Setting definitions of childhood asthma in epidemiologic studies

BACKGROUND

The definitions of childhood asthma differ among epidemiological studies. We aimed to compare the diagnostic accuracy and agreement of previous asthma definitions and to evaluate questionnaire-driven asthma definition patterns.

METHODS

Data on 808 participants aged 7-12 years from 20 schools were analyzed. Asthma definitions based on symptoms assessed by questionnaire, parent-reported medical asthma diagnosis, current use of asthma medication, airway reversibility after bronchodilatation, and increased (≥35 ppb) levels of exhaled nitric oxide (eNO) were compared with a gold standard (medical diagnosis of asthma with asthma symptoms in the past 12 months and/or airway reversibility). Concordance was assessed by Cohen's kappa. Data-driven analysis was applied to the questionnaire, and six scores were determined "asthma," "rhinitis," "cough," "non-specific respiratory symptoms," "treated asthma," and "uncontrolled asthma." Tree decisions were built using these scores.

RESULTS

Definitions of asthma based on respiratory symptoms, airway reversibility, and parent-reported medical diagnosis had a low sensitivity but high specificity. Agreement between reported and objective measures was poor. Parent-reported medical asthma diagnosis, but not reversibility or eNO, was able to predict questionnaire-driven symptom patterns. Decision trees indicated that those with recent non-specific respiratory symptoms had a higher probability of positive bronchodilation.

CONCLUSION

A standardized operational definition of asthma should include a composite score based on reported asthma medical diagnosis, symptoms, and lung function.

School environment associates with lung function and autonomic nervous system activity in children: a cross-sectional study

Children are in contact with local environments, which may affect respiratory symptoms and allergic sensitization. We aimed to assess the effect of the environment and the walkability surrounding schools on lung function, airway inflammation and autonomic nervous system activity. Data on 701 children from 20 primary schools were analysed. Lung function, airway inflammation and pH from exhaled breath condensate were measured. Pupillometry was performed to evaluate autonomic activity. Land use composition and walkability index were quantified within a 500 m buffer zone around schools. The proportion of effects explained by the school environment was measured by mixed-effect models. We found that green school areas tended to be associated with higher lung volumes (FVC, FEV1 and FEF25–75%) compared with built areas. FVC was significantly lower in-built than in green areas. After adjustment, the school environment explained 23%, 34% and 99.9% of the school effect on FVC, FEV1, and FEF25–75%, respectively. The walkability of school neighbourhoods was negatively associated with both pupil constriction amplitude and redilatation time, explaining −16% to 18% of parasympathetic and 8% to 29% of sympathetic activity. Our findings suggest that the environment surrounding schools has an effect on the lung function of its students. This effect may be partially mediated by the autonomic nervous system.

Integrating piezoresistive sensors on the embouchure analysis of the lower lip in single reed instrumentalists: implementation of the lip pressure appliance (LPA)

Background

It is essential to understand, characterize, and measure the embouchure mechanism of a wind instrumentalists, where the applied forces on the perioral tissues can usually promote discomfort or pain.

Methods

The sample consisted of five clarinet players and five saxophone players. The embouchure force measurements at the lower lip area were assessed using a piezoresistive sensor (FlexiForceTM, Tekscan, Boston, USA, 0.07 kgf/cm2) placed on the lower part of the mouthpiece of the single reed instrument. Furthermore, each participant performed three times three different notes at different pitches: high, medium, and low. An intraoral device was manufactured in order to dissipate the existing pressures.

Results

The piezoresistive sensors applied to the mouthpiece of the five clarinetists presented values between 16 and 226 g of force. In the case of the five saxophonists, the values registered were between 5 and 320 g of force.

Conclusions

Piezoresistive sensors are a valid option to characterize that single reed instrumentalists apply substantial forces at the lower lip that can be equivalent to medium orthodontic forces. The implementation of the Lip Pressure Appliance can be a valid solution on the prevention of eventual lesions resulting from the embouchure forces.

