Mediastinal germ cell tumor associated with histiocytic sarcoma of spleen: case report of an unusual association

We present an unusual association of mediastinal germ cell tumor containing seminoma and angiosarcoma components and splenic histiocytic sarcoma. A 15-year-old boy presented with chest pain. Histopathologically, an anterior mediastinal mass contained typical seminoma, immature teratoma, embryonal carcinoma, angiosarcoma, yolk sac tumor, and polyembryoma. An abdominal ultrasonogram revealed a huge splenomegaly with multiple ill-defined low echogenic nodules, 1 month after the second cycle of chemotherapy. Histopathologically, large, round-to-oval tumor cells with abundant eosinophilic cytoplasm often contained eccentrically placed nuclei with vesicular chromatin and an irregular nuclear membrane. The tumor cells were immunoreactive for CD68, CD31, and CD4. The cytogenetic results showed deletion of the long arm of chromosome 5 and trisomy 8. This lesion might have been on the pathway of multistep tumorigenesis toward a final leukemia.

Dermal and bronchial symptoms in children: are they caused by PAH containing parquet glue or by passive smoking?

OBJECTIVE

In 1997 a new source of potential polycyclic aromatic hydrocarbon (PAH) exposure was discovered: very high levels of (PAHs) and benzo-a-pyrene (BaP) were detected in household dust from former American Forces housing in Frankfurt am Main, Germany, built in 1955/1956. This contamination was caused by a parquet glue containing coal tar, the use of which was formerly a standard building practice in Germany. Children were considered to be at special risk for exposure to PAHs when playing on the floor via mouthing. Therefore, the children's symptoms and complaints were analysed for association with PAH contamination in parquet glue and household dust as well as with internal exposure to PAHs via determination of 1-hydroxypyrene in urine samples.

PARTICIPANTS AND METHODS

Two hundred and eighty seven children <6 years of age living more than 12 months in the former US-housing estates are enrolled in this analysis, representing 22.3% of the children <6 years of age living there. Their spot urine samples were analysed for 1-hydroxypyrene. The level of BaP in parquet glue and in household dust was available in the homes of 215 and 212 children, respectively. There were no hints for differences in PAH contamination in parquet glue or in household dust of the participants' flats compared to the flats of the non responders. In 246 cases data on environmental tobacco smoke exposure at home was known as well. Data on symptoms and complaints observed by their parents during the preceding 12 months (1-year prevalence) were obtained using the ISAAC questionnaire (modified).

RESULTS

The following 1-year prevalences were reported: 15% itching eczema in elbows, 10% itching and urticaria, 6% itching in the palate and throat, 20% sneezing and running nose or stuffed nose, 15% nosebleed; 25% wheezing, 42% dry cough, and 60% frequent infectious disease. No consistent associations between symptoms and BaP in parquet glue or in household dust or urinary levels of 1-hydroxypyrene in the children could be found. However, associations between symptoms and exposure to environmental tobacco smoke at home were to be seen, significant for dermal and bronchial symptoms.

CONCLUSION

Informed about PAHs in parquet glue and household dust many parents demanded for total redevelopment of their flats. According to statistical evaluation of the children's symptoms, observed by their parents, no hints for an association with exposure via BaP in parquet glue or household dust were found. However, significant associations between symptoms and the exposure to environmental tobacco smoke were observed, especially bronchial and dermal symptoms. Therefore instead of redevelopment of flats with parquet glue containing coal tar, intensified information on the harmful effects of passive smoking in childhood seems to be mandatory.

Gender Disparities in Health: Strategic Selection, Careers, and Cycles of Control

This article proposes a dynamic model of the intersections between gender, health, and the life course incorporating processes of strategic selection--of roles, relationships, and behavior. Men and women make decisions within a tangled web of multilayered, often contradictory, and frequently outdated institutional contexts of opportunity and constraint. Both their decisions and the institutions shaping them reflect prior as well as ongoing socialization and allocation mechanisms. These institutionalized scripts and regimes tend to reproduce gendered biographical paths around two central life foci: paid work (or careers) and unpaid family work (or careers). The gendered nature of occupational and family-care paths, in turn, produces patterned disparities in a constellation of health-related resources, relationships, and risks, as well as feelings of mastery and control. We call for research charting alternative constellations of these gendered health careers, their antecedents, temporal patterning, and consequences.

Role of perioperative parenteral nutrition in severely malnourished patients with Crohn’s disease

AIM: To evaluate the effect of perioperative parenteral nutrition on serum immunoglobulin, weight change, and post-operative outcome in severely malnourished patients with Crohn’s disease.

METHODS: Thirty-two severely malnourished patients with Crohn’s disease who had undergone surgery in our hospital were reviewed. Sixteen patients who received perioperative parenteral nutrition were enrolled in the study group, and the other 16 patients who did not receive parenteral nutrition were enrolled in the control group. Serum immunoglobulin, body mass index (BMI), liver function, weight change, and postoperative complications were evaluated.

RESULTS: Serum IgM levels elevated 1 wk before surgery in both groups, and decreased to normal value (from 139 ± 41 to 105 ± 29 mg/dL, P = 0.04) 4 wk after operation in the study group, while no significant changes was noted in the control group (from 133 ± 16 to 129 ± 13 mg/dL, P = 0.34). There were no significant changes in concentrations of IgG and IgA. The BMI of the study group increased from 13.9 ± 0.6 to 15.3 ± 0.7 kg/m² (P = 0.02) with no significant change in the control group (14.1 ± 0.7 and 14.5 ± 0.5, respectively, P = 0.81). The percentage of resuming work was higher in the study group than in the control group.

CONCLUSION: Perioperative parenteral nutrition possibly ameliorates the humoral immunity, reverses malnutrition, and facilitates rehabilitation.

[Birth weight and familial smoking]

INTRODUCTION

Tobacco smoking during pregnancy is an important risk factor in the pediatric population and has been associated with an increase in low birth weight (LBW) infants.

PATIENTS AND METHODS

We carried out a retrospective case-control study of infants admitted to the Infants Department of the Hospital Universitario Infantil Niño Jesús in Madrid. Data from 2370 infants admitted to the hospital between 2002 and 2004 were collected.

RESULTS

The odds ratio (OR) for having a LBW infant was 1.42 (95 % CI: 1.017-1.985) among mothers who smoked during pregnancy and was 1.37 (95 % CI: 1.014-1.863) among women whose partners smoked. Gestational age was also a predictive factor of birth weight: the OR was 0.585 (95 % CI: 0.545-0.628). No significant differences for risk of LBW were found between sexes (OR: 1.25; 95 % CI: 0.934-1.671).

CONCLUSIONS

Our results should reinforce the importance of smoking prevention during and after pregnancy in both parents, which could reduce many complications in children's health with a high medical, social and economic cost.

Impulse Oscillometry

OBJECTIVES

To generate reference equations in North American children to be used for assessing respiratory function through the forced oscillation (Rfo) technique, and to determine the changes in oscillatory resistance, reactance, and resonant frequency (Fres) in relation to age, body height, and weight.

DESIGN/SETTING

A prospective cross-sectional study performed on healthy children selected according to strict criteria of American Thoracic Society and European Respiratory Society recommendations.

