Retrospective definition of reaction risk in Italian children with peanut, hazelnut and walnut allergy through component-resolved diagnosis

BACKGROUND

Serum IgE evaluation of peanut, hazelnut and walnut allergens through the use of component-resolved diagnosis (CRD) can be more accurate than IgE against whole food to associate with severe or mild reactions.

OBJECTIVES

The aim of the study was to retrospectively define the level of reaction risk in children with peanut, hazelnut and walnut sensitization through the use of CRD.

METHODS

34 patients [n=22 males, 65%; median age eight years, interquartile range (IQR) 5.0-11.0 years] with a reported history of reactions to peanut and/or hazelnut and/or walnut had their serum analyzed for specific IgE (s-IgE) by ImmunoCAP^® and ISAC^® microarray technique.

RESULTS

In children with previous reactions to peanut, the positivity of Arah1 and Arah2 s-IgE was associated with a history of anaphylaxis to such food, while the positivity of Arah8 s-IgE were associated with mild reactions. Regarding hazelnut, the presence of positive Cora9 and, particularly, Cora14 s-IgE was associated with a history of anaphylaxis, while positive Cora1.0401 s-IgE were associated with mild reactions. Concerning walnut, the presence of positive Jug r 1, Jug r 2, Jug r 3 s-IgE was associated with a history of anaphylaxis to such food. ImmmunoCAP^® proved to be more useful in retrospectively defining the risk of hazelnut anaphylaxis, because of the possibility of measuring Cor a14 s-IgE.

CONCLUSIONS

Our data show that the use of CRD in patients with allergy to peanut, hazelnut and walnut could allow for greater accuracy in retrospectively defining the risk of anaphylactic reaction to such foods.

Serum and exhaled breath condensate leptin levels in asthmatic and obesity children: a pilot study

BACKGROUND

Recent studies have highlighted the possible involvement of leptin in inflammation. The leptin receptor is also expressed by alveolar macrophages, T lymphocytes and bronchial epitelial cells, suggesting a possible role in the cascade of airway inflammation.

OBJECTIVES

The aim of the study was to evaluate the levels of leptin in exhaled breath condensate (EBC) from asthmatic, normal- and overweight children, in relationship with airway inflammation.

METHODS

15 asthmatic non-obese children, 15 healthy non-asthmatic non-obese children, 11 obese children with asthma (OA) and 20 obese children without asthma (ONA) were enrolled. Body impedance of body weight, EBC collection, FeNO, spirometry and a blood sampling for serum leptin were assessed.

RESULTS

Leptin EBC levels were significantly higher (3.9 ng ml^-1 ± 1.3) in overweight children than those obese with asthma (3.6 ng ml^-1 ± 1.6; p = 0.97), non-owerweight asthmatics (2.2 ng ml^-1 ± 1.2; p < 0.0001) and in healthy children (0.9 ng ml^-1 ± 0.6; p < 0.001). Leptin EBC levels in asthmatic children were significantly higher than in healthy children (p = 0.05). Leptin serum levels were significantly higher in the overweight children compared with the asthmatics (12.7 ng ml^-1 ± 13.2; p < 0.001) and the healthy group (11.1 ng ml^-1 ± 11.2; p < 0.001). We observed a significant correlation between EBC-leptin levels and the serum-leptin levels (p = 0.001). No correlations were found between EBC-leptin levels, FeNO and lung function.

CONCLUSIONS

This study shows that leptin is measurable in EBC in children and that EBC-leptin levels are significantly higher in the obese subjects and in asthmatic ones compared with healthy subjects. Leptin may therefore represent a non-invasive marker of non-specific airway inflammation in children.

Accidental intravenous administration of paracetamol syrup in a child

OBJECTIVE AND IMPORTANCE

Medication administration errors occur frequently in clinical practice.

CLINICAL PRESENTATION

An 18-month-old child presented with vomiting and diarrhea. Due to a rise in temperature, paracetamol syrup was prescribed, but a nurse inadvertently administered the drug IV through the peripheral venous access.