Metabolic interactions in asthma

Summary

Metabolomics can be used to explore altered metabolic pathways in asthma, giving insights into its pathophysiology. We aimed to review how metabolomics has been used to understand asthma by describing metabolic pathways under research and discussing clinical implications. The search was performed in PubMed, and studies published since 2000 using a metabolomics approach, were included. A total of 32 studies were analysed. Pathways related with cellular energy homeostasis, lipid metabolism and oxidative stress, immune and inflammatory processes and others were altered. Initial studies focused on biomarker discovery. But, metabolomics can be used to evaluate drug effects on specific pathways, to highlight pathways that can further develop in new targeted treatments and to identify differences according to asthma severity and phenotypes.

Predicting health risk from exposure to trihalomethanes in an Olympic-size indoor swimming pool among elite swimmers and coaches

Disinfection by-products (DBP) such as trihalomethanes (THM) are formed when chlorine and bromine interact with natural organic materials in chlorine-treated swimming pools. Epidemiological evidence demonstrated an association between exposure to swimming pool environment and adverse health effects. Therefore, this study aimed to assess carcinogenic and non-carcinogenic risk of long-term exposure of elite swimmers and their coaches. In an Olympic-size indoor chlorinated swimming pool, THM levels were determined in water (21-69 µg/L), in the boundary layer above the water surface (59-397 µg/m³), and in the air surrounding the pool (28-390 µg/m³). These values were used to predict multi-pathway chronic daily intake (CDI), cancer risk (CR) and hazard index (HI). Oral and dermal CDI for swimmers were 2.4 × 10^-6 and 2.0 × 10^-8, respectively. The swimmers' inhalation CDI (1.9 × 10^-3 mg/kg/day) was estimated to be sixfold higher than levels obtained for coaches (3.3 × 10^-4 mg/kg/day). According to guidelines, the HI was acceptable, but CR exceeded the recommended limit for both, coaches (CR: 5.5 × 10^-7-8.5 × 10^-5; HI: 6.5 × 10^-4-1 × 10^-1) and swimmers (CR: 1.4 × 10^-5-3.6 × 10^-4 HI: 1.6 × 10^-2-4.3 × 10^-1). Our findings provide further support to the need to develop comprehensive guidelines to safeguard the health of individuals involved in elite swimming.

Exposure to indoor endocrine-disrupting chemicals and childhood asthma and obesity

BACKGROUND

Indoor air contaminants may act as endocrine-disrupting chemicals (EDCs). However, to what extent these contaminants affect health is poorly known. We aimed to assess the association between EDCs exposure and asthma, respiratory symptoms and obesity in schoolchildren.

METHODS

Data from a cross-sectional analysis of 815 participants from 20 schools in Porto, Portugal, were analysed. Symptoms were assessed, asthma was defined on lung function, and airway reversibility and body mass index (BMI) were calculated. The concentrations of 13 volatile organic compounds and 2 aldehydes identified as EDCs were measured in 71 classrooms throughout 1 week. Principal component analysis (PCA) was used to assess the effect of co-exposure. Associations were estimated by regression coefficients using linear and logistic regression models.

RESULTS

Increased individual and combined EDCs levels were found in classrooms having more children with asthma and obesity. Higher levels of hexane, styrene, cyclohexanone, butylated hydroxytoluene and 2-butoxyethanol were associated with obesity, and higher levels of cyclohexanone were associated with increased child BMI. Toluene, o-xylene, m/p-xylene and ethylbenzene were significantly associated with nasal obstruction. A positive association was found between PC1 and the risk of obese asthma (OR = 1.43, 95% CI 1.01, 1.98) and between PC2 and overweight (OR = 1.51, 95% CI 1.28, 1.79). PC1 and PC2 were also associated with nasal obstruction, and PC2 was associated with breathing difficulties and lean body mass, although EDCs concentrations were low.