MEASUREMENTS

Triplicate measures were obtained of resistance and reactance at 5, 10, 15, 20, 25, and 35 Hz as well as Fres through the impulse oscillometer (MasterScreen IOS; Jaeger/Toennies; Höchberg, Germany). Two hundred twenty-two white children--normally distributed within the 3- to 10-year age range and 100 to 150 cm in height--were recruited in Montreal, Canada. We used regression analysis to generate multiple predictive equations separately per gender and frequency on age, height, and body weight.

RESULTS

Stepwise multiple regression in both natural and logarithmic forms for height, weight, age, and gender showed that standing height was the only significant predictor for all variables. Minimal variability was noted in each subject among the triplicate measurements (p = 0.68 to 0.96). Coherence was > 0.9 at all oscillating frequencies except 5 Hz (< 0.72), with tendencies to lower values in young children.

CONCLUSIONS

Resistance and Fres decrease by height, but also by age; and reactance increases. As opposed to our past experience with spirometry in compatible age groups, the Rfo technique was well accepted by preschool children.

Imatinib mesylate as a novel treatment option for hypereosinophilic syndrome: two case reports and a comprehensive review of the literature

Hypereosinophilic syndromes (HES) are a heterogenous group of rare disorders characterized by sustained and otherwise unexplained overproduction of eosinophils with organ involvement and consecutive dysfunction. Recent reports document the efficacy of imatinib mesylate in a large proportion of HES patients (65%). Rearrangements involving the platelet-derived growth factor receptor genes (PDGFRA and PDGFRB), both tyrosine kinase receptors, have been demonstrated to be pathogenetically linked to the dysregulated clonal overproduction of eosinophils. This refined hypothesis has been confirmed by the discovery of the novel FIP1L1-PDGFRA fusion gene, which is a gain-of-function gene on chromosome 4q12. Its product is an imatinib-sensitive tyrosine kinase, which can be found in a subset of patients with HES, particularly in those responding to treatment with imatinib mesylate. Here, we sum up recent knowledge of clinical features, pathophysiology and novel treatment aspects of HES by performing a comprehensive search of the available literature and report on 94 patients. We particularly address the issue of organ involvement and specific characteristics of the variable clinical pictures. In addition, two cases will be presented, which illustrate typical clinical scenarios and treatment outcome.

Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series

BACKGROUND

Mediastinal abscesses after esophageal perforation or postoperative leakage nearly always require surgical intervention.

METHODS

Patients with paraesophageal abscesses were treated with EUS-guided or endoscopic mediastinal puncture if the abscess was >2 cm and sepsis was present. Abscess cavities were entered with a 9.5-mm endoscope after balloon dilation to allow irrigation and drainage. Debris was removed with a Dormia basket. Concomitant pleural effusions were treated with transthoracic drains. Patients received intravenous antibiotics and enteral/parenteral nutrition.

RESULTS

Twenty patients fulfilled the entry criteria. Simple drainage was sufficient in 4 cases, and puncture was impossible in one case. Of the 15 treated patients (age 39-76 years, 5 women) the etiology of perforation was Boerhaave's syndrome (n = 8), anastomotic leak (n = 3), and iatrogenic perforation (n = 4). Debridement was successful in all cases and required a median of 5 daily sessions (range 3-10). All patients became apyrexial, with a C-reactive protein < 5 mg/L within a median of 4 days (range 2-8 days). Esophageal defects were closed with endoclips (n = 7), fibrin glue (n = 4), metal stents (n = 1), or spontaneously healed (n = 3). One patient died from a massive pulmonary embolism one day after successful debridement (mortality 7%). No other complications were seen. Median follow-up was 12 months (range 3-40 months).

CONCLUSIONS

Nonoperative endoscopic transesophageal debridement of mediastinal abscesses appears safe and effective.

Childhood exposure to environmental tobacco smoke and chronic respiratory symptoms in non-smoking adults: the Singapore Chinese Health Study

BACKGROUND

Childhood exposure to environmental tobacco smoke has been extensively associated with childhood respiratory illness; fewer studies have addressed the effects on adults.

METHODS

Childhood environmental tobacco smoke exposure in relation to chronic cough, phlegm, and asthma diagnosis was studied in never smokers from a cohort of Singaporeans of Chinese ethnicity aged 45-74 years at enrollment from 1993 to 1998. From 1999 to 2004 subjects were interviewed regarding environmental tobacco smoke exposure before and after the age of 18 and the presence and duration of current symptoms of chronic cough and phlegm production and asthma diagnosis.

RESULTS

Among 35,000 never smokers, fewer had smoking mothers (19%) than fathers (48%). Although few subjects currently lived (20%) or worked (4%) with smokers, 65% reported living with a daily smoker before the age of 18 years. Living with a smoker before the age of 18 increased the odds of chronic dry cough (149 cases, odds ratio 2.1, 95% CI 1.4 to 3.3) and, to a lesser extent, phlegm, after adjustment for age, sex, dialect group, and current and past exposure to smokers at home and at work after the age of 18. Associations strengthened with higher numbers of smokers in childhood. There was no association with asthma or chronic bronchitis. There was evidence to suggest a stronger association among subjects with a lower adult intake of fibre which has previously been found to be protective for respiratory symptoms.

CONCLUSIONS

In this large study of non-smokers, living with a smoker in childhood was associated with chronic dry cough and phlegm in adulthood, independent of later exposures to environmental tobacco smoke.

Mediastinal germ cell tumors

Germ Cell Tumors (GCT) represent an important group of mediastinal tumors. Because of genetic characteristics and behavior have been divided in prepubertal and postpubertal tumors, and their origin remains controversial. The genetic changes are diverse, but the most frequent is i (12p), and can be associated to gonadal disgenesis. Histological classification is similiar to that of gonadal tumors and all histological types have been described in the mediastinum. Teratomas may undergo malignant transformation with the emergence of somatic tumors such as haematological malignancies, sarcomas, carcinomas and neurogenic tumors, and such transformation may occur in the primary site or in the metastases. Prognostic factors in mediastinal germ cell tumors include: age of the patient, histological type, distant metastases, stage, status of resection, level of serum tumor markers and proliferation markers. Immunohistochemistry is especially useful when the primary GCT is occult, to separate types of immature GCT, and to determine the lineage of malignant transformation which may be important to design treatment strategies.

New Risk Score for Patients With Acute Chest Pain, Non-ST-Segment Deviation, and Normal Troponin Concentrations

OBJECTIVES

The purpose of this research was to develop a risk score for patients with chest pain, non-ST-segment deviation electrocardiogram (ECG), and normal troponin levels.

BACKGROUND

Prognosis assessment in this population remains a challenge.

METHODS

A total of 646 consecutive patients were evaluated by clinical history (risk factors and chest pain score according to pain characteristics), ECG, and early exercise testing. ST-segment deviation and troponin elevation were exclusion criteria. The primary end point was mortality or myocardial infarction at one year. The secondary end point was mortality, myocardial infarction, or urgent revascularization at 14 days (similar to the Thrombolysis In Myocardial Infarction [TIMI] risk score).

