Management of recurrent otitis media with rapid maxillary expansion: our experience

Management of recurrent otitis media with rapid maxillary expansion: our experience.

PROBLEMS/OBJECTIVES

Recurrent otitis media is a frequent problem in the paediatric population. It is commonly associated with adenoid hypertrophy and occasionally with skeletal development syndrome characterised by maxillary anatomical alterations. When this syndrome is present in conjunction with adenoid hypertrophy, surgical management with adenoidectomy and/or myringotomy with ventilation tube positioning does not necessarily ensure a resolution of conductive hearing disorders.

METHODOLOGY

We used maxillary rapid expansion in 27 children with a mean age of 7 years affected by recurrent otitis media associated with skeletal development syndrome and adenoid hypertrophy.

RESULTS

Rapid maxillary expansion acting directly on the median palatine suture expands the palate and the nasal floor, improving nasal breathing. In addition, maxillary expansion stretches elevator and tensor palatine muscles, helping to restore normal Eustachian tube function, even in the presence of adenoid hypertrophy.

CONCLUSION

In our opinion, rapid maxillary expansion results in an improvement in skeletal-facial abnormalities associated with skeletal development syndrome and it can be considered a valid treatment for preventing recurrent otitis media in children affected by maxillary anatomical alterations.

Delayed facial nerve paralysis post middle ear surgery: herpes simplex virus activation

Delayed facial nerve paralysis post middle ear surgery: herpes simplex virus activation.

PROBLEM

Facial nerve paralysis following middle ear surgery is a nightmare for the otology surgeon. Usually this is caused by surgical trauma or local anaesthetic use. It is uncommon to see onset of facial nerve palsy more than 72 hours following the surgery.

METHODOLOGY

We report a case of facial nerve paralysis appearing 11 days following a successful canal wall-down mastoidectomy.

RESULTS

Viral screening for Herpes Virus type 1 confirmed the viral aetiology of the delayed facial paralysis.

CONCLUSION

When an ipsilateral facial nerve palsy appears more than 72 hours after an uneventful middle ear procedure, without symptoms of any infection, suspect a viral reactivation.

Biology of neurotensin: revisited study

The tridecapeptide neurotensin (NT) acts in the mammalian brain as a primary neurotransmitter or neuromodulator of classical neurotransmitters. Morphological and functional in vitro and in vivo studies have demonstrated the existence of close interactions between NT and dopamine both in limbic and in striatal brain regions. Additionally, biochemical and neurochemical evidence indicates that in these brain regions NT also plays a crucial role in the regulation of the aminoacidergic signalling. Immune cells, such as lymphocytes, macrophages and mast cells are reported to be activated by neuropeptides, such as neurotensin; this activation leads to cytokine and immunoglobulin production. In addition, neurotensin increases calcium level and the production of nitric oxide. Therefore neurotensin is deeply involved in immunity and inflammation but its real function still remains to be elucidated.

Sinus augmentation procedure of the jaw sinus in patients with mucocele

The sinus augmentation procedure of the jaw sinus (SAP) is a surgical technique which permits the prosthetic rehabilitation of the edentulous saddles by the insertion of dental implants where unfavourable conditions exist for their application. Nevertheless, apart from malignant tumors, benign pathologies exist, such as mucocele or radicular cysts, which can complicate the SAP, causing sinusal disturbances. In this study we describe our experience of SAP in patients with mucocele of the jaw sinus, and describe our surgical technique without the preventive emptying of the mucocele. Based on our experience, the SAP operation can be carried out without complications if the distance between the top of the mucocele with SAP and the osteomeatal complex (OMC) is 22 mm, or for mucocele no larger than 18 mm. In fact, these parameters guarantee that, because of the lifting of the sinusal membrane, the antral drainage (AD) duct does not alter or become obstructed.

Anti-chemokine therapy for inflammatory diseases

Chemokines are inflammatory proteins acting via G-protein coupled chemokine receptors that trigger different signaling pathways. Monocyte chemoattractant protein-1 (CCL2/MCP-1) and regulated on activation, normal T expressed and secreted (CCL5/RANTES) are the two major members of the CC chemokine beta subfamily. The roles of RANTES and MCP-1 are emerging in regulating the recruitment of inflammatory cells into tissue during inflammation. The inhibition of MCP-1 and RANTES with corresponding antibodies or other inhibitors may provide benefits in different clinical scenarios including cancer, inflammation, CNS disorders, parasitic disease, autoimmune and heart diseases. RANTES and MCP-1 may represent targets for diagnostic procedures and therapeutic intervention, and may be useful as a prognostic factor in the above diseases.

