Diagnosis of Paediatric Obstructive Sleep-Disordered Breathing beyond Polysomnography

Obstructive sleep-disordered breathing (SDB) has significant impacts on health, and therefore, a timely and accurate diagnosis is crucial for effective management and intervention. This narrative review provides an overview of the current approaches utilised in the diagnosis of SDB in children. Diagnostic methods for SDB in children involve a combination of clinical assessment, medical history evaluation, questionnaires, and objective measurements. Polysomnography (PSG) is the diagnostic gold standard. It records activity of brain and tibial and submental muscles, heart rhythm, eye movements, oximetry, oronasal airflow, abdominal and chest movements, body position. Despite its accuracy, it is a time-consuming and expensive tool. Respiratory polygraphy instead monitors cardiorespiratory function without simultaneously assessing sleep and wakefulness; it is more affordable than PSG, but few paediatric studies compare these techniques and there is optional recommendation in children. Nocturnal oximetry is a simple and accessible exam that has high predictive value only for children at high risk. The daytime nap PSG, despite the advantage of shorter duration and lower costs, is not accurate for predicting SDB. Few paediatric data support the use of home testing during sleep. Finally, laboratory biomarkers and radiological findings are potentially useful hallmarks of SDB, but further investigations are needed to standardise their use in clinical practice.

Chronic respiratory disorders due to aberrant innominate artery: a case series and critical review of the literature

BACKGROUND

Tracheal compression (TC) due to vascular anomalies is an uncommon, but potentially serious cause of chronic respiratory disease in childhood. Vascular slings are congenital malformations resulting from abnormal development of the great vessels; in this group of disorders the most prevalent entity is the aberrant innominate artery (AIA). Here we provide a report on diagnosis and treatment of AIA in nine children with unexplained chronic respiratory symptoms. We describe the cases, perform a literature review, and provide a discussion on the diagnostic workup and treatment that can help manage AIA.

METHODS

Clinical history, diagnostic procedures and treatment before and after the AIA diagnosis were retrospectively reviewed in nine children (5 boys and 4 girls), who were referred for recurrent-to-chronic respiratory manifestations over 10 years (2012-2022). We performed a comprehensive report on the ongoing clinical course and treatment as well as an electronic literature search on the topic.

RESULTS

Diagnoses at referral, before AIA was identified, were chronic dry barking cough associated with recurrent pneumonia (n = 8, 89%), lobar/segmental atelectasis (n = 3, 33%), atopic/non atopic asthma (n = 3, 33%); pneumomediastinum with subcutaneous emphysema complicated the clinical course in one case. When referred to our Unit, all patients had been previously treated with repeated antibiotic courses (n = 9, 100%), alone (n = 6, 67%) or combined with prolonged antiasthma medications (n = 3, 33%) and/or daily chest physiotherapy (n = 2, 22%), but reported only partial clinical benefit. Median ages at symptom onset and at AIA diagnosis were 1.5 [0.08-13] and 6 [4-14] years, respectively, with a relevant delay in the definitive diagnosis (4.5 years). Tracheal stenosis at computed tomography (CT) was ≥ 51% in 4/9 cases and ≤ 50% in the remaining 5 subjects. Airway endoscopy was performed in 4 cases with CT evidence of tracheal stenosis ≥ 51% and confirmed CT findings. In these 4 cases, the decision of surgery was made based on endoscopy and CT findings combined with persistence of clinical symptoms despite medical treatment. The remaining 5 children were managed conservatively.

CONCLUSIONS

TC caused by AIA may be responsible for unexplained chronic respiratory disease in childhood. Early diagnosis of AIA can decrease the use of expensive investigations or unsuccessful treatments, reduce disease morbidity, and accelerate the path toward a proper treatment.