INTERVENTION

The child was referred to the pediatric intensive care unit where his clinical condition improved and the risk of peripheral venous and pulmonary embolism was excluded.

CONCLUSION

The use of specific oral syringes should become a standard of practice in every healthcare organization and more supervision of new nurse graduates is necessary. Also, attention to the relationship with parents should be guaranteed because the communication of medical errors is a highly challenging aspect of these errors.

Significant association among growing pains, vitamin D supplementation, and bone mineral status: results from a pilot cohort study

The aim of our study was to analyze the possible relationship between growing pains, vitamin D levels, and bone mineral status. We enrolled 33 children affected by growing pains. Their pain intensity was evaluated through a questionnaire using the Wong-Baker Faces Pain Rating Scale for pain assessment. Serum 25-hydroxyvitamin D (25-OH-D), parathyroid hormone (PTH), and alkaline phosphatase levels were measured as well. A quantitative ultrasound assessment (QUS) was also done, measuring both the amplitude-dependent speed of sound (AD-SOS) and the bone transmission time (BTT), correlating, respectively, with bone density and with cortical thickness. After 3 and 24 months of vitamin D supplementation, we re-evaluated pain intensity and laboratory results. After 24 months we re-assessed QUS parameters. At the beginning of the study the children reported a mean growing pain intensity of 7.5 ± 1.6 SD. The mean values of 25-OH-D and PTH levels were 15.7 ± 6.9 ng/ml and 57.3 ± 27.3 pg/ml, respectively. The AD-SOS Z score was -0.53 ± 1.19 SD, and the mean value of the BTT Z score was -0.72 ± 0.96 SD. After the first 3 months of vitamin D supplementation we observed an increase in 25-OH-D levels (34.1 ± 17.8, p < 0.001) and a reduction in both PTH levels (47.3 ± 30.6, p = 0.135) and pain intensity (2.7 ± 2.2, p < 0.001). After 24 months we observed a further significant reduction in the pain intensity (3.9 ± 3.4, p < 0.001) and in PTH levels (43.7 ± 28.5, p = 0.004) and an improvement in the QUS parameters, in particular in BTT Z scores (p = 0.014). Our study suggests an interesting relationship between growing pains, vitamin D levels and bone mineral status.

International consensus on (ICON) pediatric asthma

Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.

Asthma, allergy and respiratory infections: the vitamin D hypothesis

The recent discovery that every tissue in the human body has vitamin D receptors and that vitamin D has pleiotropic effects has prompted an increased interest in this hormone. Vitamin D deficiency is widespread and on the increase. There is no consensus on the serum vitamin D levels to consider appropriate for global health, the cutoffs for its deficiency, or the doses to use for its supplementation. Vitamin D seems to correlate closely with host reactions against various respiratory infections. Epidemiological studies have shown that low serum 25-hydroxyvitamin D levels are associated with a higher risk of upper and lower respiratory infections in children and a shortage of vitamin D may contribute to asthmatic patients' symptoms and morbidity rates. There are studies highlighting associations between childhood asthma, fetal lung and/or immune development, and maternal vitamin D intake. An insufficiency of this vitamin also seems to be implicated in the onset of childhood atopy and food allergies. The hypothesis is that vitamin D could have a central role in these pathological situations and that it may represent a novel preventive and/or therapeutic strategy. This article reviews and discusses published data on the relationship between vitamin D and asthma and allergy, emphasizing the need for controlled, prospective studies on vitamin D supplementation to clarify whether it has a role in the prevention of and treatment for asthma and allergic conditions.

Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report

Asthma is the leading chronic disease among children in most industrialized countries. However, the evidence base on specific aspects of pediatric asthma, including therapeutic strategies, is limited and no recent international guidelines have focused exclusively on pediatric asthma. As a result, the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology nominated expert teams to find a consensus to serve as a guideline for clinical practice in Europe as well as in North America. This consensus report recommends strategies that include pharmacological treatment, allergen and trigger avoidance and asthma education. The report is part of the PRACTALL initiative, which is endorsed by both academies.

Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report

Asthma is the leading chronic disease among children in most industrialized countries. However, the evidence base on specific aspects of pediatric asthma, including therapeutic strategies, is limited and no recent international guidelines have focused exclusively on pediatric asthma. As a result, the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology nominated expert teams to find a consensus to serve as a guideline for clinical practice in Europe as well as in North America. This consensus report recommends strategies that include pharmacological treatment, allergen and trigger avoidance and asthma education. The report is part of the PRACTALL initiative, which is endorsed by both academies.

[Societal cost of pre-lingual deafness]

Congenital hearing loss still remain an important medical and social problem for the delayed language development. Object of this study is to provide an updated and close estimate of the economic burden involved in pre-lingual hearing loss. Data were provided by the Ministry of Health data bank, the Ministry of Education national data bank, the National Institute of Social Insurance national data bank and the Italian Central Statistics Institute. The information was collected by means of a specially provided Societal Cost Questionnaire (SCQ). Direct medical costs, direct non-medical costs and indirect welfare costs involved in deafness were included in the cost estimate. Was enrolled in the study a sample of subjects with pre-lingual deafness, with a mean bilateral neuro-sensorial hearing impairment equal to 60 dB or more for 500, 1,000 and 2,000 Hz frequency tones in the better ear detected in neonatal age, had prevented speech from developing. The statistical assessment was performed according to an actuarial approach, considering the estimated life expectancy at birth, based on updated population data from census 2001. Based on life expectancy, the lifetime mean cost assessed for a subject affected by profound pre-lingual deafness turned out to be equal to Euro 737,994.76 for a male and Euro 755,404.02 for a female. Unlike other disabling affections, deafness weighs significantly more on the social system than on the health system. As a matter of fact, the direct medical costs, such as audiological diagnosis, hearing aids, etc., only account for 3.8% of the societal cost, whereas education, rehabilitation and welfare costs reach 96.2% of the total. Finally, our results suggest that societal costs can only be reduced by zeroing in on promotion and broadening of effective prevention strategies. The appropriate public health measures (such as the universal newborn hearing screening) set up and implemented in several European and non-European countries proved effective and reduced the handicap degree resulting from deafness. The investment in prevention will be widely paid.

The role of house dust mite elimination in the management of childhood asthma: an unresolved issue

Indoor allergens are likely to be direct environmental causes of asthma and mite exposure, and sensitization is the most important environmental risk factor for childhood asthma in temperate zones. Analagous to occupational asthma, allergen avoidance in asthmatic children sensitized and exposed to mite allergens is associated with a reduction in airway hyperresponsiveness and symptoms associated with improvement in lung function. The long-term effect of this strategy needs to be prospectively evaluated considering both the timing and duration of exposure, as well as the timing and duration of removal. In order to be successful, it is important to achieve and maintain a major reduction on allergen levels, for a long period of time.

Treating asthma in children with beclomethasone dipropionate: Pulvinal versus Diskhaler

Seventy-two children (mean age, 10.1 years) with stable moderate asthma who completed a 7-day run-in period were randomized to receive a 4-week treatment with beclomethasone dipropionate (200 micrograms twice daily) administered through two different powder inhalers (Pulvinal; Chiesi Farmaceutici S.p.A, Parma, Italy and Diskhaler; Glaxo-Wellcome, Evreux, France) in a parallel group design. Sixty-nine patients completed the study. Morning and evening peak expiratory flow values, the use of rescue salbutamol, and the severity of clinical symptoms were recorded daily on a diary card. Pulmonary function tests were performed at baseline and then after 2 and 4 weeks of treatment. Pulmonary function values, daily morning and evening peak expiratory flow, and most of the clinical symptoms significantly improved, although the use of rescue salbutamol significantly decreased from the second week of treatment until the end of the study in both groups. Equivalence of efficacy between groups was demonstrated for both pulmonary function and clinical parameters. We conclude that the Pulvinal inhaler is as efficacious as the Diskhaler in beclomethasone-based therapy of asthmatic children.

