Latex sensitisation and allergy in children with myelomeningocele

Advancing the allergenicity assessment of new proteins using a text mining resource

With a society increasingly demanding alternative protein food sources, new strategies for evaluating protein safety issues, such as allergenic potential, are needed. Large-scale and systemic studies on allergenic proteins are hindered by the limited and non-harmonized clinical information available for these substances in dedicated databases. A missing key information is that representing the symptomatology of the allergens, especially given in terms of standard vocabularies, that would allow connecting with other biomedical resources to carry out different studies related to human health. In this work, we have generated the first resource with a comprehensive annotation of allergens' symptomatology, using a text-mining approach that extracts significant co-mentions between these entities from the scientific literature (PubMed, ∼36 million abstracts). The method identifies statistically significant co-mentions between the textual descriptions of the two types of entities in the literature as indication of relationship. 1,180 clinical signs extracted from the Human Phenotype Ontology, the Medical Subject Heading terms of PubMed together with other allergen-specific symptoms, were linked to 1,036 unique allergens annotated in two main allergen-related public databases via 14,009 relationships. This novel resource, publicly available through an interactive web interface, could serve as a starting point for future manually curated compilation of allergen symptomatology.

Perinatal Management of Pregnancies with Fetal Congenital Anomalies: A Guide to Obstetricians and Pediatricians

BACKGROUND

Congenital anomalies are responsible for approximately 20% of all neonatal deaths worldwide. Improvements in antenatal screening and diagnosis have significantly improved the prenatal detection of birth defects; however, these improvements have not translated into the improved neonatal prognosis of babies born with congenital anomalies.

OBJECTIVES

An attempt has been made to summarise the prenatal interventions, if available, the optimal route, mode and time of delivery and discuss the minimum delivery room preparations that should be made if expecting to deliver a fetus with a congenital anomaly.

METHODS

The recent literature related to the perinatal management of the fetus with prenatally detected common congenital anomalies was searched in English peer-reviewed journals from the PubMed database to work out an evidence-based approach for their management.

RESULTS

Fetuses with prenatally detected congenital anomalies should be delivered at a tertiary care centre with facilities for neonatal surgery and paediatric intensive care if needed. There is no indication for preterm delivery in the majority of cases. Only a few congenital malformations, like highrisk sacrococcygeal teratoma, congenital lung masses with significant fetal compromise, fetal cerebral lesions or neural tube defects with Head circumference >40 cm or the biparietal diameter is ≥12 cm, gastroschisis with extracorporeal liver, or giant omphaloceles in the fetus warrant caesarean section as the primary mode of delivery.

CONCLUSION

The prognosis of a fetus with congenital anomalies can be significantly improved if planning for delivery, including the place and time of delivery, is done optimally. A multidisciplinary team should be available for the fetus to optimize conditions right from when it is born.

Advances in Fetal Surgical Repair of Open Spina Bifida

Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.

Antenatal counselling for prospective parents whose fetus has a neurological anomaly: part 2, risks of adverse outcome in common anomalies

After diagnosis of a fetal neurological anomaly, prospective parents want to know the best and worst-case scenarios and an estimation of the risk to their infant of having an atypical developmental outcome. The literature on developmental outcomes for fetal neurological anomalies is poor: studies are characterized by retrospective design, small sample size, often no standardized assessment of development, and differing definitions of anomalies. This review provides an aide-memoir on the risks of adverse neurodevelopmental outcome for ventriculomegaly, cortical anomalies, microcephaly, macrocephaly, agenesis of the corpus callosum, posterior fossa anomalies, and myelomeningocele, to assist healthcare professionals in counselling. The data in this review should be used alongside recommendations on counselling and service design described in part 1 to provide antenatal counselling.

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment

BACKGROUND

In childhood, the most common reason for a neurogenic bladder is related to spinal dysraphism, mostly myelodysplasia.

AIMS

Herein, we present the EAU/ESPU guidelines in respect to the diagnostics, timetable for investigations and conservative management including clean intermittent catheterization (CIC).

MATERIAL AND METHODS

After a systematic literature review covering the period 2000 to 2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update.