CONCLUSIONS

Our findings further support the role of EDCs in asthma and obesity development. Moreover, even low levels of indoor exposure may influence the risk of asthma, respiratory symptoms and obesity.

A new classification of wind instruments: Orofacial considerations

Background/objective

Playing a wind instrument implies rhythmic jaw movements where the embouchure applies forces with different directions and intensities towards the orofacial structures. These features are relevant when comparing the differences between a clarinettist and a saxophone player embouchure, independently to the fact that both belong to the single-reed instrument group, making therefore necessary to update the actual classification.

Methods

Lateral cephalograms were taken to single-reed, double-reed and brass instrumentalists with the purpose of analyzing the relationship of the mouthpiece and the orofacial structures.

Results

The comparison of the different wind instruments showed substantial differences. Therefore the authors purpose a new classification of wind instruments: Class 1 single-reed mouthpiece, division 1- clarinet, division 2 -saxophone; Class 2 double-reed instruments, division 1- oboe, division 2- bassoon; Class 3 cup-shaped mouthpiece, division 1- trumpet and French horn, division 2- trombone and tuba; Class 4 aperture mouthpieces, division 1- flute, division 2 - transversal flute and piccolo.

Conclusions

Elements such as dental arches, teeth and lips, assume vital importance at a new nomenclature and classification of woodwind instruments that were in the past mainly classified by the type of mouthpiece and not taking into consideration its relationship with their neighboring structures.

The Warburg effect: persistence of stem-cell metabolism in cancers as a failure of differentiation

Background

Two recent observations regarding the Warburg effect are that (i) the metabolism of stem cells is constitutive (aerobic) glycolysis while normal cellular differentiation involves a transition to oxidative phosphorylation and (ii) the degree of glucose uptake of a malignancy as imaged by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is associated with histologic measures of tumor differentiation. Combining these observations, we hypothesized that the high levels of glucose uptake observed in poorly differentiated cancers may reflect persistence of the glycolytic metabolism of stem cells in malignant cells that fail to fully differentiate.

Patients and methods

Tumor glucose uptake was measured by FDG-PET in 552 patients with histologically diverse cancers. We used normal mixture modeling to explore FDG-PET standardized uptake value (SUV) distributions and tested for associations between glucose uptake and histological differentiation, risk of lymph node metastasis, and survival. Using RNA-seq data, we carried out pathway and transcription factor analyses to compare tumors with high and low levels of glucose uptake.

Results

We found that well-differentiated tumors had low FDG uptake, while moderately and poorly differentiated tumors had higher uptake. The distribution of SUV for each histology was bimodal, with a low peak around SUV 2-5 and a high peak at SUV 8-14. The cancers in the two modes were clinically distinct in terms of the risk of nodal metastases and death. Carbohydrate metabolism and the pentose-related pathway were elevated in the poorly differentiated/high SUV clusters. Embryonic stem cell-related signatures were activated in poorly differentiated/high SUV clusters.

Conclusions

Our findings support the hypothesis that the biological basis for the Warburg effect is a persistence of stem cell metabolism (i.e. aerobic glycolysis) in cancers as a failure to transition from glycolysis-utilizing undifferentiated cells to oxidative phosphorylation-utilizing differentiated cells. We found that cancers cluster along the differentiation pathway into two groups, utilizing either glycolysis or oxidative phosphorylation. Our results have implications for multiple areas of clinical oncology.