Cell-specific differences in the regulation of IL-6 expression by PMA

We have studied the regulation of IL-6 expression in human blood monocytes and lymphocytes. LPS and IFN-gamma induced IL-6 gene expression with a similar qualitative profile in both cell types. Treatment of monocytes and lymphocytes with PMA resulted, instead, in different effects: monocytes accumulated IL-6 and its message, while lymphocytes were inhibited either in the absence or the presence of LPS and IFN-gamma. These results suggest that the signal transduction pathways triggered by LPS and IFN-gamma are similar in both cell types, while PMA may activate a tissue-specific pathway which leads to opposite responses.

The efficacy and tolerability of fluticasone propionate aqueous nasal spray in children with seasonal allergic rhinitis

Fluticasone propionate aqueous nasal spray (FPANS) contains fluticasone propionate, which is a new topically active glucocorticoid with approximately twice the potency of belcomethasone dipropionate. In this European multicentre study, 143 children with seasonal allergic rhinitis were recruited: 47 received FPANS 100 micrograms once a day (od), 46 received FPANS 200 micrograms od, and 50 patients received placebo od, for 4 weeks. Treatment efficacy was assessed using diary card nasal symptom scores for sneezing, rhinorrhoea, blockage and itching, and eye watering/irritation. Patients receiving FPANS 100 micrograms or FPANS 200 micrograms demonstrated statistically significant improvements in median nasal symptom scores in all the symptoms recorded, when compared with placebo. There were no statistically significant differences between the FPANS 100 micrograms and FPANS 200 micrograms groups in improvement in nasal symptom scores. There was no effect on eye watering/irritation symptoms which could be attributed to either FPANS 100 micrograms or FPANS 200 micrograms when compared with placebo. Use of rescue antihistamine medication was significantly reduced in the FPANS 100 micrograms group when compared with placebo. The adverse events profile was similar in all three treatment groups, and the events reported were generally mild and related to the patients' rhinitis.

Ligation of members of the beta 1 or the beta 2 subfamilies of integrins by antibodies triggers eosinophil respiratory burst and spreading

Eosinophils interact with extracellular matrix proteins and endothelial cells through adhesion proteins belonging to the beta 1 and beta 2 subfamilies of integrins. Extending previous observations, we found that tumour necrosis factor (TNF) and granulocyte-macrophage colony-stimulating factor stimulated generation of superoxide anion by eosinophils plated on fibronectin-coated surfaces. As studies with adherent neutrophils indicated that TNF might act as activating leucocyte integrins to deliver signals involved in activation of cell functions, we investigated the effects of monoclonal antibodies (mAb) directed against VLA-4 (CD49d/CD29), LFA-1 (CD11a/CD18), CR3 (CD11b/CD18) or the common beta 2 subunit (CD18) on generation of eosinophil toxic oxygen molecules and spreading. We show that cross-linking of members of both the beta 1 and the beta 2 integrin subfamilies triggers eosinophil respiratory burst and spreading. Evidence for the selectivity of anti-integrin mAb effects is derived from the findings that isotype-matched mAb of other specificities (anti-class I MHC Ag, anti-beta 2-microglobulin, anti-CD4) did not trigger eosinophil functions. The findings presented in this paper suggest that integrin-dependent, eosinophil adhesion in sites of allergic reaction may be accompanied by release of toxic oxygen molecules involved in tissue damage.