RANTES (CCL5) potentiates calcium ionophore in the production of LTB4 in rat adherent macrophages from granuloma induced by KMnO4: inhibiton by NDGA

The activation of monocytes/macrophages by several stimuli is an initial event in the inflammatory response. To ascertain the importance of LTB(4) and 5-lypoxigenase in the inflammatory site, we isolated and stimulated rat adherent granuloma macrophages (RAGMs) with calcium ionophore in the presence or absence of regulated on activation, normal T expressed and secreted (RANTES) [CCL5] at different concentrations. We tested the hypothesis that RANTES may influence the production of LTB(4) stimulated by calcium ionophore A23187 (2.5 microM/ml) in rat adherent granuloma macrophages derived from granuloma induced by potassium permanganate diluted 1:40 saturated solution. To test this hypothesis, we measured LTB(4) production, in rat granuloma macrophages stimulated with A23187 (2.5 microM) alone and in combination with RANTES at different concentrations. In these studies, the cell-free supernatant of stimulated RAGMs with the ionophore A23187, resulted in a drastic increase of LTB(4). However, when the cells were treated with the combination RANTES plus A23187 the stimulatory effect was more pronounced than A23187 alone. LTB(4) production was quantitated. The calcium ionophore A23187 directly induced LTB(4) in macrophages, this production was markedly enhanced when the cells were pretreated with RANTES. However, the addition of RANTES in the absence of calcium ionophore A23187 did not directly induce LTB(4) release, nor was lypoxigenase expression augmented. Preincubation of RAGMs with NDGA (nordihydroguiaretic acid) (10(-5)M) completely abolished the production of LTB4 on RAGMSs challenged with A23187 in combination with RANTES or A23187 alone in the supernatants. Similar effects were obtained when the cells were pretreated with dexamethasone. These data suggest, for the first time, that RANTES may stimulate the release of LTB(4), only when it is associated to other stimuli and for this reason we conclude that RANTES modulates inflammatory diseases, and may require other stimuli to be effective in amplifying its spectrum of action(s).

Salbutamol increases SMN mRNA and protein levels in spinal muscular atrophy cells

Spinal muscular atrophy (SMA) is an inherited neuromuscular disorder caused by homozygous absence of the survival motor neuron gene (SMN1). All patients have at least one, usually two to four copies of the related SMN2 gene which, however, produce insufficient levels of functional SMN protein due to the exclusion of exon 7 in the majority of SMN2 transcripts. Here, we show that salbutamol, a beta2-adrenoceptor agonist, determines a rapid and significant increase in SMN2-full length mRNA and SMN protein in SMA fibroblasts, predominantly by promoting exon 7 inclusion in SMN2 transcripts. These data, together with previous clinical findings, provide a strong rationale to investigate further the clinical efficacy of salbutamol in SMA patients.

Megalencephaly and perisylvian polymicrogyria with postaxial polydactyly and hydrocephalus (MPPH): report of a new case

Megalencephaly (MEG), or enlargement of the brain, can either represent a familial variant with normal cerebral structure, or a rare brain malformation associated with developmental delay and neurological problems. MEG has been split into two subtypes: anatomical and metabolic. The latter features a build-up inside the cells owing to metabolic causes. Anatomical MEG has been detected in many different conditions, including many overgrowth syndromes. In 2004 Mirzaa et al. reported five non-consanguineous patients with a new MCA/MR syndrome characterized by severe congenital MEG with polymicrogyria (PMG), postaxial polydactyly (POLY) and hydrocephalus (HYD). The authors argued that these findings identified a new and distinct malformation syndrome, which they named MPPH. We report on a new case of MPPH, the first to be described after the original series (Mirzaa et al., 2004).

Randomized, double-blind, placebo-controlled trial of phenylbutyrate in spinal muscular atrophy

OBJECTIVE

To assess the efficacy of phenylbutyrate (PB) in patients with spinal muscular atrophy in a randomized, double-blind, placebo-controlled trial involving 10 Italian centers.

METHODS

One hundred seven children were assigned to receive PB (500 mg/kg/day) or matching placebo on an intermittent regimen (7 days on/7 days off) for 13 weeks. The Hammersmith functional motor scale (primary outcome measure), myometry, and forced vital capacity were assessed at baseline and at weeks 5 and 13.

RESULTS

Between January and September 2004, 107 patients aged 30 to 154 months were enrolled. PB was well tolerated, with only one child withdrawing because of adverse events. Mean improvement in functional score was 0.60 in the PB arm and 0.73 in placebo arm (p = 0.70). Changes in the secondary endpoints were also similar in the two study arms.

CONCLUSIONS

Phenylbutyrate was not effective at the regimen, schedule, and duration used in this study.

The cardiofaciocutaneous syndrome

The cardiofaciocutaneous (CFC) syndrome is a condition of sporadic occurrence, with patients showing multiple congenital anomalies and mental retardation. It is characterised by failure to thrive, relative macrocephaly, a distinctive face with prominent forehead, bitemporal constriction, absence of eyebrows, hypertelorism, downward-slanting palpebral fissures often with epicanthic folds, depressed nasal root and a bulbous tip of the nose. The cutaneous involvement consists of dry, hyperkeratotic, scaly skin, sparse and curly hair, and cavernous haemangiomata. Most patients have a congenital heart defect, most commonly pulmonic stenosis and hypertrophic cardiomyopathy. The developmental delay usually is moderate to severe. The syndrome is caused by gain-of-function mutations in four different genes BRAF, KRAS, mitogen-activated protein/extracellular signal-regulated kinase MEK1 and MEK2, all belonging to the same RAS-extracellular signal-regulated kinase (ERK) pathway that regulates cell differentiation, proliferation and apoptosis. The CFC syndrome is a member of a family of syndromes that includes the Noonan and Costello syndromes, presenting with phenotypic similarities. Noonan syndrome is caused by mutations in the protein tyrosine phosphatase SHP-2 gene (PTPN11), with a few people having a mutation in KRAS. Costello syndrome is caused by mutations in HRAS. The protein products of these genes also belong to the RAS-ERK pathway. Thus, the clinical overlap of these three conditions, which often poses a problem of differential diagnosis, is explained by their pathogenetic relatedness.