Cardiotoxicity of environmental contaminant tributyltin involves myocyte oxidative stress and abnormal Ca2+ handling

Tributyltin (TBT) is an organotin environmental pollutant widely used as an agricultural and wood biocide and in antifouling paints. Countries began restricting TBT use in the 2000s, but their use continues in some agroindustrial processes. We studied the acute effect of TBT on cardiac function by analyzing myocardial contractility and Ca²⁺ handling. Cardiac contractility was evaluated in isolated papillary muscle and whole heart upon TBT exposure. Isolated ventricular myocytes were used to measure calcium (Ca²⁺) transients, sarcoplasmic reticulum (SR) Ca²⁺ content and SR Ca²⁺ leak (as Ca²⁺ sparks). Reactive oxygen species (ROS), as superoxide anion (O2^•-) was detected at intracellular and mitochondrial myocardium. TBT depressed cardiac contractility and relaxation in papillary muscle and intact whole heart. TBT increased cytosolic, mitochondrial ROS production and decreased mitochondrial membrane potential. In isolated cardiomyocytes TBT decreased both Ca²⁺ transients and SR Ca²⁺ content and increased diastolic SR Ca²⁺ leak. Decay of twitch and caffeine-induced Ca²⁺ transients were slowed by the presence of TBT. Dantrolene prevented and Tiron limited the reduction in SR Ca²⁺ content and transients. The environmental contaminant TBT causes cardiotoxicity within minutes, and may be considered hazardous to the mammalian heart. TBT acutely induced a negative inotropic effect in isolated papillary muscle and whole heart, increased arrhythmogenic SR Ca²⁺ leak leading to reduced SR Ca²⁺ content and reduced Ca²⁺ transients. TBT-induced myocardial ROS production, may destabilize the SR Ca²⁺ release channel RyR2 and reduce SR Ca²⁺ pump activity as key factors in the TBT-induced negative inotropic and lusitropic effects.

Wind Instrumentalist Embouchure and the Applied Forces on the Perioral Structures

Introduction:

The wind instrumentalist embouchure is probably one of the most demanding tasks that occurs during their musical performance. It is important to quantify the forces that are applied during the wind instrumentalist embouchure on the perioral structures.

Objective:

Quantify the force on the perioral structures involved during the embouchure mechanism of wind instrumentalists.

Methods:

Piezoresistive sensors of FlexiForceTMwere placed on the mouthpiece of 28 different wind instrumentalists, in order to obtain the applied forces transmitted to the upper lip or the lower lip. The application of the sensors were done according to the particular characteristics of the different types of wind instruments, single reed, double reed or metal. Each participant performed three times three different notes at different pitches: high, medium and low. The average medium and maximum pressure was obtained from the nine essays. The sensors were connected to a data acquisition board from National Instruments and the results displayed in LabVIEW 2011.

Results:

Measurement values were obtained for the different groups of wind instruments. In an ascending order, the pressures registered where for the bassoon (6g-31g), the oboe (17g-125g), the saxophone (39g-120g), the clarinet (54g-106g), the trumpet, (63g-172g), the bisel flute (73g-245g), the French horn (56g-305g), the transversal flute (220g-305g) and the trombone (201g-325g).

Conclusion:

Metal instrumentalists seem to apply greater forces than woodwind musicians when performing the embouchure mechanism, being in this specific case the trombone the instrument from the metal group to exert more force, while on the contrary, the bassoon registered the lower values.

Exhaled breath condensate volatilome allows sensitive diagnosis of persistent asthma

BACKGROUND

The diagnosis and phenotyping of paediatric asthma are particularly complex due to the lack of currently available sensitive diagnostic tools. This often results in uncertainties associated with inhaled steroid therapy prescription. Therefore, this study aimed to investigate whether volatile organic compounds measured in exhaled breath condensate can be used as biomarkers for asthma diagnosis in the paediatric population.

METHODS

A total of 64 participants, aged 6-18 years, were recruited on a random basis during visits to an outpatient allergy clinic and to a juvenile football team training session. Lung function, airway reversibility and skin prick tests were performed. Exhaled breath condensate samples were collected, and breathprints were assessed using an electronic nose. Information on medical diagnosis of asthma, rhinitis and atopic dermatitis was retrieved for each participant. A hierarchical cluster model based on the volatilome profiles was then created.