Obstructive Sleep Apnoea in Children with Down Syndrome: A Multidisciplinary Approach

A comprehensive evaluation of obstructive sleep apnoea (OSA) may allow for the development of more efficient management of Down syndrome (DS). We aimed to evaluate the effect of a multidisciplinary approach to DS with OSA. A total of 48 DS children aged 4−12 years were prospectively investigated with nasal endoscopy, orthodontic examination, and overnight polygraphy (PG); the Italian Child Sleep Habits Questionnaire (CSHQ-IT) was filled out by the mothers. The total CSHQ-IT score was 63 (96% of children reporting sleep problems). The major ear, nose, and throat characteristics were enlarged palatine tonsils (62%), adenoid tonsils (85%), and chronic rhinosinusitis (85%). DS children showed orthognathic profile in 68% of cases, class I relationship in 63%, and cross-bite in 51%. PG revealed OSA in 67% of cases (37% mild, 63% moderate−severe). The oxygen desaturation index (ODI) was higher in the group with OSA (5.2) than with non-OSA (1.3; p < 0.001). The ODI was higher (p = 0.001) and SpO2 lower (p = 0.03) in children with moderate−severe OSA than with mild OSA. The apnoea−hypopnea index (AHI) and percentage time with SpO2 < 90% were higher in DS children with grade III than with grade I or II adenoids (5 vs. 1, p = 0.04, and 1.2 vs. 0.1, p = 0.01, respectively). No significant correlations were found between PG and the total CSHQ-IT score or orthodontic data. However, children showing associated cross-bite, grade III adenoids and size 3 or 4 palatine tonsils showed higher AHI and ODI than those without (p = 0.01 and p = 0.04, respectively). A coordinated multidisciplinary approach with overnight PG is a valuable tool when developing diagnostic protocols for OSA in DS.

Alert Germ Infections: Chest X-ray and CT Findings in Hospitalized Patients Affected by Multidrug-Resistant Acinetobacter baumannii Pneumonia

Acinetobacter baumannii (Ab) is an opportunistic Gram-negative pathogen intrinsically resistant to many antimicrobials. The aim of this retrospective study was to describe the imaging features on chest X-ray (CXR) and computed tomography (CT) scans in hospitalized patients with multidrug-resistant (MDR) Ab pneumonia. CXR and CT findings were graded on a three-point scale: 1 represents normal attenuation, 2 represents ground-glass attenuation, and 3 represents consolidation. For each lung zone, with a total of six lung zones in each patient, the extent of disease was graded using a five-point scale: 0, no involvement; 1, involving 25% of the zone; 2, 25−50%; 3, 50−75%; and 4, involving >75% of the zone. Points from all zones were added for a final total cumulative score ranging from 0 to 72. Among 94 patients who tested positive for MDR Ab and underwent CXR (males 52.9%, females 47.1%; mean age 64.2 years; range 1−90 years), 68 patients underwent both CXR and chest CT examinations. The percentage of patients with a positive CT score was significantly higher than that obtained on CXR (67.65% > 35.94%, p-value = 0.00258). CT score (21.88 ± 15.77) was significantly (p-value = 0.0014) higher than CXR score (15.06 ± 18.29). CXR and CT revealed prevalent bilateral abnormal findings mainly located in the inferior and middle zones of the lungs. They primarily consisted of peripheral ground-glass opacities and consolidations which predominated on CXR and CT, respectively.

Osteoarticular pain: therapeutic approach by paradigms

Osteoarticular pain is a common condition in the adult population. It is a nociceptive pain modulated by different factors, and it is one of the major symptoms that force patients to seek medical advice. Since osteoarticular pain has a complex pathophysiology and it is not a linear condition, we propose in this paper an original approach to osteoarticular pain by paradigms, where a paradigm refers to a framework of concepts, results, and procedures within which subsequent work is structured. The paradigm presented is a conceptual tool that could help clinicians to choose the correct therapy considering both pain characteristics and clinical features.

Linguistic adaptation and psychometric evaluation of Italian version of children's sleep habits questionnaire

Background

The Children’s Sleep Habits Questionnaire (CSHQ) is a parent-report questionnaire used to examine sleep behavior in children. Linguistic adaptation of CSHQ into several languages and/or psychometric analysis of reliability have been published.

