUSIONS

Injuries are events that in many cases can be prevented with appropriate strategies. Passive environmental strategies, including product modification by manufacturers, are the most effective. However, regulation regarding small parts of potentially dangerous objects covers products addressed to children use but objects not projected for children, such as stationary items, are excluded. Our study testifies that stationary is involved in a non-negligible percentage of FB injuries, mainly due to insertion in the ears. Frequently, injuries happen under adult supervision. These results confirm the fact that when passive preventive strategies are not practical, active strategies that promote behavior change are necessary and information about this issue should be included in all visits to family pediatricians.

Foreign bodies in children: a comparison between Argentina and Europe

RATIONALE AND AIM

Foreign bodies (FB) aspiration, ingestion, insertion or inhalation can be a serious occurrence, resulting in fatality if not promptly recognized and solved. The aim of the current paper is to present foreign body ingestion's cases observed at the Children's Hospital Gutierrez in Buenos Aires in 5 years of ORL activity and to compare main findings with data coming from other well known already published case series.

METHODS

A prospective study was realized on children having ingested, inhaled, aspirated or introduced FBs, with regard to age and sex distribution, FB's type, dimensions and consistency, FB's location, clinical presentation, removal and occurrence of complications.

RESULTS

FBs retrieved amounted to 2336 cases. The most common location was the nose (66.7%), where the most frequent FBs retrieved were inorganic (72.7%) and occurred in children younger than 3 years old (54.2%), the only position where children younger than 3 years are a majority in respect to the older ones. The presence of the adult was seen in the preponderance of cases (88.4%). Symptoms varied between the different anatomical systems, with cough as predominant when concerning aspiration, local pain or inflammation in inhalation and insertion, and vomiting in for the FBs ingestion cases. All the foreign bodies retrieved were clustered in categories, due to necessity when extremely various and with low absolute frequency. The most common FBs retrieved were pearls (20.2%), followed by stationery products (mostly rubbers) and coins. Complications had a low rate in all the studies.

CONCLUSIONS

The study stresses the importance of primary prevention, seen as the active care of adults toward children manipulating foreign bodies potentially dangerous. This presence may not avoid the event, but in case of FBs aspiration, ingestion, insertion or inhalation, it could be the main factor leading to a faster and correct treatment. Prompt removal of the foreign body decreases the risk of complications, resulting in a lower length of hospitalization. Symptoms were various and differed in all the studies, showing that their wide amount indicates the importance of registries to early recognize and therefore treat a pathology that might be mistaken for something different due to unspecific signs. Secondary prevention with specific training of doctors on clinical post-trauma guidelines for treatment and active participation of doctors to the broadening of the current registries seem to be other ways for lowering the outburst of FBs injuries.

Management of foreign bodies in the airway and oesophagus

BACKGROUND

Ingestion and/or aspiration of foreign bodies (FB) are avoidable incidents. Children between 1 and 3 years are common victims for many reasons: exploration of the environment through the mouth, lack of molars which decreases their ability to properly chew food, lack of cognitive capacity to distinguish between edible and inedible objects, and tendency to distraction and to perform other activities, like playing, whilst eating. Most FBs are expelled spontaneously, but a significant percentage impacts the upper aerodigestive tract. Approximately 80% of children's choking episodes are evaluated by pediatricians. The symptoms of aspiration or ingestion of FBs can simulate different paediatric diseases such as asthma, croup or pneumonia, delaying the correct diagnosis.

SYMPTOMS

There are three clinical phases both in aspiration and in ingestion of FBs: initial stage (first stage or impaction or FB) shows choking, gagging and paroxysms of coughing, obstruction of the airway (AW), occurring at the time of aspiration or ingestion. These signs calm down when the FB lodges and the reflexes grow weary (second stage or asymptomatic phase). Complications occur in the third stage (also defined as complications' phase), when the obstruction, erosion or infection cause pneumonia, atelectasis, abscess or fever (FB in AW), or dysphagia, mediastinum abscess, perforation or erosion and oesophagus (FB in the oesophagus). The first symptoms to receive medical care may actually represent a complication of impaction of FB. LOCATIONS AND MANAGEMENT: Determining the site of obstruction is important in managing the problem. The location of the FB depends on its characteristics and also on the position of the person at the time of aspiration. Determining the site of obstruction is important in managing the problem. Larynx and trachea have the lowest prevalence, except in children under 1year. They are linked with the most dangerous outcomes, complete obstruction or rupture. Bronchus is the preferred location in 80-90% of AW's cases. Esophageal FBs are twice more common than bronchial FBs, although most of these migrate to the stomach and do not require endoscopic removal. Diagnosis of FB proceeds following the traditional steps, with a particular stress on history and radiological findings as goal standards for the FB retrieval. The treatment of choice for AW's and esophageal FBs is endoscopic removal. Endoscopy should be carried out whenever the trained personnel are available, the instruments are checked, and when the techniques have been tested. The delay in the removal of FBs is potentially harmful. The communication between the endoscopist and the anaesthesiologist is essential before the procedure to establish the plan of action; full cooperation is important and improves the outcome of endoscopy.