RESULTS

Primary and secondary end point rates were 6.7% and 5.4%. A risk score was constructed using the variables related to the primary end point: chest pain score > or =10 points (hazard ratio [HR] = 2.5; 1 point), > or =2 pain episodes in last 24 h (HR = 2.2; 1 point), age > or =67 years (HR = 2.3; 1 point), insulin-dependent diabetes mellitus (HR = 4.2; 2 points), and prior percutaneous transluminal coronary angioplasty (HR = 2.2; 1 point). Patients were classified into five categories of risk (p = 0.0001): 0 points, 0% event rate; 1 point, 3.1%; 2 points, 5.4%; 3 points, 17.6%; > or =4 points, 29.6%. The accuracy of the score was greater than that of the TIMI risk score for the primary (C index of 0.78 vs. 0.66, p = 0.0002) and secondary (C index of 0.70 vs. 0.66, p = 0.1) end points.

CONCLUSIONS

Patients presenting with chest pain despite no ST-segment deviation or troponin elevation show a non-negligible rate of events at one year. A risk score derived from this specific population allows more accurate stratification than when using the TIMI risk score.

Smoking behaviour change among fathers of new infants

Protecting infants from exposure to parental tobacco smoke is key to positive health outcomes in childhood and later life. While mothers' smoking has been well researched, fathers' smoking has received little attention. This paper reports data from a cross-sectional survey of 286 smoking fathers in the English Midlands, interviewed when their infants were 8-14 weeks old. It examines whether fathers attempt and successfully achieve two smoking behaviours positively associated with infant health: quitting and not smoking in the home. The birth of a new baby was not associated with attempting or successfully quitting smoking for the majority of fathers. Less than 20% had tried to quit and only 4% had successfully quit smoking since the birth of their baby. Half of the participants reported that they had not changed their cigarette consumption since their baby's birth. Not smoking in the home appeared to be a more achievable behaviour for many fathers; 78.0% had attempted and 60% had successfully achieved not smoking in home. Independent predictors of attempting to quit were fathers' own cigarette consumption and level of knowledge about infant exposure to tobacco smoke. Attempting to abstain from smoking in the home and being successful in the attempt were both independently associated with partner's smoking status, number of financially dependent children and father's social class. Findings suggest that promoting reductions in cigarette consumption and improving knowledge levels among fathers about passive smoking in infants may encourage more quit attempts. Not smoking in the home is a more achievable behaviour and is linked to fathers' caring and economic circumstances and their partner's smoking status. Influences on fathers' smoking behaviour appear to be multi-factorial. Understanding father's smoking and developing health promotion strategies to protect infants from passive smoking is likely to depend on research which can bridge the caring and economic spheres of their lives.

Postoperative Crohn's disease

More than three quarters of patients with Crohn's disease (CD) will require surgery. After resection, disease recurs postoperatively with a median time to second resection of about 10 years. Despite its importance, the postoperative period remains one of the most poorly understood clinical settings in the field. Postoperatively, CD may exhibit unique pathophysiologic features, but the current state of knowledge does not allow for identification of patients at risk for relapse, and leaves clinicians without guidance on optimal maintenance treatment. Therapies used as maintenance for CD in other settings may have different efficacies when used after surgery, and clinical research in patients requiring surgery is limited by the subset of patients available for study. Despite the many limitations in current knowledge of postoperative CD, it is an exciting field because new developments have improved patient care, and ongoing research has the potential for further gains.

Recurrence after segmental resection for colonic Crohn's disease

Background

Segmental colonic resection is commonly performed in patients with colorectal Crohn's disease. The aim of this study was to evaluate the outcome after segmental colonic resection and to define risk factors for re-resection.

Methods

Consecutive patients who had an initial segmental colonic resection for Crohn's colitis between 1987 and 2000 were evaluated. Patients who underwent ileocolonic resection were excluded. Patient-, disease- and treatment-related variables were assessed as possible risk factors for disease recurrence.

Results

Ninety-one patients (62 women) with a median follow-up of 8·3 years were studied. Thirty patients (33 per cent) had at least one re-resection, of whom 20 finally underwent total (procto)colectomy. Female sex and a history of perianal disease were identified as independent risk factors for re-resection: odds ratio 12·52 (95 per cent confidence interval (c.i.) 2·38 to 65·84) and 13·94 (95 per cent c.i. 3·02 to 64·27) respectively. Forty (44 per cent) of the 91 patients had a stoma at the end of the study period. Of the 30 patients who had re-resection, 24 finally had a stoma.

Conclusion

Segmental resection for Crohn's colitis is justified. Recurrence is more frequent in women and in those with a history of perianal disease.

Factors affecting recurrence after surgery for Crohn’s disease

Although in Crohn’s disease post-operative recurrence is common, the determinants of disease recurrence remain speculative. The aim of this study was to examine factors affecting post-operative recurrence of Crohn’s disease. A Medline-based literature review was carried out. The following factors were investigated: age at onset of disease, sex, family history of Crohn’s disease, smoking, duration of Crohn’s disease before surgery, prophylactic medical treatment (corticosteroids, 5-amino salicylic acid [5-ASA] and immunosuppressants), anatomical site of involvement, indication for surgery (perforating or non-perforating disease), length of resected bowel, anast-omotic technique, presence of granuloma in the specimen, involvement of disease at the resection margin, blood transfusions and post-operative complications. Smoking significantly increases the risk of recurrence (risk is approximately twice as high), especially in women and heavy smokers. Quitting smoking reduces the post-operative recurrence rate. A number of studies have shown a higher risk when the duration of the disease before surgery was short. There were, however, different definitions of ‘short’ among the studies. Prophylactic cortic-osteroids therapy is not effective in reducing the post-operative recurrence. A number of randomized controlled trials offered evidence of the efficacy of 5-ASA (mesalazine) in reducing post-operative recurrence. Recently, the thera-peutic efficacy of immunosuppressive drugs (azathioprine and 6-mercaptopurine) in the prevention of post-operative recurrence has been investigated and several studies have reported that these drugs might help prevent the recurrence. Further clinical trials would be necessary to evaluate the prophylactic efficacy of immunosuppressants. Several studies showed a higher recurrence rate in patients with perforating disease than in those with non-perforating disease. However, evidence for differing recurrence rates in perforating and non-perforating diseases is inconclusive. A number of retrospective studies reported that a stapled functional end-to-end anastomosis was associated with a lower recurrence rate compared with other types of anastomosis. However, prospective randomized studies would be necessary to draw a definite conclusion. Many studies found no difference in the recurrence rates between patients with radical resection and non-radical resection. Therefore, minimal surgery including strictureplasty has been justified in the management of Crohn’s disease. In this review, the following factors do not seem to be predictive of post-operative recurrence: age at onset of disease, sex, family history of Crohn’s disease, anatomical site of disease, length of resected bowel, presence of granuloma in the specimen, blood transfusions and post-operative complications. The most significant factor affecting post-operative recurrence of Crohn’s disease is smoking. Smoking significantly increases the risk of recurrence. A short disease duration before surgery seems, albeit to a very minor degree, to be associated with a higher recurrence rate. 5-ASA has been shown with some degree of confidence to lead to a lower recurrence rate. The prophylactic efficacy of immunosuppressive drugs should be assessed in future. A wider anastomotic technique after resection may reduce the post-operative recurrence rate, though this should be investigated with prospective randomized controlled trials.

The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey

BACKGROUND

Lower reimbursements for endoscopic procedures and increasing demand for screening endoscopy over the past decade have spurred efforts to increase efficiency in the performance of endoscopic procedures. Two dichotomous approaches have emerged: (1) unsedated endoscopy and (2) propofol sedation. The aim was to determine national practice patterns of unsedated endoscopy and propofol sedation, and to assess endoscopists' attitudes toward unsedated screening with an electronic survey.