RESULTS

A two-cluster exhaled volatile organic compound-based hierarchical model was able to significantly discriminate individuals with asthma from those without the disease (AUC = 0.81 [0.69-0.93], P < 0.001). Individuals who had persistent asthma and were prescribed corticosteroid therapy by the physician were also significantly distinguished in the model (AUC = 0.81 [0.70-0.92], P < 0.001). Despite being less specific, the method showed higher overall accuracy, sensitivity and AUC values when compared to spirometry with bronchodilation.

CONCLUSIONS

Analysis of the exhaled breath condensate volatilome allowed the distinction of paediatric individuals with a medical diagnosis of asthma, identifying those in need of corticosteroid therapy.

QUALIDADE DE PÁGINAS BRASILEIRAS DA INTERNET QUE DISPONIBILIZAM INFORMAÇÕES SOBRE MICOSES HUMANAS

Considerando que no Brasil não há mecanismos de controle sobre os critérios técnicos de qualidade das páginas da internet que divulgam informações sobre saúde e/ou doenças, é importante que estudos sejam desenvolvidos, visando avaliar a qualidade técnica dessas páginas. Nesse sentido, o presente estudo objetivou avaliar a qualidade das informações técnicas de websites brasileiros que divulgam informações a respeito das principais micoses humanas. Após ampla busca no Google, foram selecionados 132 websites de escopo informativo para a análise. Foram avaliados nos websites aspectos relacionados à: “autoria”, “formação técnica do autor do website”, “qualificação/titulação do autor”, “apresentação de datas de criação e atualização do website”, “serviços de comunicação com o usuário”, “lista de referências”, “elementos gráficos”, “espaço publicitário” e “ferramenta de busca dos conteúdos internos”. Os resultados obtidos revelam que, grande parte dos websites avaliados não oferecem os padrões de qualidade técnica fundamentais para a disseminação da informação. A autoria das informações sobre micoses humanas foi identificada em apenas 42% dos websites, a atuação profissional dos autores em 19%; a constatação de que as informações presentes nos websites são fornecidas por profissionais qualificados na área da saúde em 22%; a data da publicação ou última atualização das informações disponíveis na rede em 47%; serviços de comunicação com os usuários presente em 45%; citação de fontes bibliográficas em apenas 23% e a presença de imagens ou figuras que facilitam a compreensão das informações em apenas 36%. Portanto, considera-se preeminente e necessário o aperfeiçoamento da qualidade técnica dos websites que informam sobre micoses humanas, uma vez que, as infecções fúngicas são muito prevalentes no Brasil.

Abstract P1-18-05: Management of bone marrow involvement in advanced breast cancer: Retrospective multicenter cohort study

Background: Optimal management of bone marrow metastasis (BMM) in advanced breast cancer (ABC) remains unknown. Associated severe cytopenias often urge treatment, but they are also a challenging factor for delivering chemotherapy (CT). Since BMM in ABC is infrequent, available data are scarce.

Aim: Clinical and prognostic characterization of ABC patients with BMM and its management; evaluation of the effectiveness of treating BMM with more myelosuppressive CT regimen (that we hypothesized that could be more active in the BMM) Vs. less myelosuppressive regimen.

Methods: Retrospective cohort study of patients with pathological confirmation of BMM (positive myelogram or osteomedullary biopsy) between Jan'2010 and Dec'2016 in the two major Portuguese cancer centers. Patients with diagnosis of a second carcinoma or active hemato-oncological condition within 5 years before BMM were excluded. We considered the more myelosuppressive regimens those with &gt; 5% risk of febrile neutropenia according to Truong et al 2015(1). Kaplan-Meier and log-rank methodology were used to estimate survival and Cox regression to identify the covariates with independent prognostic value. Statistical level of significance was 5%.