Main text

Our aim was to translate the original 33-items CSHQ from English to Italian and to examine its reliability for use in 4–10 years-old children of Italy. After translation and back-translation procedure of the original CSHQ, the Italian CSHQ (CSHQ-IT) was administered to 69 mothers of healthy children. Reliability of CSHQ-IT was examined by the internal consistency of the scale (using the Cronbach’s alpha coefficient), and by the test-retest analysis obtained by asking mothers who had completed the CSHQ-IT at baseline to re-complete it after a two-week interval (measured with the Lin’s Concordance Correlation Coefficient, CCC). The CSHQ-IT showed adequate internal consistency (Cronbach’s alpha = 0.81 for the total scale). The total CSHQ-IT score showed a strong correlation in retests (CCC 0.87; 95% Confidence Interval, 0.80; 0.92).

Conclusion

CSHQ-IT is a valuable tool for evaluating sleep behavior in children 4–10 years-old in Italy. Future research should be implemented to provide definitive validity of CSHQ-IT in children with sleep-disordered breathing.

Coronavirus Disease 2019 in Children

Since its appearance in Wuhan in mid-December 2019, acute respiratory syndrome coronavirus 2 (SARS-CoV-2) related 19 coronavirus disease (COVID-19) has spread dramatically worldwide. It soon became apparent that the incidence of pediatric COVID-19 was much lower than the adult form. Morbidity in children is characterized by a variable clinical presentation and course. Symptoms are similar to those of other acute respiratory viral infections, the upper airways being more affected than the lower airways. Thus far, over 90% of children who tested positive for the virus presented mild or moderate symptoms and signs. Most children were asymptomatic, and only a few cases were severe, unlike in the adult population. Deaths have been rare and occurred mainly in children with underlying morbidity. Factors as reduced angiotensin-converting enzyme receptor expression, increased activation of the interferon-related innate immune response, and trained immunity have been implicated in the relative resistance to COVID-19 in children, however the underlying pathogenesis and mechanism of action remain to be established. While at the pandemic outbreak, mild respiratory manifestations were the most frequently described symptoms in children, subsequent reports suggested that the clinical course of COVID-19 is more complex than initially thought. Thanks to the experience acquired in adults, the diagnosis of pediatric SARS-CoV-2 infection has improved with time. Data on the treatment of children are sparse, however, several antiviral trials are ongoing. The purpose of this narrative review is to summarize current understanding of pediatric SARS-CoV-2 infection and provide more accurate information for healthcare workers and improve the care of patients.

Sufentanil Sublingual Tablet System: from rationale of use to clinical practice

The control of post-operative pain in Italy and other western countries is still suboptimal. In recent years, the Sufentanil Sublingual Tablet System (SSTS; Zalviso; AcelRx Pharmaceuticals, Redwood City, CA, USA), which is designed for patient-controlled analgesia (PCA), has entered clinical practice. SSTS enables patients to manage moderate-to-severe acute pain during the first 72 postoperative hours directly in the hospital setting. However, the role of SSTS within the current framework of options for the management of post-operative pain needs to be better established. This paper presents the position on the use of SSTS of a multidisciplinary group of Italian Experts and provides protocols for the use of this device.

P1814ATYPICAL FEATURES IN A TYPICAL DISEASE: ONE THOUSANDS FACES OF IGA NEPHROPATHY IN PAEDIATRIC PATIENTS

Background and Aims

Immunoglobulin A Nephropathy (IgAN) is the most common cause of idiopathic glomerulonephritis in paediatric patients.

The typical presentation is characterized by recurrent episodes of macroscopic haematuria or persistent microhaematuria with mild or overt proteinuria. Renal function is normally preserved, though a slow progression to chronic kidney disease (CKD) may occur.