Double blind, placebo controlled study of nedocromil sodium in asthma

After a two week baseline, 209 asthmatic children (mean age 10 years, range 6-17) were randomly allocated to receive 4 mg nedocromil sodium (n = 110) or placebo (n = 99) four times daily for 12 weeks in addition to their current treatment. The children completed daily diary cards and visited the clinic at four week intervals. Statistically significant differences in favour of nedocromil sodium were seen for clinician assessment of asthma severity and diary card symptom scores, pulmonary function and inhaled beta 2 bronchodilator use. Total symptom score decreased by 50% from baseline in the nedocromil sodium group and by 9% in the placebo group during the final four weeks. Nedocromil sodium was considered very or moderately effective by 78% of children/parents (placebo 59%) and 73% of clinicians (placebo 50%). Nausea, headache and sleepiness, and dyspnoea led to withdrawal of one child from nedocromil sodium and placebo treatments, respectively. Reports of sore throat and headache were marginally greater with the nedocromil sodium treatment. It is concluded that nedocromil sodium was both effective and safe in the treatment of asthma in children.

Irreversible respiratory failure in an achondroplastic child: the importance of an early cervicomedullary decompression, and a review of the literature

The authors report the case of a girl with achondroplasia suffering from a progressively worsening hypotonic quadriparesis. CT scan showed slight dilatation of ventricular and subarachnoid spaces, with well-defined evidence of cortical sulci and gyri. This aspect was compatible with the diagnosis of macrocrania and megalencephaly (CP being 51 cm). The foramen magnum was narrowed, the transverse diameter measuring 15 mm and the 50th percentile being, for age, 26 mm. Somatosensory evoked potentials (SEPs) revealed bilaterally prolonged interpeak latencies Erb-N13, slowing of central conduction time N13-N20 from right median nerve stimulation, and block from left median nerve. The suspicion of cervicomedullary compression was confirmed by MRI, showing a very marked stenosis with compression exerted by the odontoid process. Further, a stenotic cervical canal and optic nerves verticalization were manifest. The patient underwent neurosurgical decompression by suboccipital craniectomy and cervical-C1 laminectomy. In spite of treatment, both neurologic and respiratory problems (rapid, shallow and almost abdominal breathing) were unchanged. The girl died 4 1/2 months later. The authors emphasize the important role of SEPs in detection of cervicomedullary compression in achondroplastic children and also stress the necessity of an early surgical treatment as the only condition for possible clinical improvement and/or full recovery.

[The rehabilitation hiatus]

A gap its often to be found between medical rehabilitation after a disease or accident and professional reintegration. Causes and consequences as well as means of preventing it are being shown.

Progressive myoclonic encephalopathy in X-linked hypogamma-globulinemia. Case report, review of the literature and its relationship with progressive encephalopathy in children with A.I.D.S

A 7-year-old boy suffering from X-linked hypogammaglobulinemia and progressive myoclonic encephalopathy is reported. The onset of neurological disturbances is at four years of age with ataxic gait and myoclonic jerks. The EEG shows a progressive slowing of background activity, bilateral diffuse and repetitive, pseudoperiodic, high amplitude slow waves, myoclonic jerks polygraphically documented. The CT-scan shows generalized cerebral atrophy, white matter hypodensity--principally in the frontal regions -, multiple nodular calcifications, also in the basal ganglia. Two years after the onset of neurological signs, the boy is completely bedridden, spastic, dement and blind; the myoclonic jerks persist. Finally the relationship is discussed with both the previously reported patients with the same affection, and with similar progressive encephalopathy in children suffering from A.I.D.S.

Biphasic (early and late) asthmatic responses to exercise in children with severe asthma, resident at high altitude

Twenty-three children with severe asthma who had been resident at high altitude for at least 3 months, considerably reduced their requirement for regular anti-asthma therapy. On a standard exercise challenge in low humidity, ten had no response, seven had isolated immediate bronchospasm and six had biphasic responses with immediate bronchospasm followed 4-10 h later by a late reaction sustained for at least 2 h. The existence of biphasic responses after exercise, similar to those observed after antigen challenge, supports the concept of mast cell involvement in exercise-induced asthma.