RESULTS

The EAU/ESPU guideline panel advocates a proactive approach. In newborns with spina bifida, CIC should be started as soon as possible after birth. In those with intrauterine closure of the defect, urodynamic studies are recommended be performed before the patient leaves the hospital. In those with closure after birth urodynamics should be done within the next 3 months. Anticholinergic medication (oxybutynin is the only well-investigated drug in this age group-dosage 0.2-0.4 mg/kg weight per day) should be applied, if the urodynamic study confirmed detrusor overactivity. Close follow-up including ultrasound, bladder diary, urinalysis, and urodynamics are necessary within the first 6 years and after that the time intervals can be prolonged, depending on the individual risk and clinical course. In all other children with the suspicion of a neurogenic bladder due to various reasons as tethered cord, inflammation, tumors, trauma, or other reasons as well as those with anorectal malformations, urodynamics-preferable video-urodynamics, should be carried out as soon as there is a suspicion of a neurogenic bladder and conservative treatment should be started soon after confirmation of the diagnosis of neurogenic bladder. With conservative treatment the upper urinary tract is preserved in up to 90%, urinary tract infections are common, but not severe, complications of CIC are quite rare and continence can be achieved at adolescence in up to 80% without further treatment.

DISCUSSION AND CONCLUSIONS

The transition into adulthood is a complicated time for both patients, their caregivers and doctors, as the patient wants to become independent from caregivers and treatment compliance is reduced. Also, transition to adult clinics for patients with neurogenic bladders is often not well-established.

Spina bifida in pregnancy: A review of the evidence for preconception, antenatal, intrapartum and postpartum care

Women with spina bifida in pregnancy require complex multi-disciplinary management. Most women have uncomplicated pregnancies; however, complications are more frequent than in 'low risk' pregnancies. Careful antenatal planning and management of the complications can optimise outcome. There are currently no guidelines on the management of pregnant women with spina bifida, but there is a growing body of evidence from case reports and series examining the antenatal and postnatal course of these women. In this review, we examine the available literature and provide a framework on the prenatal counselling, antenatal, intrapartum and postnatal management of pregnant women with spina bifida.

Experience in the Early Surgical Management of Myelomeningocele in Zanzibar

BACKGROUND

Neural tube defects are a large health burden for East African countries. Health strategies in the prevention of this disease include nutritional prophylaxis, prenatal diagnosis, and availability of early neonatal neurosurgery. The main objective of this study is to describe our experience in the early surgical management of neural tube defects in the Zanzibar archipelago.

METHODS

From December 2016 to December 2017, we prospectively collected data on all patients admitted with the diagnosis of myelomeningocele. We collected variables regarding demographics, maternal health, preoperative imaging, surgical procedures, and complications at follow-up.

RESULTS

We collected data on 19 patients. Mean age was 9.8 ± 18.7 days. Of these patients, 52.6% were male and 47.3% were female; 47.3% patients were from Unguja, 42.0% from Pemba, and 5.2% from mainland Tanzania; 68.4% of all mothers were found to have undergone prenatal ultrasonography and 89.5% of all patients received surgery. Surgical wound infection was present in 29.4% of all surgical patients and 52.9% developed secondary hydrocephalus.

CONCLUSIONS

Neural tube defects are a prevailing condition in East Africa. We believe that more health initiatives should address its prevention, mainly through maternal nutrition. On the basis of our findings, we consider early neonatal neurosurgery as the most important factor in reducing immediate morbidity and mortality.

Spinal cord malformations

Malformations of the spinal cord are one of the most frequent malformations. They should be clearly divided into two completely different families of malformations: open dysraphisms and occult dysraphisms. Open dysraphism mostly consists in myelomeningocele (MMC). Its incidence is 1/1000 live births with a wide variation. Folic acid supplementation has been shown to reduce its risk. In most cases, the diagnosis is done prenatally by serum screening and ultrasound and may lead to termination of pregnancy. In case of decision to continue pregnancy, surgical treatment must be achieved during the first days of life, and in 50 to 90% of cases, a ventricular shunt must be installed. The follow-up of these children must be continued throughout life looking for late complications (Chiari II and syringomyelia, vertebral problems, neuropathic bladder, tethered cord). Occult dysraphisms are a heterogeneous group of malformations. Lipomas (filum and conus) are the most frequent and their treatment remains controversial. Diastematomyelia, neurenteric cysts, dermal sinus, and more complex forms (Currarino syndrome) belong to this group. Most of them can and must be diagnosed prenatally or at birth by careful examination of the lower back for the cutaneous stigmata of the disease to decrease the risk of neurological, urological, or orthopedic permanent handicap.