METHODS

A short survey was developed and then was converted to a Web-based format. All national members of the American Society for Gastrointestinal Endoscopy (ASGE) were invited via electronic mail (e-mail) to participate. Survey data were collected electronically.

RESULTS

Two e-mails elicited responses to the Web survey from 18% (724) of national ASGE members contacted, within 2 weeks. Of the respondents, 45% do not routinely offer unsedated EGD and colonoscopy, and only 15% of those respondents plan to incorporate unsedated endoscopy into their practice in the next year. Of the 55% who currently perform unsedated endoscopy, 85% do no more than 25 unsedated procedures per year. Lack of patient acceptance was the most common reason cited for not offering unsedated endoscopy. Most endoscopists felt that the availability of unsedated esophagoscopy or colonoscopy would not significantly increase screening for Barrett's esophagus or colonic polyps/colorectal cancer, respectively. Routine use of propofol sedation for EGD, colonoscopy, and ERCP/EUS was reported by 19%, 22%, and 19%, respectively. Community practitioners were more likely to use propofol than those at academic centers (p < 0.0002 for all). Of those not currently using propofol, 43% plan to incorporate it into their practice within the next year. Over 70% of respondents would themselves choose to be sedated for routine endoscopic procedures.

CONCLUSIONS

Electronic surveys allow for rapid distribution and data collection but suffer from a limited response rate. The survey suggests that unsedated endoscopy has limited acceptance in the United States, and, without a major intervention that affects endoscopists' attitudes, its use is not likely to increase significantly. Unsedated endoscopy will not have a great impact on endoscopic screening. In contrast, propofol sedation has already gained acceptance in the community, and the routine use of propofol in endoscopy units will likely increase in the future.

Parent reported home smoking bans and toddler (18-30 month) smoke exposure: a cross-sectional survey

AIMS

To study the relation between the use of parent reported home smoking bans and smoke exposure among children aged 18-30 months.

METHODS

A total of 309 smoking households with children aged 18-30 months, who were part of the Coventry Cohort study, consented to participate in this cross-sectional survey.

RESULTS

Although parents in almost 88% of smoking households reported using harm reduction strategies to protect their toddlers from smoke exposure, only 13.9% reported smoking bans in the house. Mean log urinary cotinine:creatinine ratio was significantly lower for those children whose parents reported no smoking in the house (1.11, 95% CI 0.64 to 1.49) compared with none/less strict strategies (1.87, 95% CI 1.64 to 2.10). In linear regression models fitted on log cotinine:creatinine ratio, no smoking in the house was independently associated with a significant reduction in cotinine:creatinine ratio (B = -0.55, 95% CI -0.89 to -0.20) after adjusting for mother's and partner's average daily cigarette consumption, housing tenure, and overcrowding. The final model accounted for 44.3% of the variance.

CONCLUSIONS

Not smoking in the house was associated with a reduction in mean urinary cotinine:creatinine ratio in children aged 18-30 months; the relation persisted after adjustment for levels of mother's and partner's daily cigarette consumption and sociodemographic factors. Results suggest that home smoking bans in this age group have a small but significant effect on smoke exposure independent of levels of parental tobacco consumption.

Treatment of postoperative Crohn's disease

At 1 year after a first resection, up to 80% of patients show an endoscopic recurrence, 10-20% have clinical relapse, and 5% have surgical recurrence. Smoking is one of the most important risk factors for postoperative recurrence. Preoperative disease activity and the severity of endoscopic lesions in the neoterminal ileum within the first postoperative year are predictors of symptomatic recurrence. Mesalamine is generally the first-line treatment used in the postoperative setting but still provokes considerable controversy as to its efficacy, in spite of the results of a meta-analysis. Immunosuppressive treatment (azathioprine, 6-MP) is based on scant evidence but is currently used as a second-line treatment in postsurgical patients at high risk for recurrence, with symptoms or with early endoscopic lesions in the neoterminal ileum. Nitroimidazole antibiotics (metronidazole, ornidazole) are also effective in the control of active Crohn's disease in the postoperative setting. Given their known toxicity, they may be used as a third-line treatment as initial short-term prevention therapy rather than for long-term use. Conventional corticosteroids, budesonide or probiotics have no proven role in postoperative prophylaxis. Infliximab has not as yet been studied for use in the prevention of relapse after surgery.

Luteal phase support in assisted reproductive technology

PURPOSE OF REVIEW

The purpose of this review is to discuss luteal support in assisted reproduction and to provide an evidence-based overview of the current options available.

RECENT FINDINGS

The luteal phase has been found to be defective in virtually all of the stimulation protocols used for in-vitro fertilization. Common mechanisms such as supraphysiological levels of estradiol, decreased output of luteinizing hormone, inhibition of the corpus luteum and asynchronization of estradiol and progesterone may be involved in insufficient function of the corpus luteum in assisted reproductive technology.

SUMMARY

Gonadotropin releasing hormone agonist undoubtedly provides benefits in stimulated cycles, however it also has adverse effects, inhibition of the corpus luteum together with supraphysiological hormonal profiles finally leading to luteal phase defects. Luteal phase support with human chorionic gonadotropin or progesterone after assisted reproduction results in increased pregnancy rates. The role of luteal phase support in these cycles has also been recently elucidated. Use of human chorionic gonadotropin for luteal phase support is associated with a marked increase in the risk of ovarian hyperstimulation syndrome, therefore progesterone is the preferred choice. Data on the benefits of estrogen supplementation are conflicting. Among the routes of progesterone administration, reductions in pregnancy rates are noted on oral administration. In spite of a lack of statistical significance, the intramuscular route seems to be more beneficial than the vaginal route when considering rates of ongoing pregnancy and live birth. Further clarification is needed on the ideal dose, the optimal route and the duration of progesterone administration in assisted reproduction.

Emerging drugs in assisted reproduction

Infertility affects approximately 15% of couples of reproductive age. In assisted reproductive technology (ART), medications play a crucial role in stimulating ovaries to produce several oocytes and prepare the endometrium to be receptive after replacing one or more embryos into the uterine cavity. The availability of recombinant human follicle stimulating hormone, luteinising hormone and human chorionic gonadotrophin; of gonadotrophin-releasing hormone (GnRH) agonists and antagonists; and of luteal supplementation with progesterone have allowed the tailoring of several stimulation schemes, which have enhanced the pregnancy outcome after ART treatment. However, the remaining risk of ovarian hyperstimulation syndrome, the still low implantation rates, the unacceptably high rates of multiple pregnancies and the daily parenteral administration of medications do not constitute the features of a patient-friendly procedure. Therefore, a number of molecules with gonadotrophin-like activity, inhibition of GnRH receptor ability, or endometrium receptivity enhancement properties are currently under active investigation. Orally bioactive therapeutic preparations, in particular, may revolutionize in vitro fertilisation (IVF) treatment in the near future. Nevertheless, the implementation of mild ovarian stimulation protocols with single embryo transfer policy and further development of oocyte in vitro maturation techniques may lead to a less drug orientated IVF treatment.