CONCLUSIONS

Ingestion and or aspiration of FB in children are multifactorial in their aetiology, in their broad spectrum of different resolutions for the same FB and in the response of each patient to the treatment. Prevention remains the best treatment, implying an increased education of parents on age-appropriate foods and household items, and strict industry standards regarding the dimensions of toy parts and their secure containers.

Foreign bodies in the ears in children: the experience of the Buenos Aires pediatric ORL clinic

Even if foreign body (FB) insertion in the external auditory canal (EAC) is not an uncommon event, the literature based on large series is scarce. In the present study, ear FB cases observed at the Children's Hospital Gutierrez in Buenos Aires over five years of otorhinolaryngology (ORL) activity are presented, and the main findings are compared with data coming from other well-known published case series. Three hundred ninety-two injury cases were observed. Eighty percent of them occurred while the child was playing; in 328 cases (83.7%), adults were present. The retrieved FB included food items and objects usually available at home, such as pins, while fragments of toys were found in only 2 cases. These findings testify to the efficacy of regulations imposing manufacturing quality standards on toys; on the other hand, parents seem to be unaware of the risk imposed by FB insertion, since injuries usually happen under adult supervision while children are manipulating objects not adapted for their age.

Epidemiology of foreign bodies injuries in Ecuador: a first look based on a single centre experience

OBJECTIVE

The analysis of foreign bodies (FB) injuries in the upper aero-digestive tract is not available for Ecuador and in this context, the present article represent the is the first presenting to the international community the basic epidemiological data on the Ecuador's experience on foreign bodies juries.

METHODS

Data on 258 cases were gleaned using Susy Safe database, choosing the cases coming from Ecuador's institutions, namely Francisco De Icaza Bustamante Children Hospital, in Guayaquil (Ecuador) which collects data on children injuries due to foreign bodies with the aid of a standardized case report forms.

RESULTS

Patients showed a female:male ratio of 1:1.2. Fifty-three percent of the children were younger than 2 years of age, with a mean age of 3.22 years. The most frequent location of retrieval was the oesophagus (37.98%) followed by the ears (34.88%). Coins were the most frequent cause of accident (37.21%). Seeds and grain were the most frequent food FBs and they were seen in 13.95% of cases. Adult presence was recorded in 113 cases. There was indeed a significant correlation between the presence of an adult and the activity that the children were doing when the incident occurred.

CONCLUSIONS

This first breach into the analysis of injuries in Ecuador gives the confirmation that the results coming from country's data agreed with the general Susy Safe ones. Similar preventive strategies are therefore highly recommended, stressing that primary prevention has the main role in children's protection.

Nasal foreign bodies: the experience of the Buenos Aires pediatric otolaryngology clinic

OBJECTIVE

The aim of the present paper is to present nasal foreign cases observed at the Children's Hospital Gutierrez in Buenos Aires, Argentina, over a 4-year period and to compare the main findings with data from other case series.

METHODS

A prospective study was undertaken on children having inhaled/aspired a foreign body (FB), with regard to age and sex distribution, FB type, dimensions and consistency, FB location, clinical presentation, removal and occurrence of complications.

RESULTS

A total of 1559 cases of foreign body inhalation were observed. The mean age of the children was 3.48 years (SD 1.60). Injuries frequently occurred during recreational activities: in 1154 cases (74.1%) the child was playing, while in 52 cases the accident occurred during a party. In 1417 cases (90.9%) adults were present. Children frequently (1123 cases) insert small objects with a rigid consistency in their noses, like pearls or little metal objects. In the majority of cases nasal FB injuries are due to insertion of inorganic objects (72.7%).