Spinal cord injuries in children and adolescents

This chapter provides an overview of spinal cord injuries (SCI) in children and adolescents, including epidemiology, medical and musculoskeletal complications, rehabilitation and psychosocial aspects. Males are more commonly affected than females during adolescence; however, as the age at injury decreases, the preponderance of males becomes less marked, and by 3 years of age the number of females with SCIs equals that of males. The neurologic level and degree of completeness varies with age; among children injured prior to 12 years of age approximately two-thirds are paraplegic and approximately two-thirds have complete lesions. Among adolescents, approximately 50% have paraplegia and 55% have complete lesions. Management of pediatric-onset SCI should be family centered and developmentally based, responsive to the dynamic changes that occur during growth and development. Distinctive anatomical and physiological features of children and adolescents, along with growth and development, are responsible for unique manifestations and complications of pediatric SCI. SCI without radiological abnormalities (SCIWORA), birth injuries, lap-belt injuries, upper cervical injuries, and the delayed onset of neurological deficits are relatively unique to pediatric SCI. Children who sustain their SCI before puberty experience a higher incidence of musculoskeletal complications, such as scoliosis and hip dislocation.

Latex sensitization and allergy in children with spina bifida in Turkey

PURPOSE

The latex allergy is known as a very frequent problem of children with spina bifida (SB). The aim of this prospective study is to determine the frequency of latex sensitization and allergy in Turkish children with SB and to evaluate the related risk factors.

METHODS

We enrolled a total of 175 children and collected them in four groups of patients: children with SB, children who had neurosurgical disorders other than SB, atopic children with allergic diseases, and healthy children as control group. All cases were evaluated for latex sensitivity and allergy with skin prick tests and specific IgE. The diagnosis of latex allergy was confirmed with the latex provocation test.

RESULTS

Ten children with SB, two children with other neurological disorders, and three atopic children with allergic disease were found "sensitized to latex". Among these sensitized children, only one child with SB had latex allergy. Multivariate logistic regression analysis of the children with SB and other neurologic disorders and the whole group of patients showed that skin test positivity, the presence of noncentral nervous system (CNS) surgery, and the number of the operations were significant risk factors for latex sensitization.

CONCLUSIONS

Our study showed that rates of latex sensitivity and allergy in children with SB in Turkey are significantly lower than published rates in literature. We also found that atopy, the presence of non-CNS operations in children with SB and other neurologic disorder, and total number of operations in the whole group of patients are the most important risk factors for latex sensitization.

Prevalance of latex sensitization and associated risk factors in Turkish children with spina bifida

PURPOSE

Among children with spina bifida there is a high prevalence of latex allergy in reports from Europe and USA. The aim of this study was to investigate the incidence of latex sensitization and associated risk factors in children with spina bifida in Middle-Eastern region (Istanbul, Turkey).

MATERIALS AND METHODS

Eighty consecutive children affected with spina bifida were included in the study. Data were collected about age, sex, family and personal history of atopy, and the number and type of operations classified as neurosurgical, urological, and orthopedic. All patients underwent skin prick test using latex solutions and cross-reacting foods. Total and latex-specific IgE levels were also measured.

RESULTS

Latex sensitization was shown in 16% (13/80) of the patients with specific IgE > 0.7 kU/L. The number of operation, using intermittent bladder catheterization and ventricular-peritoneal shunt were significantly associated with latex sensitization.

CONCLUSION

The incidence of latex sensitization in this study was lower than reported in the literature. Environmental factors such as the type and number of operations and geographical location may play a role in the development of latex sensitization.