Maintenance of X- and Y-inactivation of the pseudoautosomal (PAR2) gene SPRY3 is independent from DNA methylation and associated to multiple layers of epigenetic modifications

Maintenance of X-inactivation is achieved through a combination of different repressive mechanisms, thus perpetuating the silencing message through many cell generations. The second human X-Y pseudoautosomal region 2 (PAR2) is a useful model to explore the features and internal relationships of the epigenetic circuits involved in this phenomenon. Recently, we demonstrated that DNA methylation plays an essential role for the maintenance of X- and Y-inactivation of the PAR2 gene SYBL1; here we report that the silencing of the second repressed PAR2 gene, SPRY3, appears to be independent of DNA methylation. In contrast to SYBL1, the inactive X and Y alleles of SPRY3 are not reactivated in cells treated with a DNA methylation inhibitor and in cells from ICF (immunodeficiency, centromeric instability, facial anomalies) syndrome patients, which have mutations in the DNA methyltransferase gene DNMT3B. SPRY3 X- and Y-inactivation is associated with a differential enrichment of repressive histone modifications and the recruitment of Polycomb 2 group proteins compared to the active X allele. Another major factor in SPRY3 repression is late replication; the inactive X and Y alleles of SPRY3 have delayed replication relative to the active X allele, even in ICF syndrome cells where the closely linked SYBL1 gene is reactivated and advanced in replication. The relatively stable maintenance of SPRY3 silencing compared with SYBL1 suggests that genes without CpG islands may be less prone to reactivation than previously thought and that genes with CpG islands require promoter methylation as an additional layer of repression.

Trisomy 21: conference report and 1990 update

The most relevant data and stimulating ideas presented and discussed at the symposium are briefly summarized. They centered around four major foci: the genotype, the phenotype, the pathogenesis of Down syndrome (DS), and the Down person. The molecular genetic approaches to the isolation of genes encoded by chromosome 21, the definition of a possible "critical region," and the acquisition of further insights on the origin of trisomy 21 were the main topics of the analysis of the genotype. The study of the phenotype concentrated essentially on three complex traits related to the nervous, immune, and hematologic systems, which show great sensitivity to developmental disturbances, with major effects on DS subjects' health and behavior. The difficulties of investigating the pathogenesis of the syndrome were outlined, but the theoretical bases for devising sound and complete experimental approaches were also delineated. Finally, the special attention that in the last decade the medical and sociopsychological sciences gave to Down persons was also underlined, and future developments indicated. DS still remains a challenge to science and medicine; however, from the symposium emerged a less pessimistic view on actual potentialities for a decisive advancement in its basic knowledge.

Growth delay in Down syndrome and zinc sulphate supplementation

Children affected with Down syndrome (DS) show deficient growth, immunodeficiency--especially concerning the T-cell population--and low plasma zinc levels. New growth charts have been recently proposed, and zinc supplementation to the diet has been reported to improve transiently the efficiency of the immune system. The aim of this study was to evaluate if in DS children zinc sulphate therapy could improve the growth rate and affect some endocrine parameters. We studied 22 patients (16 males and 6 females) who received zinc sulphate for 6 to 9 months. Fifteen of 22 patients studied reached a higher centile in their growth rate, whereas the remaining seven showed no change, at least to date. The average height velocity changed from 23.84 +/- 7.98 mm/6 months to 40.80 +/- 7.68 mm/6 months. Growth hormone serum level was 5.94 +/- 4.89 ng/ml compared with 7.49 +/- 6.75 ng/ml before and after therapy, respectively. Somatomedin serum level was 160.27 +/- 68.88 mU/ml and 205 +/- 124.07 mU/ml before and after therapy, respectively. In conclusion, zinc sulphate therapy of patients with DS affects not only the immune system, as previously reported, but can also accelerate growth.

Pericentric inversion of chromosome 9: prevalence in 300 Down syndrome families and molecular studies of nondisjunction

The incidence of Down syndrome (DS) families where one of the parents is an heterozygous carrier of pericentric inversion of the heterochromatic region of chromosome 9-inv(9) (qh) - was determined in 3 independent groups of 100 families each. The total number of 17 such families found in the sample is significantly greater than the expected number of 5.73 for a sample of non-DS families of equal size. Consequently, the statistical association of the presence of inv (9) (qh) in one parent with the birth of a DS offspring, and the correlative 3-fold increased risk of a DS child for such families, seem to be demonstrated. A study of the origin of nondisjunction, using restriction fragment length polymorphism (RFLP) segregation analysis with a sufficient number of chromosome 21 specific probes, has provided complete information in 7 of 8 available families. Although the statistical interpretation of the results is not straightforward, due to the small size of the sample, the observed data do not contradict the assumption that the presence of inv (9) (qh) in a parent increases, by a factor of about 3, the chance that the offspring will inherit an extra chromosome 21 from that parent. Nevertheless, gathering further data appears desirable because stronger evidence would have relevance both for clinical implications and for the understanding of the function of heterochromatin, particularly with respect to meiotic and mitotic processes.