CONCLUSION

Injuries are frequently due to the incorrect manipulation of objects not conceived for children use, including pins, nails, screws and floats. Batteries and magnets deserve particular mention because they require immediate treatment, as they can cause septal necrosis and perforation within hours. Unfortunately, an adult being present does not seem to be sufficient to prevent injuries, and parents are frequently unaware of the danger. The dissemination of information regarding safe behaviors could be fundamental in preventing injuries and need to be promoted by family pediatricians and health practitioners.

Safety, tolerability and efficacy of sublingual allergoid immunotherapy with three different shortened up-dosing administration schedules

Sublingual immunotherapy with monomeric allergoid, given according to the standard schedule, was reported to be effective and safe in many clinical trials. However, a long period of time may elapse before achievement of a clinical benefit. This study was thus performed using two different shortened (4-day) induction (= up-dosing) schedules, which allowed a rapid achievement of the maintenance dosage. Overall, 86 patients suffering from rhinitis and oculorhinitis have been recruited, none of whom had received immunotherapy before. The study design was prospective, randomized, with three parallel groups receiving, according to a randomization list, one of the three induction (two up-dosing one no-up-dosing) phase schedules under study. A fourth group of patients served as controls, and did not receive any sublingual immunotherapy but only rescue medications if and when necessary. All patients were evaluated to assess their baseline conditions, and thereafter at 3 and 6 months. The evaluation parameters were: Visual Analogue Scale, symptom-medication scores, nasal provocation test. All three induction schedules under study were well accepted by the patients, with very few adverse reactions. The clinical efficacy, evaluated with Visual Analogue Scale (p < 0.001), symptom-medication scores (p < 0.02) and nasal provocation tests (p < 0.01), was found to be significant in all three sublingual immunotherapy-treated groups of 64 (n86) patients, but was not significant in controls 22 (n86). According to the Authors, with this simplified schedule process, sublingual immunotherapy is a therapeutic option that is becoming increasingly well-accepted not only by allergy specialists but also by patients.

Choking injuries and food products containing inedibles: a survey on mothers' perception in the United Kingdom

Although recent investigations showed no specific hazard resulting from Food Products Containing Inedibles as compared to the wider category of toys, in view of recent findings and subsequent study of the European Registry of Foreign Bodies Injuries, a potential threat has been identified in a lack of parental supervision in the event of injury. Indeed, according to the report of the European Registry of Foreign Bodies Injuries, almost 80% of the injuries occur under parental supervision, which is obviously inadequate. The aim of this short contribution is to present the results of a Computer Assisted Personal Interviewing survey in the UK focused on the knowledge that mothers, fathers and other adults have on the issue of choking. A total of 1946 interviews have been conducted in the UK, in January 2001, all of which directed to subjects over 15 years of age. Data are presented as percentages and absolute numbers. The statistical significance of group differences has been evaluated with the chi-square test with continuity correction. All analyses have been performed using the R system. Those replying to the interview comprised 804 males and 1102 females. Of these, 10% had a child between 0 and 36 months, 9% between 3 and 4 years, 16% between 5-10 years and 13% between 11-15 years. Of those responding, 7% had bought Kinder Surprise within the last two weeks before the interview, 14% within the last three months, and the remaining 53% before, while 26% had never bought Kinder Surprise. These findings would appear to offer a confirmation that mothers tend to balance potential risks with the benefits of exposing the child to a stimulating activity. This mechanism of a controlled exposure to risk, has already been identified as one of the important mechanisms in the psychological development of the child.

Foreign Bodies Causing Asphyxiation in Children: The Experience of the Buenos Aires Paediatric ORL Clinic

Inhalation or aspiration of a foreign body (FB) occurs relatively frequently in young children. The size, shape, type and site of arrest of the FB lead to variability in the clinical picture. The present study included data from 65 cases of FB inhalation presenting over 1 year at the Children's Hospital Gutierrez, Buenos Aires, Argentina, compared with information from four well-known published case series chosen as representative of other cultural and geographical backgrounds: the USA, Europe, North Africa (Egypt) and Asia (India). The mean age of children studied was 4.03 years. Injuries happened mainly at home (53 cases [81.54%]) and under adult supervision (59 cases [90.77%]). The most frequently inhaled FB was nuts, however, in contrast to previous reports, the majority of incidents involved inhalation of an inorganic, rather than an organic (food) FB. Complications included pneumonia (three cases), atelectasis (two cases) and pneumonitis (one case). No deaths were recorded. These data suggest that children play with objects inappropriate for their age, such as pins and nails, that adults may not be aware of the choking risks, and that more effort is required in educating caregivers about these risks.