Risk factors for latex sensitization in young children with myelomeningocele. Clinical article

OBJECT

Patients with myelomeningoceles (MMCs) are at increased risk of latex allergy and sensitization. Number of surgeries and history of atopy are known risk factors. The object of this study was to evaluate the role of diagnostic procedures and nonsurgical treatments in latex sensitization in young patients with MMC.

METHODS

Seventy-three children with MMC were included in the study. For each child a questionnaire was administered and serum determination of IgE was performed, and 62 children underwent skin prick tests (SPTs), 60 of which had reliable results. Multivariate logistic regression modeling was performed, using latex sensitization as the dependent variable.

RESULTS

The mean age of the 73 patients was 3.8 years. The SPT results were positive in 30.6%, whereas results of testing for latex-specific IgE were positive in only 8.2%. In univariate analysis, history of untethering, barium enema, and number of clean intermittent catheterizations (CICs) per day were significantly associated with positive results on the SPT. Although the number of surgical procedures was significantly higher in patients who had shunts, no significant relationship between the presence of a shunt and latex sensitization was seen.

CONCLUSIONS

The young age of the patients in this study may account for the low prevalence of latex sensitization that was found. In young patients with MMC, the numbers of CICs per day, a history of untethering, circumcision, and a barium enema performed without latex-free equipment could be risk factors for latex sensitization. The use of latex-free gloves in all procedures performed in these cases, nonlatex polyvinyl chloride catheters in CIC, and ordinary nonballoon tips in barium enemas could decrease the risk of sensitization.

Myelomeningocele: long-term neurosurgical treatment and follow-up in 202 patients

OBJECT

In this paper the authors focus on the long-term management of myelomeningocele (MMC) and its associated conditions.

METHODS

During a 25-year period, 220 consecutive patients with MMC underwent surgical repair. There were 203 cases (92%) of enlarged ventricles, but only 171 cases (78%) of hydrocephalus. Seven infants (3%) presented with early brainstem dysfunction; two improved after ventricular drainage, whereas five required craniocervical decompression.

RESULTS

Overall, five neonates (2%) died; 215 patients (98%) were eventually discharged from the hospital and of these, 202 (94%) remained in the authors' outpatient program. During the follow-up (range 1-25 years, mean 9.3 years), 96 patients required shunt revision (63% of shunts); 16 patients (8%) experienced late brainstem dysfunction that was treated by shunt placement in eight and by craniocervical decompression in the other eight; 137 patients (68%) harbored hydrosyringomyelia, but only six required surgical treatment; 40 patients (20%) presented symptoms of tethered cord, but surgical detethering was indicated in just 22 patients (11%). There were five deaths (2%), and severe adjunctive neurological morbidity was reported in 18 patients (9%) (owing to various causes). "Social" results have been evaluated by extrapolating 38 patients older than 15 years of age whose initial lesions were below L-2: 37 (97%) of these patients were fully independent, had "social urinary continence," and attended normal schools.

CONCLUSIONS

Currently, many patients with MMC reach adulthood and social continence; self-care may be expected in a large percentage of cases. Nevertheless, there are many associated neurological conditions that have to be faced, and a coordinated network of care remains necessary throughout the patient's life. Moreover, these patients often present with so many peculiarities that indications for treatment, choice of proper techniques, and results are not always clear and evident.

Exercise with latex sport bands represents a risk for latex allergic patients

Based on two clinical observations of adverse reactions during exercise with latex sport bands, we aimed to assess the possible risk for allergic patients posed by this equipment by investigating allergen content and IgE binding potential. Protein extracts of three different latex sport bands were characterized with sera of latex allergic patients. The IgE recognition profile of the allergic patients was identified by component resolved diagnosis and the allergen composition of the extracts was characterized by inhibition assays with the recombinant latex allergens Hev b 1, 3, 5, 6.02, and 8. The sera showed pronounced IgE binding to all three blotted extracts, however with diverse patterns. Inhibition assays revealed the presence of Hev b 1, 3, 5, and 8 in latex sport band extracts. The clinical relevance of contained allergens was demonstrated by strong skin reactions when testing with latex sport bands. From our results we conclude that latex sport bands contain clinically relevant allergens and may cause latex allergic individuals to experience allergic symptoms, potentially amplified by exercise-induced mechanisms. Even though latex is labeled on products, it is important that patients as well as athletic trainers and physical therapists recognize the risk of adverse reactions with these bands.