Preproorexin and orexin receptors are expressed in cortisol-secreting adrenocortical adenomas, and orexins stimulate in vitro cortisol secretion and growth of tumor cells

Orexins A and B are hypothalamic peptides that originate from the proteolytic cleavage of preproorexin and act through two subtypes of receptors, named OX1-R and OX2-R. OX1-R almost exclusively binds orexin-A, whereas OX2-R is nonselective for both orexins. We previously found that orexin-A, via the OX1-R, stimulates cortisol secretion from dispersed human adrenocortical cells. In this study, we demonstrate that six of eight cortisol-secreting adenomas expressed preproorexin mRNA, and seven of 10 adenomas contained measurable amounts of orexin-A but not orexin-B. Normal adrenal cortexes neither expressed preproorexin nor contained orexins. All adenomas expressed OX1-R and OX2-R mRNAs, and real-time PCR showed that the expression of both receptors was up-regulated in adenomas, compared with normal adrenal cortex. Orexin-A concentration-dependently raised basal cortisol secretion from freshly dispersed normal and adenomatous cells, minimal and maximal effective concentrations being 10(-10) and 10(-8) m, and the peptide efficacy (percent increase elicited by 10(-8) m orexin-A) was significantly higher in adenomas than in the normal adrenal cortex. Orexin-B was ineffective, thereby indicating that orexin secretagogue action is mediated by the OX1-R. In contrast, both orexins (10(-8) m) raised the proliferative activity of cultured normal and adenomatous cells, suggesting that this effect is mediated by OX2-R or both receptor subtypes. Collectively, our findings allow us to conclude that the orexin system is overexpressed in cortisol-secreting adenomas and suggest that orexin-A may act as an autocrine-paracrine regulator of the secretory activity and growth of some of these adrenal tumors.

A novel microdeletion syndrome with loss of the MSH2 locus and hereditary non-polyposis colorectal cancer

Constitutional chromosome deletions can predispose to the development of cancer with the phenotypic characteristics of inherited cancer syndromes, when the deleted region encompasses a tumour suppressor gene. Examples of such conditions are represented by the cytogenetic deletions associated with retinoblastoma, Wilms tumour and familial adenomatous polyposis. So far, no constitutional deletions involving the genes implicated in hereditary non-polyposis colorectal cancer (HNPCC) have been identified. This may be at least partially because of the lack of distinctive phenotypic manifestations in HNPCC. We describe the first case of a constitutional microdeletion associated with HNPCC. Suspicion of a microdeletion was prompted by the association of mental retardation, postnatal growth deficiency, minor congenital anomalies and early onset (37 years) sporadic colon cancer. The patient was found to harbour a microdeletion within chromosome 2p16-p21, including the MSH2 gene. Since there are very few reports of deletions of the 2p16-p21 region, our observation sets the grounds for the definition of a novel multiple congenital anomaly/mental retardation/cancer microdeletion syndrome.

Genitourinary anomalies in Mowat-Wilson syndrome with deletion/mutation in the zinc finger homeo box 1B gene (ZFHX1B). Report of three Italian cases with hypospadias and review

Hypospadias, when the urethra opens on the ventral side of the penis, is a common malformation seen in about 3 per 1,000 male births. It is a complex disorder associated with genetic and environmental factors and can be part of genetic syndromes. Mowat-Wilson syndrome (MWS) is a multiple congenital anomaly syndrome characterized by a distinct facial phenotype, Hirschsprung disease, microcephaly and mental retardation. It is caused by mutations in the zinc finger homeo box 1B gene, ZFHX1B (SIP1). To date, 68 deletion/mutation-positive cases have been reported. Genitourinary anomalies are common in MWS. Here we report that hypospadias is common in males with this syndrome. In 39 patients where this information was available, hypospadias was present in 46% of patients (18/39). In the 3 Italian male cases reported here, hypospadias was always present. MWS should be considered by endocrinologists in patients with hypospadias associated with developmental delays/mental retardation, in particular in the presence of a distinct facial phenotype.

Mutation analysis of the NSD1 gene in a group of 59 patients with congenital overgrowth

Sotos syndrome is characterized by pre- and post-natal overgrowth, typical craniofacial features, advanced bone age, and developmental delay. Some degree of phenotypic overlap exists with other overgrowth syndromes, in particular with Weaver syndrome. Sotos syndrome is caused by haploinsufficiency of the NSD1 (nuclear receptor SET domain containing gene 1) gene. Microdeletions involving the gene are the major cause of the syndrome in Japanese patients, whereas intragenic mutations are more frequent in non-Japanese patients. NSD1 aberrations have also been described in some patients diagnosed as Weaver syndrome. Some authors have suggested a certain degree of genotype-phenotype correlation, with a milder degree of overgrowth, a more severe mental retardation, and a higher frequency of congenital anomalies in microdeleted patients. Data on larger series are needed to confirm this suggestion. We report here on microdeletion and mutation analysis of NSD1 in 59 patients with congenital overgrowth. Fourteen novel mutations, two previously described and one microdeletion were identified. All patients with a NSD1 mutation had been clinically classified as "classical Sotos," although their phenotype analysis demonstrated that some major criteria, such as overgrowth and macrocephaly, could be absent. All patients with confirmed mutations shared the typical Sotos facial gestalt. A high frequency of congenital heart defects was present in patients with intragenic mutations, supporting the relevance of the NSD1 gene in the pathogenesis of this particular defect.