However, in rare cases IgAN may assume atypical features, presenting with nephrotic syndrome (NS), acute kidney injury (AKI) or assuming the characteristic of a rapidly progressive glomerulonephritis, leading to significant difficulties in management and critical impact on prognosis.

Method

Of total 756 renal biopsies performed in our centre from 2000 till 2019, 174 (23%) diagnosis of IgA nephropathy were made: 123 (70,6%) of 174 with a milder histological stage (I or II according to Lee’s) and 51 (29,3%) with severe stages (III-IV).

Clinical onset of these 51 patients was mostly characterized by a nephritic syndrome with micro-macrohaematuria, though in 7 of them it assumed atypical features (table 1).

Results

Patients 1, 2, 3 and 4 showed a rapidly progressive IgAN with extensive crescentic lesions at histological evaluation.

In all of the four patients the onset of the disease was characterised by a compromised renal function, thought, according to the medical history, in patients 2 and 4 clinical signs of nephropathy had started some months before the first medical evaluation.

This detail, considering the poorer clinical outcome of patients 2 and 4 (table 1), strongly highlights the need of promptness in the treatment of these conditions.

Patient 1 achieved a complete remission after steroid pulse therapy (Pozzi scheme), while for patients 2,3,4 an additional immunosuppressive treatment was required.

The nephropathy of patient 5 was, instead, characterized by AKI with consistent macrohaematuria. Interestingly, the severity of the clinical presentation was not related to the glomerular lesion (the histology showed a minimal change disease), rather to the intra-tubular haemorrhage, causing an obstructive acute kidney injury. Patient 5 achieved a complete remission after steroid treatment.

The onset of IgAN in patients 6 and 7 was characterized by a nephrotic syndrome, which is a very uncommon feature (&lt;2% of all IgAN).

Patient 6, who showed a massive proteinuria (till 11 grams/24 hours) was promptly treated with steroid and tacrolimus, achieving a complete remission in 6 moths.

Patient 7, a sri-lankan girl, was diagnosed in 2008 in Sri-Lanka.

She underwent treatment with steroid and Mycophenolate and successively, for the persistence of proteinuria, with Cyclosporine A.

From 2014 she has been followed by our centre. Despite a second cycle with Cyclosporine she has shown a persistence of proteinuria and a slow progression to CKD.

Conclusion

This study highlights that a typical disease like IgAN may hide behind an atypical and severe presentation.

Moreover, the blackboard of the atypical forms is extremely heterogeneous, stretching from NS to crescentic and progressive diseases.

As a consequence, the treatment of these conditions is not codified and represents an important challenge for the clinician.

This calls for multicentric studies which could provide shared recommendation for the management of these atypical forms of IgAN.

P0165HYPERTENSION IN OVERWEIGHT AND OBESE CHILDREN: IMPACT ASSESMENT OF ABPM PARAMETERS

Background and Aims

We describe the relationship between overweight and obesity and Hypertension on ABPM.

Method

We conducted a cross-sectional study using a database of patients aged 6-16 years, who had undergone 24h ABPM from December 2002 through December 2016. ABPM were performed using the validated device Spacelab 90217. Were evaluated the 24h MAP, daytime MAP, nocturnal MAP, systolic and diastolic load, MAP Systolic and Diastolic. Subjects were grouped by BMI Z-score into overweight (&gt;1&lt;2), obese (BMI Z-score &gt;2&lt;3) and severe obese (BMI Z-score &gt;3). A total of 1016 patients were enrolled and recorded n.1210 ABPMs. Obese pts were 202 (19.8%); 126 M;76F;median age 10,2 y. Overweight childrens were 97 (11.9%);52 M;45F;median age 8,4y.