Ingested foreign bodies causing complications and requiring hospitalization in European children: results from the ESFBI study

BACKGROUND

In young children, particularly those aged 1-3 years, aerodigestive tract foreign bodies (FB) are a common pediatric problem. The aim of the present study was therefore to characterize the risk of complications and prolonged hospitalization due to FB in the upper digestive tract in terms of the characteristics of the injured patients (age, gender), typology and features of the FB, the circumstances of the accident and hospitalization details.

METHODS

A retrospective study was done in 19 hospitals in 19 corresponding European countries of 186 cases of injury due to the presence of an FB in the mouth, esophagus and stomach (ICD935), out of the 2103 overall cases of FB reported in other locations.

RESULTS

Complications arose in 14 cases and hospitalization was required in 164 cases. No deaths were observed. A higher incidence of hospitalization in male patients (61%) was observed. Median age for children who experienced complications was 2 years old. The most common FB removal technique was esophagoscopy. In the majority of cases the children were treated by the ENT Department. The most common FB were coins, batteries and fish bones among food.

CONCLUSION

Because batteries, as well as coins and fish bones among food were the most common type of FB encountered, and because recent development of technology has accelerated broad use of disk-type batteries, parents should be aware of this hazard, and an educational campaign for public education for this serious problem is advisable.

Foreign body aspiration in children: field report of a German hospital

BACKGROUND

The aspiration of foreign bodies (FB), especially by small children, is a life-threatening situation and can be fatal. The aim of this survey was to study the types of foreign bodies in the upper airways and digestive tract, and the circumstances leading to the aspiration on the basis of hospital records of the Berlin University Hospital in Germany from 1997-2002.

METHODS

We performed a retrospective review of hospital records using a standardized protocol. Foreign body aspiration that occurred in children aged 0-14 were considered for inclusion in the database. During the study period, 78 patients with a diagnosis of FB were included in the database. Forty-five patients were male and 33 were female. The median age was 1.

RESULTS

In 89.5% of all cases, the children were under the age of 3. Seventy-five of the 78 patients had a foreign body in the trachea/bronchial trees/lungs based on International Classification of Diseases-9 codes at the time of discharge. At the time the injury occurred, the children had either been eating (41.1%) or playing (50.0%). More than 50% of the children were being supervised by an adult at the time the injury occurred. The foreign bodies (FB) were always extracted by using an endoscopic procedure (n= 43 rigid, n= 6 flexible and n= 29 combination of both methods). Moreover, hospitalization was always required due to an institutional requirement. The most commonly found foreign bodies were seeds, nuts, berries and grains.

CONCLUSION

Most of the foreign bodies were found in the bronchial tubes, trachea, and lungs. The extraction method from these areas is rigid and/or flexible bronchoscopy or gastrointestinal endoscopy, a procedure requiring anesthesia. There seems to be no association between the aspirated foreign bodies and other purchased objects or packaging material. The fact that a large fraction of the injuries occur under the supervision of the adults suggests that the number and severity of the injuries could be reduced by educating parents and children. Our experience confirms, therefore, that further research into the behavioral aspects leading to FB injuries is needed.

[Efficacy of inhalation therapy with water of Salsomaggiore (Italy) in chronic and recurrent nasosinusal inflammation treatment]

OBJECTIVES

Aim of the research was the demonstration of the efficacy of thermal water vs saline in the recurrent and chronic nasosinusal pathologies treatment.

MATERIALS AND METHODS

120 patients randomized into 2 groups of 60 subjects each, all affected by recurrent or chronic rhinosinusitis with/without I degree nasal polyposis. At the beginning and at the end of the study, in all the subjects the clinical history, objective examination and the instrumental analysis of nasal functions by active anterior rhinometry, acustic rhinometry, nasal mucociliary transport time determination and nasal mucosa scraping were performed. Patients of the study group underwent crenotherapy treatment (vapour inhalation, aerosol and nasal douching) with thermal water for 14 days at Salsomaggiore Thermal baths. Other patients underwent nasal douching and aerosol with saline twice a day for 14 days at the Rhinologic Centre of the ENT Clinic of Siena University.

RESULTS

At the end of the study, only the patients undergone to crenothrapic treatment with salt-bromine-iodic water showed a significant improvement of nasal obstruction, rinorrea and number of nocturnal arousals. The improvement, even if present, was not significant in the control group. Same positive variations were observed concerning nasal mucosa congestion, nasal secretion and mucociliary transport time reaching the significance in the study group.