Hereditary nonpolyposis colorectal cancer: an approach to the selection of candidates to genetic testing based on clinical and molecular characteristics

OBJECTIVE

Identification of clinical and molecular characteristics associated with constitutional MLH1 and MSH2 mutations and definition of a stepwise strategy for the selection of colorectal cancer (CRC) patients amenable to MLH1 and MSH2 genetic testing.

METHODS

90 unrelated CRC patients were initially selected on the basis of either familial or early onset occurrence of CRC. They were screened for the presence of constitutional MLH1 and MSH2 mutations and for microsatellite instability (MSI).

RESULTS

16 pathogenetic mutations (9 MLH1 and 7 MSH2) were identified in 41% of Amsterdam hereditary nonpolyposis colorectal cancer (HNPCC) families, 5% of suspected HNPCC families, and 14% of sporadic early-onset CRC patients. The presence of the mutations correlated with MSI, with early age of onset and proximal location of the tumor, and with the presence of some extracolonic tumors of the HNPCC spectrum and/or multiple tumors in the family.

CONCLUSIONS

Evaluation of clinical and molecular characteristics is useful for the identification of candidates to MLH1 and MSH2 mutational analysis and allows the application of a rational approach to genetic testing.

[Report on the activities carried out in the research project of the Ministry of Instruction, University, and Research entitled "Environmental and occupational exposure to inorganic lead: assessment of toxic effects of current doses and related preventive measures"]

It is here presented the project sustained by the Ministry of Public Instruction, University and Research "Environmental and Occupational Exposure to Inorganic Lead: assessment of human health effects due to current doses and preventive measures" ruled out between 2001 and 2003. The aim of the study was to investigate about the toxic effects related to current occupational exposures to inorganic lead (particularly those effects concerning blood pressure, carcinogenic risk, nervous and immunological systems), to identify hypersusceptibility conditions, particularly the ALAD genetic polymorphism and to evaluate the role of traditional biomarker and the possibility of introducing new ones. In the present article the procedures followed during the project lasting and the contribution of each Unit are described. The results of the research, presented in detail in the current issue, do confirm the inadequacy of the biological exposure index nowadays ruled by Lex 25/2002.

[Reduced thymulin production during occupational exposure to lead]

Thymulin is a thymic hormone that being activated by binding a zinc ion promotes differentiation and several functions of T lymphocytes. It has been demonstrated only in experimental animals that metallic lead (Pb) is able to cause adverse effects on thymocyte number and function. The objective of this study is to evaluate the plasmatic level of active thymulin of 58 male workers being exposed for more than one year to low lead doses with respect to 59 male never exposed workers. All these were subjected to anamnesis collection, medical examination and determination of blood lead (PbB), plasmatic lead (PbPl), plasmatic thymulin, urinary lead (PbU) and urinary zinc (ZnU) levels. The mean plasma concentration of active thymulin was significantly lower in lead exposed than in non exposed workers. Active thymulin was also significantly and negatively correlated to PbB, PbPl and PbU level and resulted to be significantly and negatively influenced by PbB. Lead exposed workers had slightly higher zinc concentration in urine than non exposed workers, increasing ZnU levels by class of PbB. It is the first time that a toxic effect of lead on plasmatic active thymulin levels is demonstrated in humans, particularly in occupationally exposed workers. This study opens perspectives for further research that would both confirm the results and verify the mechanisms of action of lead on thymulin either direct or indirect and the possible role of zinc.

[Lead: indicators of dose and effects on heme]

In the present study the role of the traditional biomarkers of exposure and effect on haeme system during lead exposure was analysed: the opportunity of introducing new biomarkers such as lead and delta-aminolevulinic acid in plasma was also evaluated, especially by considering the current levels of exposure. The population in study was constituted by 371 males owning to different production fields and selected by five national units. The results suggest caution in the use of lead in plasma as a biomarker of lead exposure in the biological monitoring procedures, mainly in reason of its great variability affecting in particular the sampling time and the pre-analytical treatment of the sample. The other biomarkers were well correlated between them and with the exposure biomarkers for lead in blood >300 microg/L, suggesting the BEI to which the protection of workers exposed to lead would be guaranteed (instead the actual of 600 microg/L).

[ALAD polymorphism and indicators of dose and effects of occupational exposure to inorganic lead]

The delta-aminolevulinate dehydrase (ALAD) genetic polymorphism was investigated along with biomarkers of lead exposure and effect on 333 male workers, occupationally exposed to lead, with blood lead levels (PbB) higher than 100 microg/l. ALAD genotype frequencies were distributed as expected among Caucasians. Workers bearing at least one ALAD-2 allele showed PbB values slightly higher than those from ALAD-1-1 subjects, who also exhibited higher urinary delta-aminolevulinic acid (ALAU) and blood zinc protoporphyrin (ZPP) levels. The plasmatic lead (PbP)/PbB ratio was similar in both groups. Exposure and effect biomarkers were significantly each other correlated among ALAD-1-1 subjects only, who showed also a significant inverse relationship between ALAD activity and ZPP values. Results confirm previous studies, supporting the hypothesis that ALAD polymorphism may interfere with toxico-kinetic and toxico-dynamic parameters of occupational exposure to Pb.

Solitary median maxillary central incisor syndrome: clinical case with a novel mutation of sonic hedgehog

Solitary median maxillary central incisor (SMMCI) is a rare dental anomaly. It is usually considered as a minor manifestation of holoprosencephaly (HPE). Some reported families had severe cases of HPE in some members and SMMCI in others. Mutations of Sonic Hedgehog (SHH) have been documented in these families. SMMCI has also been found as an isolated finding or together with other anomalies such as microcephaly, short stature, endocrine pathology, and choanal atresia. We describe a patient with SMMCI and a novel SHH mutation: Val332Ala.