Urologischer Erkrankungen bei Patienten mit Meningomyelozele

Since the 1980s the management of children and adolescents with meningomyelocele has undergone major changes. The introduction of pharmacotherapy with antimuscarinic agents, clean intermittent catheterization (CIC) and antibacterial prophylaxis has revolutionized the management of children with neurogenic bladder. The co-operation between neonatologists, neurosurgeons, paediatric neurologists, paediatricians, paediatric urologists, paediatric nephrologists, paediatric orthopaedists and paediatric surgeons is necessary to achieve an optimized therapy in each individual patient. In this interdisciplinary consensus paper we provide definitions and classifications as well as a timetable for the appropriate investigations. The conservative and surgical options are explained in detail. A short review is given concerning orthopaedic management, incidence of latex allergy, options for bowel management, diagnosis and treatment of urinary tract infections, problems with sexuality and fertility as well as the long-term compliance of these patients and their relatives.

Unexpected source of latex sensitization in a neonatal intensive care unit

We report a term infant with gastroschisis who presented with a systemic allergic reaction at a specific time of each day coinciding with infusion from a new preparation of total parenteral nutrition and intravenous lipid emulsion. The source of latex was traced to the rubber stopper of the lipid emulsion. We present this case to highlight the possibility of allergy from this unexpected source in a neonate.

Medical problems in adolescents with myelomeningocele (MMC): an inventory of the Swedish MMC population born during 1986-1989

AIM

To describe the prevalence of myelomeningocele (MMC) and the medical needs of adolescents, 15-18 years, with MMC in Sweden, at a time when they are on the threshold of adulthood, leaving paediatrics.

METHODS

In a retrospective study, we identified all adolescents with MMC, born during 1986-1989 and living in Sweden on July 1, 2004. An inventory was agreed upon with questions concerning their medical problems and need for medical care.

RESULTS

There were 175 persons 15-18 years of age, born with MMC or lipoMMC (prevalence 3.8 per 10,000). Hydrocephalus was seen in 86%, 31% had been operated because of tethered cord syndrome, and 6% for Chiari malformation symptoms. The majority had motor impairments. Clean intermittent catheterisation for bladder emptying was used by 85%, and 59% used enemas on a regular basis because of the neurogenic bowel dysfunction. Renal dysfunction was seen in 1.7% of the adolescents.

CONCLUSION

Lifelong follow-up by many specialists, among others neurologists and neurosurgeons, urotherapists and urologists, orthopaedic surgeons and orthotists, is necessary for individuals with MMC. The complex medical situation, often in combination with cognitive difficulties, makes it necessary to coordinate medical services for this increasing group of adults with multiple impairments.

Latex allergy within a cohort of not-at-risk subjects with respiratory symptoms: prevalence of latex sensitization and assessment of diagnostic tools

BACKGROUND

Immunoglobluin E (IgE)-mediated hypersensitivity to natural rubber latex (NRL) is a major problem in allergy practice. Currently, the use of skin prick tests (SPTs) with latex extracts and specific IgE detection for the diagnosis of NRL allergy in suspected patients is directed to identification of risk factors. Many cases of NRL allergy remain undiagnosed due to misreporting of symptoms by the patients or lack of proper questions asked by the physician.

MATERIALS AND METHODS

A total of 6,126 subjects referred for respiratory symptoms underwent SPTs with NRL. Positive subjects were resurveyed for exposure to NRL, and specific IgE for NRL extracts and recombinant molecules was determined. Immunoblots of NRL extracts were performed to identify IgE patterns.

RESULTS

Forty-six of 3,930 sensitized subjects had a positive SPT with NRL, displaying a prevalence of NRL sensitization of 0.75% for the general and 1.2% for the sensitized population. Eleven out of 46 (23.9%) subjects could be defined as NRL asymptomatic, whereas 35 (76.1%) developed symptoms upon exposure to NRL. Specific IgE to NRL was detected for 22 (75.86%) of 29 tested sera. Seventeen out of 22 (77%) sera displayed specific IgE to recombinant allergens with most reactions to Hev b 5, Hev b 6.01 and Hev b 6.02. Immunoblots of NRL extract fractions with patients' sera showed heterogeneous patterns.