Results

Among overweight childrens (BMI Z-Score &gt;1&lt;2): 12 (12.3%) had hypertension, 22 (22.6%) pre-hypertension, 15 (15.4%) MH; non dipping pattern was recorded in 26 (52%). 48 were normotensive. Among obese childrens, 122 had hypertension (60.3%): 24 pts had Masked Hypertension (19.6%); 72 (59.0%) had severe ambulatory hypertension with BMI z-score &gt;3 (mean 3.8) ,and in this category all pts were both systolic and diastolic non dipping. 32 (64%) obese with BMI z-score &gt;2, &lt;3 were non-dipping. Diastolic load was significantly higher (p&gt;0,0001) in severe obese. 28 pts had ambulatory prehypertension (13.8%), 11 pts had White Coat Hypertension (4.9%).41 pts had normotension (20.2%).

Conclusion

The severity of ambulatory hypertension increased with increased BMI Z-score. The non-dipping status is associated, not only with higher BMI Z-score, but was present in overweight and obese with BMI z-score &gt;2&lt;3 also. ABPM is an effective tool that should become routine in all obese patient, but also in overweight childrens, which may lead to better treatments and prevention methods.

P1831ABPM DIFFERENCE BETWEEN OBESE AND NON OVERWEIGHT HYPERTENSIVE CHILDREN

Background and Aims

The goal of our study was to analyze the difference in ABPM pattern in overweight and non overweight hypertensive children

Method

The ABPM were performed using Spacelab 90207 and recorded over 24h.Readings were taken every 15 minutes while awake,and every 20 minutes while asleep. In both groups were evaluated the 24h MAP,daytime MAP,nocturnal MAP, systolic and diastolic load,mean 24h SBP and DBP.

A total of 108 pts were enrolled. Pts were divided in two groups.In the first group 54 pts non overweight with primary hypertension:33 male and 21 female with mean age of 10.4 y. In the second group the obese hypertensive children, with mean age of 10.5 y, were divided into two subgroups according to BMI Z-scores:subgroup 1 BMI Z-score &gt;2&lt;3 n 40 pts (17 f;21m); subgroup 2 BMI Z-score &gt;3 n (4f;10m).

Results

Systolic load was significantly higher in obese group (p 0,0409).In obese group n.12 were dipper (22,2%).Obese with BMI zscore &gt;3 was all non dipper (n14 ;100%). In the lean group n 26 was dipper (48.1%),and 28 (51.8%) non dipper. 24 h MAP, Systolic and Diastolic load were significantly higher (p 0,0001) in the obese with BMI z score &gt;3 compared to the lean group.

Conclusion

The statistically significant pathological pattern among obese is the increase inmean PAS and systolic load, as well as the absence of night dipping in severe obese. The increase in systolic load is already evident in obese mild.This gives a significant predictive value of cardiovascular damage to ABPM which increases with the severity of obesity worse.

Inhaled medications in cystic fibrosis beyond antibiotics

Structural lung disease begins very early in children with cystic fibrosis (CF), often in the first three months of life. Inhaled medications represent an attractive therapeutic approach in CF that are routinely used as early intervention strategies. Two aerosolized solutions, hypertonic saline and dornase alfa, have significant potential benefits by improving mucociliary clearance, with minimal associated side-effects. In particular, they favor rehydration of airway surface liquid and cleavage of extracellular DNA in the airways, respectively, consequently reducing rate of pulmonary disease exacerbations. Indirect anti-inflammatory effects have been documented for both drugs, addressing each of the three interrelated elements in the vicious cycle of lung disease in CF: airway obstruction, inflammation and infection. This short review aimed to summarize the main papers that support potential clinical impact of inhaled solutions on pulmonary disease in CF.

Recurrent Pneumonia in Children: A Reasoned Diagnostic Approach and a Single Centre Experience

Recurrent pneumonia (RP), i.e., at least two episodes of pneumonia in one year or three episodes ever with intercritical radiographic clearing of densities, occurs in 7.7%–9% of children with community-acquired pneumonia. In RP, the challenge is to discriminate between children with self-limiting or minor problems, that do not require a diagnostic work-up, and those with an underlying disease. The aim of the current review is to discuss a reasoned diagnostic approach to RP in childhood. Particular emphasis has been placed on which children should undergo a diagnostic work-up and which tests should be performed. A pediatric case series is also presented, in order to document a single centre experience of RP. A management algorithm for the approach to children with RP, based on the evidence from a literature review, is proposed. Like all algorithms, it is not meant to replace clinical judgment, but it should drive physicians to adopt a systematic approach to pediatric RP and provide a useful guide to the clinician.