[New biomarkers of exposure]

In this paper we have defined the new biomarkers of exposure (NBE) as those biomarkers discovered in the last five years and, among previously validated biomarkers, also those applied in different ranges of doses or those determined in biological matrices which differ from matrices originally considered. We examined the results from the surveys carried out by the main Italian research units involved in biological monitoring, i.e. those from the Universities of Brescia, Milan, Naples, Padua, Parma, Pavia, Turin and Verona. The data were collected using a standardized model and included the following: type of element or organic compound, type of biomarker, analytical technique and method, their relationship with environmental monitoring data, their relationship with effect indicators or effects in general, improvement with respect to old biomarkers, reference values. Twenty two NBEs were identified: 14 elements and chemical compounds as such or as metabolites, 4 examples of mixtures, 3 of new matrices, one of speciation. Among the others, aspects such as interest in requiring NBE, quality assurance, availability, cost-benefit ratio were discussed. We conclude that development of this specific field of research appears to be a crucial point for future improvement in risk assessment and health surveillance procedures.

Nonhomologous Robertsonian translocations(NHRTs) and uniparental disomy(UPD) risk: an Italian multicentric prenatal survey

OBJECTIVES

The risk of uniparental disomy (UPD) occurrence associated with the prenatal finding of balanced nonhomologous Robertsonian translocations (NHRTs) has been estimated only on limited empirical data. The aim of the study was to verify the estimate of the general risk, to get narrower confidence intervals by cumulating the data and to obtain risk estimates for specific translocation types.

METHODS

We tested for UPD 160 prenatal specimens referred to the participant centers after the cytogenetic finding of NHRT.

RESULTS

One case of upd(14)mat was found, associated with a 45,XX,der(14;22)mat fetal karyotype. The general empirical risk of UPD occurrence in NHRT carrier fetuses, corrected for the actual number of chromosomes analyzed, was 0.76% (95% CI 0.02-4.25%). Cumulative data with previous studies gives a general risk of UPD associated with NHRT of 0.80% (95% CI 0.17-2.34%). The UPD risk for the specific NHRT der(13;14) did not significantly differ from that of the other NHRTs taken together.

CONCLUSION

The present survey confirms the previously estimated risk of occurrence of UPD in offspring of NHRT carriers as a low, but not negligible risk, worth being investigated in prenatal diagnosis.

ELITE-S2: the multifactorial movement analysis facility for the International Space Station

Experimental observations of adaptation processes of the motor control system to altered gravity conditions can provide useful elements to the investigations on the mechanisms underlying motor control of human subject. The microgravity environment obtained on orbital flights represents a unique experimental condition for the monitoring of motor adaptation. The research in motor control exploits the changes caused by microgravity on the overall sensorimotor process, due to the impairment of the sensory systems whose function depends upon the presence of the gravity vector. Motor control in microgravity has been investigated during parabolic flights and short-term space missions, in particular for analysis of movement-posture co-ordination when equilibrium is no longer a constraint. Analysis of long-term adaptation would also be very interesting, calling for long-term body motion observations during the process of complete motor adaptation to the weightlessness environment. ELITE-S2 is an innovative facility for quantitative human movement analysis in weightless conditions onboard the International Space Station (ISS). ELITE-S2 is being developed by the Italian Space Agency, ASI is to be delivering the flight models to NASA to be included in an expressed rack in US Lab Module in February 2004. First mission is currently planned for summer 2004 (increment 10 ULF 2 ISS).

Rhinopharynx endoscopy in the diagnosis of chronic otitis media with effusion in infancy

Chronic otitis media with effusion is an inflammatory process of the mucosa of the middle ear persisting for more than 3 months, being most frequent in infancy, and is correlated with marked tube obstruction. In infancy, the most frequent cause of this obstruction is adenoid hypertrophy and diagnosis, clinical or radiological, is often not confirmed by rhinopharynx fiberendoscopy. Since, in these cases, treatment is often surgical, it is possible that small patients may be submitted, unnecessarily, to adenoidectomy. In collaboration with the Paediatric Clinic, the present study on an infant outpatient population with nasal respiratory difficulty, associated with chronic otitis media with effusion, was, therefore, aimed at standardizing the endoscopic diagnosis of patients with suspected adenoid hypertrophy. Between October and December 2002, 32 consecutive patients, aged between 4 and 11 years, all oral breathers with OME, were sent to our attention from the Paediatric Clinic. All those patients, with indication for adenoidectomy, have been enrolled in the study and submitted to fiberendoscopic examination of the external ear and nose. Nasal respiration was confirmed with active anterior rhinomanometry. Endoscopic evaluation of the rhinopharynx, aimed at assessing adenoid dimensions and their relationship with the auditory tube, has been expressed in four degrees of increasing severity and adenoidectomy was indicated in those cases, classified, by us, as third and fourth degree. In our experience, endoscopic examination of the rhinopharynx has, however, shown that only 9 children (28.2%) presented an absolute need to undergo adenoidectomy since they were carriers of massive adenoid hypertrophy with tubal obstruction and consequent bilateral glue ear (3rd and 4th degree) while, in all other cases (71.8%), the clinical and radiological findings did not correspond to endoscopic data. Diagnostic accuracy that characterizes rhinopharyngeal fiberendoscopy is, therefore, in our opinion, of fundamental importance to avoid these errors, as far as possible, and in establishing an appropriate therapeutic programme.