CONCLUSIONS

SPTs with NRL extract should be routinely performed in patients with respiratory symptoms. Hev b 5, Hev b 6.01 and Hev b 6.02 are the most important allergens, but further characterization of NRL extracts is needed to identify novel allergens and to clarify the role of crossreactive carbohydrate determinants.

Special considerations for breastfeeding the infant with spina bifida

At present, no research has examined the unique breastfeeding needs of a mother and her infant with spina bifida (SB). This mother-infant dyad will face many unique challenges during the prenatal period, postdelivery, and postsurgical repair of the myelomeningocele (MMC). Each of these periods presents an opportunity for effective evidence-based nursing interventions to promote successful provision of human milk (HM). Beyond the need for nursing care during these crucial events, parents need education about the potential benefits of HM for the long-term complications of SB. Although there is no published evidence specifically related to the benefits of HM for mothers and their infants with SB, studies related to the general benefits of HM suggest that the mothers may enjoy enhanced maternal psychological adjustment while infants with SB may experience improved pain management, reduced infection rates, decreased incidence of allergy, improved cognitive development, and decreased incidence of obesity. Further research is needed to better understand the unique relationship between HM and SB.

Anaphylactic reactions during cesarean section

Sensitization to latex seems to occur more frequently in women than in men. Obstetric and gynecological surgical procedures have recently been shown to be a common setting for latex anaphylaxis. We analyzed all the cases of anaphylactic reactions during 1240 cesarean sections in 2004; the patients were questioned for risk factors and underwent allergy testing for drugs and latex. Four patients had anaphylaxis under spinal anesthesia and in all cases it was due to latex allergy. Reported symptoms included facial edema, profuse sweating, itching, generalized erythematous rash and hypotension. Only one patient manifested a severe reaction which included bronchospasm, dyspnea, tachypnea and anaphylactic shock, requiring orotracheal intubation and epinephrine. Our data showed a high incidence (1:310) of intraoperative latex anaphylactic reactions in the one-year study period. This may be related to the very specific population (all women) in a very specific setting (obstetrics). To prevent anaphylactic reactions during obstetric surgery it is important to identify potential risk factors to include, for example atopy, adverse reactions to foods and latex items. If latex allergy is confirmed or strongly suspected, patients should be managed in a latex-safe environment. Premedication with antihistamines and steroids might be useful to further reduce the risk. After the delivery, specific desensitization may represent a good therapeutic option.

Sublingual desensitization in children with congenital malformations and latex allergy

The frequency of latex allergy in children requiring multiple surgery ranges from 16.7% to 65%. The aim of this study was to investigate the safety and efficacy of latex desensitization in a group of 10 patients with a history of multiple surgical procedures and clinically manifested allergy to latex. We selected 10 children (female-male ratio = 5:5), aged 4-16 yr (mean +/- s.d.: 9 +/- 4), with a history of multiple surgical procedures, adverse reactions to latex and positive skin test to latex and/or specific immunoglobulin E (IgE). Latex allergy diagnosis was confirmed by specific provocation tests (cutaneous, sublingual, mucous, conjunctival tests). Rush (4-day) sublingual desensitization was performed with increasing doses of latex extract (ALK Abellò) under patients' tongue until the highest dose of 500 microg of latex. A maintenance therapy (10 drops of undiluted solution three times a week) was recommended. During the 2-yr follow-up mean values of specific IgG4 and IgE, eosinophilic cationic protein and total IgE did not show significant variations. Patients did not manifest any adverse effect during the rush phase and only two patients manifested mild local symptoms during the maintenance therapy. All the challenges showed a reduction in terms of percentage of positivity and mean scores. All the patients showed a reduction of the mean individual score (p < 0.001). Furthermore patients who needed dental examination or surgery underwent such procedures without the occurrence of symptoms. Our preliminary results show sublingual desensitization to latex can be an important therapeutic tool in the management of young allergic patients requiring multiple operations.