Results: We included 74 patients: 74% with disease stage I-III at presentation, 74% ductal and 12% lobular invasive carcinomas, 58% grade 2 and 27% grade 3, 80% hormone receptor + / HER2-, 4% HER2+ and 12% triple negative (TN). Median time from ABC diagnosis to BMM was 10 months (IQR 2-36), synchronous in 34%. At diagnosis of BMM, median age was 57 years-old (IQR 47-65), 57% were post-menopausal, 97% had bone metastasis, 50% had visceral metastasis, 53% performed ≥ 2 previous palliative systemic treatments and 53% were exposed to bisphosphonates. The most frequent immunohistochemistry change in BMM biopsy was the loss of progesterone receptor expression (37%). Bicytopenia (anemia/thrombocytopenia) was the trigger for BMM investigation in 69% of cases, with grade 3-4 anemia in 16% and grade 3-4 thrombocytopenia in 26%. Median survival after BMM diagnosis was 5 months (95% CI, 3-11); overall survival at 12 and 24 months were 35% (CI 26-48%) and 24% (CI 15-36%), respectively. First treatment after BMM was CT in 58% (median survival, 11 months) and endocrine therapy in 14% (median survival, 3 months). An anti-HER2 regimen was used in 4% and 22% did not receive any treatment after BMM. On multivariate analysis, TN subtype (HR 4.02, CI 1.46-11.01), thrombocytopenia (G0 reference; G1-2: HR 2.47, CI 1.11-5.56; G3-4: HR 4.89, CI 1.85-12.91) and ≥ 2 palliative systemic treatments (HR 2.77, CI 1.46-5.27) were associated with worse prognosis. Within those treated with CT, there was a trend for a deleterious survival effect of more myelosuppressive regimens (HR 2.19, CI 0.94-5.09; 5 months Vs. 14 months, n=31), after controlling for subtype, number of previous regimens and thrombocytopenia.

Conclusion: BMM was not a late event in ABC disease course and had worse prognosis in multi-treated patients, in TN subtype and in the presence of thrombocytopenia. No benefit was shown with the use of more myelosuppressive CT regimens.

(1)Truong J et al, Ann Oncol. 2016 Apr;27(4):608-18.

Citation Format: Martins-Branco D, Ferreira SC, Pereira I, André S, Varelas A, Leal C, Esteves S, Abreu MH, Sousa S, Moreira A, Brito M. Management of bone marrow involvement in advanced breast cancer: Retrospective multicenter cohort study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-18-05.

Thermographic Study of the Orofacial Structures Involved in Clarinetists Musical Performance

INTRODUCTION

Wind instrumentalists like clarinetists, may present a muscular hyperactivity on certain groups of the cranio-cervico-mandibular complex, due to their musical activity. Therefore, the use of infrared thermography can be used to assess and characterize the orofacial structures involved in clarinet performance.

AIM

The objective of this study was to analyze and record the thermal patterns using the thermographic camera Flir® E60sc to evaluate anatomically and physiologically certain orofacial structures of the cranio-cervical-mandibular complex, such as the masticatory muscles and the region of the temporomandibular joint.

METHODOLOGY

A sample of 30 clarinetists completed an individual questionnaire composed of two components (musical and clinical history of the participant), and were subjected to a clinical examination. Four thermographic images were taken of the cranio-cervical-mandibular complex at a rest position with frontal, right lateral, left lateral and anterior dentoalveolar components views. Each musician performed a piece of music for an uninterrupted period of 10 min. New thermographic images were captured with the same incidences, after the performance, respecting the same protocol.

RESULTS

There were statistically significant differences in the areas corresponding to the left temporal muscle, the orbicularis muscle (labial component), the left and right perioral teguments, as well as in the upper central incisors. There was also statistical evidence regarding the initial and final temperature asymmetries regarding temporal muscle and orbicular muscles (labial and marginal components).

CONCLUSION

Infrared thermography has been shown to be an effective complementary diagnostic tool in the monitorization of the cranio-cervical-mandibular complex of clarinetists.