Fantoni's translaryngeal tracheotomy complications. Personal experience

Tracheotomy is a surgical procedure which, in conditions of acute respiratory emergency, guarantees an adequate airway through the trachea whereas, in cases of chronic respiratory failure, it is used to improve ventilation through the reduction of the dead respiratory space. Over the last few years, surgical techniques used in tracheotomy have been considerably modified, not only to respond to the needs of clinical indications but also on account of problems related to management of the patient and tracheostomy tube, particularly in the home setting. Besides traditional surgical techniques, in fact, in the Intensive Care Unit, percutaneous dilatative procedures are being used with increasing frequency, in particular, translaryngeal tracheotomy according to Fantoni. The latter, however, according to reports in the literature, has been shown to be followed by a higher peri-operative complication rate (40%) which involves maintenance of good function of the tracheostomy, a condition which is particularly dangerous in the management of patients in the home setting. Personal experience is described in the management of 6 patients submitted to tracheotomy according to Fantoni and in combined home treatment, who, some time after the operation. presented 'embedding' of the tracheostomy tube in the tracheostomy opening. The six patients were treated at home with ventilatory support using automatic ventilation system and were submitted, in our Clinic, to a surgical review with preparation of a tracheotomy according to the conventional method. Our experience showed a particular feature of the difficulty in the management of patients presenting respiratory diseases, submitted to translaryngeal tracheotomy and, thereafter, maintained in combined home treatment: in these subjects, in fact, the presence of the tube, the difficulty in cleaning the peristomial skin, the reduced autonomy from the automatic ventilation system and the frequent coexistence of mucopurulent tracheo-bronchial inflammatory diseases, trigger micro-lesions of the stoma and, therefore, scar keloid, narrowing of the lumen and embedding of the tube itself. In conclusion, in our personal experience, we are of the opinion that translaryngeal tracheotomy, since it is easily carried out and is a slightly invasive procedure, plays a very important role in the management of the Intensive Care Unit patient but should be reserved for the few cases requiring tracheostomy for limited periods of time, in low risk patients and within the first 18 days after the acute damaging event.

Short term microgravity effect on isometric hand grip and precision pinch force with visual and proprioceptive feedback

Experiments executed on the upper limb are assuming increasing significance in the frame of the Human Physiology in space, for at least two reasons: the upper limb is the principal means of locomotion for the subject living in a space station; furthermore, fatigue can have a significant effect on the hand, for the ordinary work on board, and in particular for the extra-vehicular activities. The degradation of the performances affecting the muscular-skeletal apparatus can be easily recognized on the upper limb, by exerting specific scientific protocols, to be repeated through the permanence of the subject in weightlessness conditions. Another aspect relevant to the effect of microgravity on the upper limb is associated with the alteration of the motor control programs due to the different gravity factor, affecting not only the bio-mechanics of the subject, but in general all his/her psycho-physical conditions, induced by the totally different environment. Specific protocols on the upper limb can facilitate the studies on learning mechanisms for the motor control. The results of such experiments can be transferred to the Earth, useful for treatment of subjects with local traumas or diseases of the Central Nervous System.

Assisted reproductive technology and congenital overgrowth: Some speculations on a case of Pallister-Killian syndrome

We report on a boy with Pallister-Killian syndrome (PKS) who was conceived by assisted reproductive technology (ART), specifically in vitro fertilization (IVF) with parents' gametes. A prenatal diagnosis performed elsewhere by CVS failed to detect the presence of the isochromosome 12p that was demonstrated postnatally in approximately 50% of cultured skin fibroblasts. Given that the patient did not show the congenital overgrowth typical of PKS, we speculate that ART might have restricted overgrowth in this particular case. More broadly, we hypothesize that overgrowth might protect from early demise fetuses conceived by ART, a technology known to cause low and very low birth weight.

Mutations of the 'minor' mismatch repair gene MSH6 in typical and atypical hereditary nonpolyposis colorectal cancer

Mutations of the mismatch repair (MMR) genes MLH1 and MSH2 are associated with hereditary nonpolyposis colorectal cancer (HNPCC), a highly penetrant autosomal dominant condition characterized by hypermutability of short tandemly repeated sequences in tumor DNA. Mutations of another MMR gene, MSH6, seem to be less common than MLH1 and MSH2 defects, and have been mostly observed in atypical HNPCC families, characterized by a weaker tumor family history, higher age at disease onset, and low degrees of microsatellite instability (MSI), predominantly involving mononucleotide runs. We have investigated the MSH6 gene sequence in the peripheral blood of 4 HNPCC and 20 atypical HNPCC probands. Two frameshift mutations within exon 4 were detected in 2 patients. One mutation was found in a proband from a typical HNPCC family, who had developed a colorectal cancer (CRC), a gastric cancer and a rectal adenoma. The CRC and the adenoma showed mild MSI limited to mononucleotide tracts, while the gastric carcinoma was microsatellite stable. The other mutation was detected in an atypical HNPCC proband, whose CRC showed widespread MSI involving both mono- and dinucleotide repeats. The phenotypic variability associated with MSH6 constitutional mutations represents a complicating factor for the optimization of strategies aimed at identifying candidates to MSH6 genetic testing.