Prevalence of primary adult lactose malabsorption and awareness of milk intolerance in Italy

A total of 308 healthy Italian adults (192 females, 116 males; mean age 29.2 yr) were examined using a field version of the lactose tolerance test with breath hydrogen determination. Two geographical groups were formed according to the birth places of the probands' grandparents: 208 subjects from northern Italy (mainly from the regions of Piemonte, Lombardia, and Veneto) and 100 probands from Sicily. Lactose malabsorption was diagnosed in 106 subjects in group "north" (51%) and in 71 subjects in group "Sicily" (71%). Awareness of milk intolerance was more frequent in lactose malabsorbers. The incidence of diarrhea after the test dose of lactose was significantly higher in "aware" lactose malabsorbers, when compared with persons of the same group who had not experienced milk intolerance. The significant difference in lactose malabsorption frequency between northern Italy and Sicily is further evidence of a north-south gradient of lactase gene frequencies in Europe.

Desquamative interstitial pneumonia and antigen-antibody complexes in two infants with congenital rubella

Desquamative interstitial pneumonia was observed in two infants with the late-onset congenital rubella syndrome. In both infants this unusual lung disease was associated with circulating immunoglobulin M complexes and interstitial pulmonary deposits of IgM by immunofluorescence. Both infants had IgG deficiency. The first child recovered with a reduction in IgM complex levels and synthesis of rubella-specific IgG. The second infant died during the acute phase of his illness at which time there were high serum concentrations of IgM complexes and slightly increased levels of IgG complexes. Delayed maturation of the immune response in congenital rubella may predispose to persistent antigenemia and pulmonary deposition of rubella antigen-containing IgM complexes resulting in an acute form of interstitial pneumonia.

Chemotactic responses of various differentiational stages of neutrophils from human cord and adult blood

Chemotactic response and responsiveness, that is, the ability to respond to various concentrations of the chemoattractant zymosan-activated serum was measured for cord and adult blood neutrophils. Chemotactic response of neutrophils from adult blood was two to seven times greater than that of neutrophils from cord blood. In addition, neutrophils from cord blood showed poor response to concentrations of 25% chemoattractant or less, compared to those from adults, which responded to concentrations of 10%. Further, it was found that approximately 30% of neutrophils in cord blood were the band form compared to only 9% in adult. Based upon this, a simple method was devised to assay mean migrating distance of various differentiational stages of neutrophils incorporating both distance and magnitude of their responses. The results of these assays showed that all differentiational stages of cord blood neutrophils have a mean migrating distance less than those of adults. In addition, the band form from both cord and adult blood had a mean migrating distance less than the polymorphonuclear form. Adherence studies revealed that all differentiational stages of neutrophils adhered in a similar manner, and no difference was detected between cells from cord and adult blood. Assays to test the ability of cord blood to produce chemotactic activity when activated revealed 50% less activity than that obtained from adult serum which further decreased with dilution of attractant. These data suggest that both the cellular and humoral systems involved in chemotactic responses are less in cord blood compared to adult blood.

Unilateral cryptorchidism with compensatory hypertrophy of descended testicle in prepubertal boys

5 prepubertal boys with unilateral cryptorchidism and compensatory hypertrophy of the descended testicle, 22 prepubertal boys with unilateral cryptorchidism and without CTH, and 14 prepubertal normal boys were submitted to LH-RH and to HCG tests in order to study the hormonal behaviour in CTH phenomenon before puberty. High but normal peaks of plasma LH and FSH were observed after LH-RH in CTH boys who showed a significant increase of testosterone after HCG stimulation. On the contrary the LH response to LH-RH and the testosterone response to HCG of the boys with unilateral cryptorchidism and without CTH were, as expected, significantly lower than in the control ones.

[Coronary fistula in the right ventricle]

A case of fistula between the left coronary artery and the right ventricle in a girl aged 14 months is described. The description of the case deals with the semeiological classification of cardiocoronary fistulas, the means of investigation and differential diagnostics. The therapy is purely surgical and consists in isolation, ligature and dissection of the anomalous coronary.