Response to Imatinib Mesylate in a Patient with Idiopathic Hypereosinophilic Syndrome Associated with Cyclic Eosinophil Oscillations

A 26-year-old man with idiopathic hypereosinophilic syndrome (HES) was treated with imatinib mesylate following a 5-year history of prednisolone therapy. The patient had hypereosinophilia (absolute eosinophil counts >1500/microL) occurring in cyclic oscillations as well as histologically diagnosed eosinophilic vasculitis, bursitis, and periodic soft-tissue swellings. Laboratory data revealed high levels of serum tryptase and increased numbers of mast cells in the bone marrow, but serum interleukin 5 levels were within the normal range. The disease initially responded well to 100 mg/day of imatinib mesylate but recurred 8 weeks later. Thereafter, a daily 200-mg dose was temporarily effective. Despite the response to imatinib, the FIP1L1-PDGFRA fusion gene was not detected by fluorescence in situ hybridization analysis. Additional molecular and cytogenetic studies showed neither translocations of platelet-derived growth factor receptor (PDGFR) genes nor mutations in the c-KIT or the PDGFR genes. Although imatinib mesylate is a choice of treatment for patients with HES, its precise molecular mechanism in individual cases remains to be clarified.

An oocyte donation protocol using the GnRH antagonist ganirelix acetate, does not compromise embryo quality and is associated with high pregnancy rates

PURPOSE

To evaluate the effect of the GnRH antagonist, ganirelix acetate, on oocyte quality.

METHODS

Stimulation characteristics, implantation rates and clinical pregnancy rates were compared between 29 oocyte donors 21-31 years of age who underwent 31 cycles of ovarian stimulation with gonadotropins and ganirelix acetate, and 36 infertile couples of similar age range who underwent 51 cycles of ovarian stimulation using the same protocol.

RESULTS

A significantly lower number of embryos were transferred in the donor/recipient group as compared to the infertile group (2.32+/-0.54 vs. 2.82+/-0.71, P<0.05). In contrast, implantation and clinical pregnancy rates per transfer, were significantly higher in the donor/recipient group (38.1% vs. 10.4%, P<0.01) and (61.3% vs. 23.1%, P<0.05) respectively, as compared to the infertile group.

CONCLUSIONS

Incorporation of ganirelix acetate for pituitary suppression in stimulation protocols for oocyte donation is associated with high pregnancy rates suggesting that ganirelix acetate does not exert an adverse effect on oocyte or embryo quality.

The adult incidence of asthma and respiratory symptoms by passive smoking in uterus or in childhood

The effects of pre- or postnatal passive smoking on the adult incidence of asthma have not been reported previously. Between 1985 and 1996/1997, we conducted an 11-year community cohort study on the incidence of asthma and respiratory symptoms in Western Norway. The cohort included 3,786 subjects aged 15 to 70 years, of which 2,819 were responders at both baseline and follow-up. The incidence of asthma and five respiratory symptoms by self-reported exposure to maternal smoking in utero and in childhood, as well as smoking by other household members in childhood, was examined. After adjustment for sex, age, education, hay fever, personal smoking, and occupational exposure, maternal smoking was associated with asthma, phlegm cough, chronic cough, dyspnea grade 2, attacks of dyspnea, and wheezing, with odds ratios (95% confidence intervals [CI]) of 3.0 (1.6, 5.6), 1.7 (1.1, 2.6), 1.9 (1.2, 3.0), 1.9 (1.2, 3.0), 2.0 (1.3, 3.0), and 1.4 (0.9, 2.2), respectively. The adjusted attributable fractions (95% CI) of the adult incidence of asthma were 17.3% (5.2, 27.9) caused by maternal smoking and 9.3% (95% CI, -23.2, 33.2) caused by smoking by other household members. Exposure to pre- and postnatal smoking carries a substantial risk for developing adult asthma and respiratory symptoms.

Is maternal smoking more determinant than paternal smoking on the respiratory symptoms of young children?

BACKGROUND

It is generally accepted that maternal smoking has more detrimental effects than paternal smoking on the respiratory health of children. The objective of this study was to assess the effects of postnatal exposure due to the smoking behaviour by father and mother in the home, and prenatal exposure from maternal smoking during pregnancy, on the respiratory symptoms in children.

METHODS

The parents of 484 children, aged 3-6 years, completed a questionnaire about smoking and respiratory symptoms in children. Bivariate and logistic regression analyses were used to examine the associated factors with respiratory symptoms.

RESULTS

The final model of logistic regression analysis showed that prenatal exposure by maternal smoking during pregnancy increased the risk of wheezing with colds (adjusted OR=2.00, 95% CI:1.13-3.55) with respect to those children whose mothers reported no smoking during pregnancy. Postnatal exposure by maternal smoking in the home, in the presence of the child, increased the risk of cough with phlegm (adjusted OR=2.79, 95% CI:1.23-6.30) with respect to those children whose mothers did not smoke in their presence. Paternal smoking was associated with wheezing and cough in the bivariate analysis, but did not remain significant in the multivariate analysis.

CONCLUSIONS

Our results underline a greater influence of exposure to maternal smoking (prenatal and postnatal) than postnatal paternal smoking on the development of respiratory symptoms in young children.

Symptoms of asthma and the home environment. The ISAAC I and III cross-sectional surveys in Münster, Germany

BACKGROUND

The indoor home environment has been shown to be associated with the presence of respiratory symptoms and atopic disease.

METHODS

Two cross-sectional surveys (1995-2000) were conducted, using data from the ISAAC phase I and III surveys, collected in Münster, Germany (n = 6,996, response 81.8%). We analyzed the prevalence ratio (PR) for several indoor exposures and asthma-related outcomes in 6- to 7-year-old children, adjusting for potential confounders.

RESULTS

Positive associations were observed regarding exposure to molds, environmental tobacco smoke, cooking with gas and space heating with fossil fuels, but most associations were not statistically significant. Surprisingly, presence of a carpet was negatively associated with most respiratory conditions. When restricting the analysis to participants without avoidance of a carpet due to a history of atopic disease, the protective associations disappeared. Mostly, present pet ownership did not show positive associations with respiratory symptoms. However, ownership at different times in life revealed positive associations, particularly in regard to birds owned in the first year of life (PR 1.51, 95% CI 1.11-2.06, for sleep disturbance due to wheeze and PR 1.28, 95% CI 1.01-1.63, for wheeze during the last 12 months, respectively).

CONCLUSIONS

Only few indoor factors were positively associated with the studied outcomes. The change of associations in participants that reported allergy-related avoidance of carpets suggests that the observed effects are a result of asthmatics' changed behavior. The effect of allergy-related change in behavior and the results observed concerning the ownership of pets at different ages underline the need of establishing a precise temporal relationship between disease and exposure.

Secondhand smoke, dietary fruit intake, road traffic exposures, and the prevalence of asthma: a cross-sectional study in young children

The authors have investigated the independent effects of exposure to secondhand smoke, road vehicle traffic, and dietary fruit intake in a cross-sectional study of asthma in young children. They surveyed all children aged 4-6 years in 235 schools in the East Midlands and East of England regions of the United Kingdom in 2003. Data on respiratory symptoms, diagnoses and treatment, smoking in the home, and dietary fruit intake were collected by parental questionnaire. A geographic information system was used to map postcodes and determine the distance of the home from the nearest main road. Responses were obtained from 11,562 children. Wheeze in the past year and physician-diagnosed asthma were reported by 14.1% and 18.2%, respectively. Both of these outcomes were more common in children who lived with a smoker, and the prevalence of asthma increased with the number of smokers in the home. Asthma prevalence was not associated with proximity of the home to a main road or with dietary fruit intake. The authors conclude that, of the potential risk factors considered in this study, preventing secondhand smoke exposure may be the most effective way of preventing asthma.