Reactivation of silenced genes and transcriptional therapy

The purpose of this review is to discuss the potential role of "transcriptional therapy" to modulate the expression of target genes in order to treat monogenic as well as multifactorial disorders. In vitro and in vivo experiments with DNA demethylating and histone hyperacetylating drugs are currently performed in several laboratories on a variety of genes. In attempting to place these results into perspective, we divided the target genes into four major categories: (1) single genes with a hypermethylated CpG island; (2) single genes without a CpG island; (3) groups of genes silenced by aberrant DNA methylation; and (4) groups of genes silenced by lack of histone acetylation. We discuss the latest advances in the field of chromatin regulation and, in particular, the role of histone methylation and that of RNA interference in gene silencing. We can expect that in the future regulation of transcription will become an effective treatment for several genetic conditions.

[Influence of genetic polymorphism of CYP1A1 and GSTM1 on the levels of urinary 1-hydroxypyrene]

In recent years scientific literature has focused the attention on the role of genetic polymorphisms and toxic effects of xenobiotics. Polycyclic Aromatic Hydrocarbons (PAHs) are widely spread xenobiotics, present both in general and work environment. Many papers analysed the influence of the genetic polymorphism of two enzymes involved in the biotransformation of PAHs, Cytochrome P450 1A1 (CYP1A1) and Glutathione S Transferase M1 (GSTM1), on the development of cancer. Some papers analysed also the role of these polymorphisms on the concentration of the biomarker of exposure to PAHs, 1-hydroxypyrene (1OHP). The Institute of Occupational Health and Industrial Hygiene of the University of Brescia focused on this last aspect by EEC project in collaboration with Latin America. In this paper a thorough examination of the general topic and the synthetic project's results are presented.

Influence of genetic polymorphisms of CYP1A1 and GSTM1 on the urinary levels of 1-hydroxypyrene

The aim of the present study is to evaluate the influence of the genetic polymorphism of two enzymes involved in the biotransformation of xenobiotics, cytochrome P450 1A1 (CYP1A1) and glutathione-S-transferase M1 (GSTM1), on the urinary levels of 1-hydroxypyrene (1-OH-P) in workers exposed to polycyclic aromatic hydrocarbons (PAHs) and in unexposed workers (controls). The study group consisted of 30 controls recruited among employees of a service company and 171 PAHs-exposed workers from two electric steel plants and an iron foundry (all males, ranging between 18 and 60 years of age). Determination of airborne PAHs and urinary 1-OH-P was performed by high-performance liquid chromatography (HPLC) with fluorimetric detection. Polymerase chain reaction (PCR)-based restriction fragment length polymorphism (RFLP) was used to determine the genetic polymorphisms of CYP1A1 (CYP1A1*2A and CYP1A1*2B) and GSTM1. No influence of the genetic polymorphism of CYP1A1 and GSTM1 on the urinary levels of 1-OH-P was observed in this study.

Continuing validity of pectoralis major muscle flap 25 years after its first application

Surgical treatment of malignant cervico-facial tumours often includes vast demolition of mucosal, cutaneous, muscle and bone tissues, requiring immediate repair of the extensive loss of substance with reconstructive pedicled or revascularised free flaps. Still today, when it is not necessary to reconstruct the mandibular bone or in particular clinical situations as found in patients in whom microsurgery is contraindicated due to general conditions or in those cases of unsuccessful microsurgical flaps, use of the pedicled flaps is still indicated, particularly the myocutaneous flap of the major pectoral muscle described approximately 25 years ago, and quite rightly referred to as "work horse" or "spare wheel" of reconstructive surgery. Study population comprises 33 patients (27 male, 6 female, mean age: 61 years, range: 36-86) observed between 2000-2002. These patients were submitted to demolitive surgery on account of malignant cervico-facial neoplasias. The role of the major pectoral muscle pedicled flap is emphasised stressing that resection of the pedicle, even a few weeks after transplant, together with the subclavicular passage, may avoid the majority of the well-known functional and aesthetic problems related to this reparative technique.

Absence of 12q21.2q22 deletions and subtelomeric rearrangements in cardiofaciocutaneous (CFC) syndrome patients

Recent publications described two patients with a CFC-like phenotype and the same deletion of chromosome region 12q21.2q22 [Rauen et al., 2000, 2002]. The patients did not have the classical CFC phenotype and presented other signs not usually seen in CFC patients: the first patient had hydrocephalus, and the second, a history of olygohydramnios, normal stature, pyloric stenosis, cutaneous syndactyly of toes and bilateral transverse palmar creases. In order to verify if classic CFC patients with normal chromosomes in conventional preparations have microdeletions within the 12q21.2q22 chromosome region, we performed FISH analysis using 12 BAC probes to screen this area. The average interval between the probes was of approximately 1 Mb. No deletions were found in any of the 17 classical CFC patients we examined. We conclude that the region 12q21.2q22 is not a candidate region for CFC syndrome and that the patients described by Rauen et al. [2000, 2002] probably have a different condition, i.e., an aneuploidy syndrome, with some phenotypic resemblance to the CFC syndrome. To further evaluate the possibility of other chromosome imbalances, we performed a subtelomeric analysis, by FISH technique, of all chromosomes, and did not find any subtelomeric rearrangements.