CONCLUSIONS

Crenotherapy with salt-bromine-iodic water should be considered as efficacious therapeutic tool in the management of chronic and recurrent rhinosinusitis.

[Clinical evaluation of the efficacy of Salsomaggiore (Italy) thermal water in the treatment of rhinosinusal pathologies]

OBJECTIVES

Aim of the research was to demonstrate the efficacy of a treatment with thermal water as nasal spray (Salsomaggiore Italy) vs saline on chronic rhinosinusitis with/out nasal polyps.

MATERIALS AND METHODS

55 patients affected by chronic rhinosinusitis with/out I degree nasal polyposis randomised into two groups were enrolled. 30 patients of the study group were treated with thermal water nasal spray 4 times/day for 4 weeks. 25 patients of the control group were treated, with the same protocol, with saline. At the beginning and at the end of the study, in all the subjects the clinical history, objective examination and the instrumental analysis of nasal functions by active anterior rhinomanometry, mucociliary transport (MCT) time determination and nasal cytology were performed.

RESULTS

At the end of the treatment patients in the study group showed an improvement statistically significant, with respect to the control group, of headache, rhinorrea and hiposmia. Significant differences were also observed between the study and control group concerning objective examination (nasal mucosa appearance and crusts) and instrumental analysis (rhinomanometric values and mucociliary transport times). Nasal cytology (epithelial and goblet cells, neutrophils, eosinophils, bacteria) improved in both groups without any statistical difference.

CONCLUSIONS

Thermal water (Salsomaggiore Italy) nasal spray showed a greater efficacy with respect to saline in the treatment of patients affected by chronic rhinosinusitis.

Foreign bodies in the nose causing complications and requiring hospitalization in children 0-14 age: results from the European survey of foreign bodies injuries study

INTRODUCTION

The occurrence of foreign bodies (FB) in otorhinolaryngological practice is a common and serious problem among pediatric patients. The aim of this work is to characterize the risk of complications and prolonged hospitalization due to FBs in the nose in terms of the characteristics of the injured patients (age, gender), typology and features of the FBs, the circumstances of the accident and the hospitalization's details.

MATERIALS AND METHODS

A retrospective study of FB associated injuries, assessing the characteristics of the injured child and the FB, the circumstances of the accident and finally the hospitalization details took place on children aged 0-14 in major hospitals of 19 European countries.

RESULTS

In total 688 cases were assessed. Complications and hospitalization occurred in 59 and 52 cases, respectively. Over 51% of patients were females. The median age of children who experienced a complication was four years. In the majority of cases FB removal was accomplished by means of a non-invasive technique (rhinoscopy with a nasal speculum or rigid fiberoptic endoscope. The majority of children were directly referred to the ENT department. The most common FBs associated with complications and hospitalization were nuts, seeds, berries, corn and beans, batteries and other inorganic objects such as broken parts of pens, paper clips and pearls. Over 38% of the injuries occurred under adults' supervision.

DISCUSSION

FB injuries in the nose are commonly encountered in clinical practice. Even if the presence of a FB is not usually life threatening, it may result in long-term complications such as perforation of the septum. Because the risks associated with FB injuries, public education about this problem is recommended.

The cost of foreign body injuries in the upper aero-digestive tract: need for a change from a clinical to a public health perspective?

OBJECTIVE

This paper addressed the impact in terms of direct costs of the injuries in children due to foreign bodies in the upper aero-digestive tract.

METHODS

Two thousand one hundred and three consecutive cases were collected from 2000 to 2002 in 16 European hospitals, 1 hospital for each participating country, and referred to children aged until 14 who had FB injuries. Costs were based on the extraction of the FB procedures and on hospitalization length, based on DRGs. Determinants of costs and of length of stay (LOS) were analyzed using a multilevel model.

RESULTS

The major cost of the treatment of FB injuries is covered by the ENT Departments, which are usually the first choice of referral, directly from the patients. Children had a mean LOS of 2.13 days (95% C.I. 1.99-2.29). Treatment of the FB was associated with a mean cost of euro 1017.37 (95% C.I. 963.27-1073.51). In the multivariable analysis higher costs are related to the modality of arrival to the hospital by walk, to the site of the injury (ICD-933, ICD-934, ICD-935 in particular) and to the use of surgery in removing the FB.

DISCUSSION

Foreign bodies injuries are posing a great threat not only with regards to the clinical aspects but also from the public health perspective, their treatment being associated with high costs, in particular when surgery is needed.