Asthma phenotypes, risk factors, and measures of severity in a national sample of US children

OBJECTIVE

To examine a nationally representative sample of US children aged 6 to 16 years old and determine whether there are differences in risk factors and measures of severity between children with different asthma phenotypes.

METHODS

We analyzed data from the Third National Health and Nutrition Examination Survey. We used questionnaire and skin-prick testing data to separate children into the following mutually exclusive categories: atopic asthma, nonatopic asthma, resolved asthma, frequent respiratory symptoms with no asthma diagnosis, and normal. We used multivariate regression to determine whether demographic or potential risk factors varied between phenotypes and whether measures of severity varied by phenotype.

RESULTS

We found that 4.8% of children had atopic asthma, 1.9% had nonatopic asthma, 3.4% had resolved asthma, and 4.3% had frequent respiratory symptoms. Risk factors varied by phenotype, for example, the mean BMI was higher among children with nonatopic asthma, prenatal maternal smoking was a risk factor for resolved asthma, and child care attendance was a risk factor for frequent respiratory symptoms with no asthma diagnosis. Patients with atopic and nonatopic asthma were similar for most measures of asthma severity (medication use, health status, and lung function impairment). In contrast, patients with resolved asthma had fewer symptoms but a similar level of lung function impairment to that seen in patients with current asthma, whereas children with frequent respiratory symptoms but no asthma diagnosis had normal lung function.

CONCLUSIONS

Asthma risk factors and measures of severity vary between children with different asthma phenotypes.

State-of-the-art interventions for office-based parental tobacco control

Parental tobacco use is a serious health issue for all family members. Child health care clinicians are in a unique and important position to address parental smoking because of the regular, multiple contacts with parents and the harmful health consequences to their patients. This article synthesizes the current evidence-based interventions for treatment of adults and applies them to the problem of addressing parental smoking in the context of the child health care setting. Brief interventions are effective, and complementary strategies such as quitlines will improve the chances of parental smoking cessation. Adopting the 5 A's framework strategy (ask, advise, assess, assist, and arrange) gives each parent the maximum chance of quitting. Within this framework, specific recommendations are made for child health care settings and clinicians. Ongoing research will help determine how best to implement parental smoking-cessation strategies more widely in a variety of child health care settings.

Racial differences in exposure to environmental tobacco smoke among children

Exposure to environmental tobacco smoke (ETS) is a major cause of morbidity and mortality among U.S. children. Despite African-American children's having a lower reported exposure to tobacco compared to whites, they suffer disproportionately from tobacco-related illnesses and have higher levels of serum cotinine than white children. The goal of this study was to test whether African-American children have higher levels of serum and hair cotinine, after accounting for ETS exposure and various housing characteristics. We investigated the level of cotinine in both hair and serum in a sample of 222 children with asthma. Using a previously validated survey for adult smokers, we assessed each child's exposure to ETS. We collected detailed information on the primary residence, including home volume, ventilation, and overall home configuration. Despite a lower reported ETS exposure, African-American children had higher mean levels of serum cotinine (1.41 ng/mL vs. 0.97 ng/mL; p = 0.03) and hair cotinine (0.25 ng/mg vs. 0.07 ng/mg; p < 0.001) compared with white children. After adjusting for ETS exposure, housing size, and other demographic characteristics, serum and hair cotinine levels remained significantly higher in African-American children (ss = 0.34, p = 0.03) than in white children (ss = 1.06, p < 0.001). Housing volume was significantly associated with both serum and hair cotinine but did not fully explain the race difference. Our results demonstrate that, despite a lower reported exposure to ETS, African-American children with asthma had significantly higher levels of both serum and hair cotinine than did white children. Identifying causes and consequences of increased cotinine may help explain the striking differences in tobacco-related illnesses.

Risk factors for atopic eczema in school children

OBJECTIVES: to study risk factors related to atopic eczema (AE) in school children of São Paulo. METHODS: 1972 parents or guardians of 6-7 years old children in the Southern Central area of São Paulo answered to a written questionnaire (standardized questionnaire of the International Study of Asthma and Allergies in Childhood plus a complementary questionnaire regarding family history of asthma and allergies, and exposure to environmental allergens). AE was defined by the presence of an itchy rash in the last year. Risk factors were analyzed through logical regression. RESULTS: the following factors were significantly associated with AE: history of maternal (OR: 4.1; 95%CI: 2.4 to 7.1) and paternal eczema (OR: 2.6; 95%CI: 1.4 to 5.0), dust in the child's bedroom (OR: 1.6; 95%CI: 1.1 to 2.4), lower maternal education (OR: 1.7; 95%CI: 1.1 to 2.7), rhinitis fever (OR: 1.7; 95%CI: 1.1 to 2.9) and wheezing in the last year (OR: 1.9; 95%CI: 1.2 to 2.8). CONCLUSIONS: our data suggest that AE has a specific pattern of inheritance. The presence of dust in the child's bedroom was the single environmental risk factor found. Diagnose of other allergic diseases, as well as the presence of recent symptoms were strongly associated with AE in children.

Extent of exposure to environmental tobacco smoke (ETS) and its dose-response relation to respiratory health among adults

Background

There is a dearth of standardized studies examining exposure to environmental tobacco smoke (ETS) and its relationship to respiratory health among adults in developing countries.

Methods

In 2004, the Syrian Center for Tobacco Studies (SCTS) conducted a population-based survey using stratified cluster sampling to look at issues related to environmental health of adults aged 18–65 years in Aleppo (2,500,000 inhabitants). Exposure to ETS was assessed from multiple self-reported indices combined into a composite score (maximum 22), while outcomes included both self-report (symptoms/diagnosis of asthma, bronchitis, and hay fever), and objective indices (spirometric assessment of FEV₁ and FVC). Logistic and linear regression analyses were conducted to study the relation between ETS score and studied outcomes, whereby categorical (tertiles) and continuous scores were used respectively, to evaluate the association between ETS exposure and respiratory health, and explore the dose-response relationship of the association.

Results

Of 2038 participants, 1118 were current non-smokers with breath CO levels ≤ 10 ppm (27.1% men, mean age 34.7 years) and were included in the current analysis. The vast majority of study participants were exposed to ETS, whereby only 3.6% had ETS score levels ≤ 2. In general, there was a significant dose-response pattern in the relationship of ETS score with symptoms of asthma, hay fever, and bronchitis, but not with diagnoses of these outcomes. The magnitude of the effect was in the range of twofold increases in the frequency of symptoms reported in the high exposure group compared to the low exposure group. Severity of specific respiratory problems, as indicated by frequency of symptoms and health care utilization for respiratory problems, was not associated with ETS exposure. Exposure to ETS was associated with impaired lung function, indicative of airflow limitation, among women only.

Conclusions

This study provides evidence for the alarming extent of exposure to ETS among adult non-smokers in Syria, and its dose-response relationship with respiratory symptoms of infectious and non-infectious nature. It calls for concerted efforts to increase awareness of this public health problem and to enforce regulations aimed at protecting non-smokers.

[Passive smoking]

INTRODUCTION

Environmental tobacco smoke is a recognized factor of morbidity and mortality. The first victims are children, sometimes starting from conception, but adults are not spared. In practice, evaluation of exposure to tobacco smoke can be achieved with more or less specific markers of tobacco smoke.

CURRENT KNOWLEDGE

Exposure of the fetus to maternal smoking and of the infant to environmental smoke can have a serious sometimes life-threatening impact. Such exposure increases the risk of spontaneous abortion, ectopic pregnancy, intrauterine growth retardation, premature membrane rupture, preterm birth, retroplacental hematoma, placenta praevia, and sudden infant death. Adult respiratory and cardiovascular disease are also influenced by environmental smoke. In France passive smoking causes premature death of 3000 persons per year.

PERSPECTIVES

Better knowledge of the risks of exposure to passive smoking can facilitate application of legislation with the objective of protecting non-smokers.

CONCLUSIONS

Rigorous application of current legislation is important to achieve the stated goals of prevention of smoking as well as assistance to cease smoking.

Modern diagnosis and treatment of primary eosinophilia

The recent discovery of an eosinophilia-specific, imatinib-sensitive, karyotypically occult but fluorescence in situ hybridization-apparent molecular lesion in a subset of patients with blood eosinophilia has transformed the diagnostic as well as treatment approach to eosinophilic disorders. Primary (i.e. nonreactive) eosinophilia is considered either "clonal" or "idiopathic" based on the presence or absence, respectively, of either a molecular or bone marrow histological evidence for a myeloid neoplasm. Clonal eosinophilia might accompany a spectrum of clinicopathological entities, the minority of whom are molecularly characterized; Fip1-like-1-platelet-derived growth factor receptor alpha (FIP1L1-PDGFRA(+)) systemic mastocytosis, platelet-derived growth factor receptor beta (PDGFRB)-rearranged atypical myeloproliferative disorder, chronic myeloid leukemia, and the 8p11 syndrome that is associated with fibroblast growth factor receptor 1 (FGFR1) rearrangement. Hypereosinophilic syndrome (HES) is a subcategory of idiopathic eosinophilia and is characterized by an absolute eosinophil count of > or =1.5 x 10(9)/l for at least 6 months as well as eosinophil-mediated tissue damage. At present, a working diagnosis of primary eosinophilia mandates a bone marrow examination, karyotype analysis, and additional molecular studies in order to provide the patient with accurate prognostic information as well as select appropriate therapy. For example, the presence of either PDGFRA or PDGFRB mutations warrants the use of imatinib in clonal eosinophilia. In HES, prednisone, hydroxyurea, and interferon-alpha constitute first-line therapy, whereas imatinib, cladribine, and monoclonal antibodies to either interleukin-5 (mepolizumab) or CD52 (alemtuzumab) are considered investigational. Allogeneic transplantation offers a viable treatment option for drug-refractory cases.

Exposure to environmental tobacco smoke and cognitive abilities among U.S. children and adolescents

We used the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994, to investigate the relationship between environmental tobacco smoke (ETS) exposure and cognitive abilities among U.S. children and adolescents 6-16 years of age. Serum cotinine was used as a biomarker of ETS exposure. Children were included in the sample if their serum cotinine levels were less than or equal to 15 ng/mL, a level consistent with ETS exposure, and if they denied using any tobacco products in the previous 5 days. Cognitive and academic abilities were assessed using the reading and math subtests of the Wide Range Achievement Test-Revised and the block design and digit span subtests of the Wechsler Intelligence Scale for Children-III. Analyses were conducted using SUDAAN software. Of the 5,365 6- to 16-year-olds included in NHANES III, 4,399 (82%) were included in this analysis. The geometric mean serum cotinine level was 0.23 ng/mL (range, 0.035-15 ng/mL); 80% of subjects had levels < 1 ng/mL. After adjustment for sex, race, region, poverty, parent education and marital status, ferritin, and blood lead concentration, there was a significant inverse relationship between serum cotinine and scores on reading (beta = -2.69, p = 0.001), math (beta = -1.93, p = 0.01), and block design (beta = -0.55, p < 0.001) but not digit span (beta = -0.08, p = 0.52). The estimated ETS-associated decrement in cognitive test scores was greater at lower cotinine levels. A log-linear analysis was selected as the best fit to characterize the increased slope in cognitive deficits at lower levels of exposure. These data, which indicate an inverse association between ETS exposure and cognitive deficits among children even at extremely low levels of exposure, support policy to further restrict children's exposure.

The midluteal decline in serum estradiol levels is drastic but not deleterious for implantation after in vitro fertilization and embryo transfer in patients with normal or high responses

OBJECTIVE

To determine the impact of the peak E(2) level and its midluteal decline on IVF-ET outcome in a group of normal- and high-responding patients.

DESIGN

Retrospective analysis of IVF-ET data.

SETTING

Tertiary-care, university-affiliated teaching hospital.

PATIENT(S)

A total of 100 patients aged </=38 years and receiving up to three embryos per transfer who underwent a similar standard controlled ovarian hyperstimulation for IVF-ET.

INTERVENTION(S)

Morning blood was collected on days 0 (hCG day), +9, and +14.

MAIN OUTCOME MEASURE(S)

Treatment cycle hormonal characteristics and percent midluteal E(2) decline in conception and nonconception cycles.

RESULT(S)

Among all cycles, a mean decline of 95.0% in serum E(2) was observed at the midluteal phase. No significant differences were found in various parameters comparing conception with nonconception cycles. Occurrence of conception did not correlate with the absolute E(2) level or with percent E(2) decline in good and high responders. Early spontaneous abortion occurred more frequently in high responders with >98% E(2) decline; however, the difference did not reach statistical significance.

CONCLUSION(S)

Multifactorial analysis refutes the negative role of supraphysiologic levels of E(2) on the day of hCG administration or its dramatic decline at the midluteal phase on the success rate after embryo transfer. A possibly increased rate of early spontaneous abortion in the high-response group warrants further verification.

Respiratory symptoms in relation to residential coal burning and environmental tobacco smoke among early adolescents in Wuhan, China: a cross-sectional study

BACKGROUND

Cigarette smoking and coal burning are the primary sources of indoor air pollution in Chinese households. However, effects of these exposures on Chinese children's respiratory health are not well characterized.

METHODS

Seventh grade students (N = 5051) from 22 randomly selected schools in the greater metropolitan area of Wuhan, China, completed an in-class self-administered questionnaire on their respiratory health and home environment.

RESULTS

Coal burning for cooking and/or heating increased odds of wheezing with colds [odds ratio (OR) = 1.57, 95% confidence interval (CI): 1.07-2.29] and without colds (OR = 1.44, 95% CI: 1.05-1.97). For smoking in the home, the strongest associations were seen for cough (OR = 1.74, 95% CI: 1.17-2.60) and phlegm production (OR = 2.25, 95% CI: 1.36-3.72) without colds among children who lived with two or more smokers.

CONCLUSIONS

Chinese children living with smokers or in coal-burning homes are at increased risk for respiratory impairment. While economic development in China may decrease coal burning by providing cleaner fuels for household energy use, the increasing prevalence of cigarette smoking is a growing public health concern due to its effects on children. Adverse effects of tobacco smoke exposure were seen despite the low rates of maternal smoking (3.6%) in this population.

The effect of educational level on the incidence of asthma and respiratory symptoms

Few studies have examined the impact of socioeconomic status on the incidence of asthma and respiratory symptoms. Between 1985 and 1996/97, we conducted an 11-years community cohort study with 2819 subjects, aged 15-70 years at baseline, in Western Norway. We examined the cumulative incidence of asthma and respiratory symptoms by educational level (primary, secondary, and university), as well as estimating the odds ratios (ORs) of educational level on the incidences, after adjustment for sex, age, hay fever, smoking habits, pack years, and occupational exposure. For all respiratory symptoms, the incidences decreased with increasing educational level. The cumulative incidence of asthma was 5.3%, 4.1%, and 1.8%, respectively, for those with a primary educational level, secondary educational level, and university level. Subjects with a primary educational level had adjusted ORs (95% CI) from 1.4 (0.9, 2.3) for the incidence of chronic cough to 2.5 (1.6, 4.0) for the incidence of dyspnea grade 2, compared to those with a university level education. The adjusted OR (95% CI) for the incidence of asthma was 2.1 (1.01, 4.4) in subjects with a primary educational level, and 2.0 (1.04, 3.6) in subjects with a secondary educational level, compared to subjects with a university educational level. In conclusion, subjects with a lower educational level had a higher risk of developing asthma and respiratory symptoms, after adjustment for sex, age, hay fever, smoking, and occupational exposure.

Respiratory health consequences of environmental tobacco smoke

Over the last several decades there has been a growing interest in examining the health consequences of environmental tobacco smoke (ETS). As a result of a wide body of research, ETS is now considered an unacceptable and entirely preventable public health hazard, and public policy increasingly discourages the presence of tobacco smoke in the public domain. This article provides an overview of the composition of ETS and the major diseases and disorders strongly linked to ETS, emphasizing the effects of ETS on pulmonary function, asthma, and lung cancer.

Rationale for the Dutch hypothesis. Allergy and airway hyperresponsiveness as genetic factors and their interaction with environment in the development of asthma and COPD

The Dutch hypothesis, formulated in the 1960s, holds that the various forms of airway obstruction are different expressions of a single disease entity. It suggests that genetic factors (eg, airway hyperresponsiveness [AHR] and atopy), endogenous factors (eg, sex and age), and exogenous factors (eg, allergens, infections, and smoking) all play a role in the pathogenesis of chronic nonspecific lung disease. This review finds evidence that AHR and smoking are common risk factors for asthma and COPD. To prove the Dutch hypothesis definitively, however, genetic studies, preferably longitudinal, must be performed. Such studies must include subjects who have airway obstruction that does not necessarily meet the current strict definitions of asthma or COPD (ie, the extremes of these conditions) that are used in clinical studies.

Efficiency issues in sedation and monitoring

Sedation and monitoring are key elements of the endoscopy process. There continues to be intense study of better methods for sedation and monitoring to improve the endoscopic "experience" for both patient and physicians alike. Our current practices will likely change in the future with technologic advances (monitoring) and expansion of our pharmacologic armamentarium (sedation).

Could immunosuppressive drugs reduce recurrence rate after second resection for Crohn disease?

BACKGROUND

The aim of this study was to assess the possible benefit of postoperative immunosuppressive drugs administration (ie, azathioprine, 6-mercaptopurine, or methotrexate) on long-term surgical recurrence rate after second anastomotic ileocolonic resection.

METHODS

From 1984 to 2000, 26 patients with CD underwent second resection for ileocolonic anastomotic recurrence. There were 14 women and 12 men (mean age +/- SD: 34 +/- 9 years). Two groups of patients were compared according to the postoperative treatment: immunosuppressive (IS) drugs group was composed of 14 patients, and control group was composed of 12 patients receiving either salicylates (n = 5) or no treatment (n = 7).

RESULTS

Clinical recurrence rate at 3 years was significantly lower in the IS group than in the control group (3/12, 25% vs 6/10, 60%; P < 0.05). Although not significant, after a mean follow-up of 80 +/- 46 months (extr. 17-178 months) after the second resection, clinical recurrence rate at follow-up was also lower in IS group (6/14, 43%) than in control group (9/12, 75%). The mean delay of recurrence was similar in both groups (27 +/- 13 months vs 28 +/- 21; NS). A third intestinal resection was performed less frequently in the IS group than in control group (2/14, 17% vs 7/12, 58%; P < 0.02).

CONCLUSIONS

In patients treated with IS drugs, the rate of postoperative recurrence after second ileocolonic CD resection is lower than in untreated patients. Our results suggest that IS drugs should be evaluated prospectively for prevention of second postoperative CD recurrence.

Systematic review: has disease outcome in Crohn's disease changed during the last four decades?

BACKGROUND

Disease outcome in Crohn's disease might have changed during the last four decades. Disease outcome measurement in Crohn's disease has methodological difficulties because of patient selection and lack of proper definition of diagnostic and outcome measurement criteria.

AIM

To assess possible changes in disease outcome in Crohn's disease during the last four decades.

METHODS

A systematic literature search was performed using the MEDLINE search engine and major international conference libraries. Articles and abstracts were selected according to stringent inclusion criteria.

RESULTS

Forty articles and nine abstracts complied with the inclusion criteria. Seven studies with a median follow-up time between 11.1 and 17 years showed standard mortality ratios in Crohn's disease ranging between 2.16 and 0.72 with a tendency of decline during the last four decades. One study with 11.4 years mean follow-up time showed a statistically significant increased relative risk for colorectal cancer that was not confirmed by three others. Sixteen publications applied in the disease recurrence category. Probability of first resective surgery ranged between 38 and 96% during the first 15 years after diagnosis. The overall recurrence and surgical recurrence rates after first resective surgery ranged between 50 and 60, and 28 and 45% respectively during the following 15 years without an apparent time trend.

CONCLUSION

This structured literature review provides no hard evidence for change in disease outcome in Crohn's disease during the last four decades.

Cholinergic systems in brain development and disruption by neurotoxicants: nicotine, environmental tobacco smoke, organophosphates

Acetylcholine and other neurotransmitters play unique trophic roles in brain development. Accordingly, drugs and environmental toxicants that promote or interfere with neurotransmitter function evoke neurodevelopmental abnormalities by disrupting the timing or intensity of neurotrophic actions. The current review discusses three exposure scenarios involving acetylcholine systems: nicotine from maternal smoking during pregnancy, exposure to environmental tobacco smoke (ETS), and exposure to the organophosphate insecticide, chlorpyrifos (CPF). All three have long-term, adverse effects on specific processes involved in brain cell replication and differentiation, synaptic development and function, and ultimately behavioral performance. Many of these effects can be traced to the sequence of cellular events surrounding the trophic role of acetylcholine acting on its specific cellular receptors and associated signaling cascades. However, for chlorpyrifos, additional noncholinergic mechanisms appear to be critical in establishing the period of developmental vulnerability, the sites and type of neural damage, and the eventual outcome. New findings indicate that developmental neurotoxicity extends to late phases of brain maturation including adolescence. Novel in vitro and in vivo exposure models are being developed to uncover heretofore unsuspected mechanisms and targets for developmental neurotoxicants.