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Direct comparison between cerebral oximetry by INVOS(TM) and EQUANOX(TM) during cardiac surgery: a pilot study

INTRODUCTION

Several near-infrared spectroscopy oximeters are commercially available for clinical use, with lack of standardization among them. Accordingly, cerebral oxygen saturation thresholds for hypoxia/ischemia identified in studies conducted with INVOS(TM) models do not necessarily apply to other devices. In this study, the measurements made with both INVOS(TM) and EQUANOX(TM) oximeters on the forehead of 10 patients during conventional cardiac surgery are directly compared, in order to evaluate the interchangeability of these two devices in clinical practice.

METHODS

Cerebral oxygen saturation measurements were collected from both INVOS(TM) 5100C and EQUANOX(TM) 7600 before anesthetic induction (baseline), two minutes after tracheal intubation, at cardiopulmonary bypass onset/offset, at aortic cross-clamping/unclamping, at the end of surgery and whenever at least one of the two devices measured a reduction in cerebral oxygen saturation equal to or greater than 20% of the baseline value. Bland-Altman analysis was used to compare the bias and limits of agreement between the two devices.

RESULTS

A total of 140 paired measurements were recorded. The mean bias between INVOS(TM) and EQUANOX(TM) was -5.1%, and limits of agreement were ±16.37%. Considering the values as percent of baseline, the mean bias was -1.43% and limits of agreement were ±16.47. A proportional bias was observed for both absolute values and changes from baseline.

CONCLUSIONS

INVOS(TM) and EQUANOX(TM) do not seem to be interchangeable in measuring both absolute values and dynamic changes of cerebral oxygen saturation during cardiac surgery. Large investigations, with appropriate design, are needed in order to identify any device-specific threshold.

The effect of aortic coarctation surgical repair on QTc and JTc dispersion in severe aortic coarctation newborns: a short-term follow-up study

Sudden death is a possible occurrence for newborns younger than 1 year with severe aortic coarctation (CoA) before surgical correction. In our previous study, we showed a significant increase of QTc-D and JTc-D in newborns with isolated severe aortic coarctation, electrocardiographic parameters that clinical and experimental studies have suggested could reflect the physiological variability of regional and ventricular repolarization and could provide a substrate for life-threatening ventricular arrhythmias. The aim of the current study was to evaluate the effect of surgical repair of CoA on QTc-d, JTc-d in severe aortic coarctation newborns with no associated congenital cardiac malformations. The study included 30 newborns (18M; 70+/-12 h old) affected by severe congenital aortic coarctation, without associated cardiac malformations. All newborns underwent to classic extended end-to-end repair. Echocardiographic and electrocardiographic measurements were performed in each patient 24 h before and 24 h after the interventional procedure and at the end of the follow-up period, 1 month after the surgical correction. All patients at baseline, 24 h and one month after CoA surgical repair did not significantly differ in terms of heart rate, weight, height, and echocardiographic parameters. There were no statistically significant differences in QTc-D (111.7+/-47.4 vs 111.9+/-63.8 ms vs 108.5+/-55.4 ms; P=0.4) and JTc-D (98.1+/-41.3 vs 111.4+/-47.5 vs 105.1+/-33.4 ms; P=0.3) before, 24 h and 1 month after CoA surgical correction. In conclusions, our study did not show a statistically significant decrease in QTc-D and JTc-D, suggesting the hypothesis that the acute left ventricular afterload reduction, related to successful CoA surgical correction, may not reduce the ventricular electrical instability in the short-term follow-up.

Fenoldopam to prevent renal replacement therapy after cardiac surgery. Design of the FENO-HSR study

INTRODUCTION

Acute kidney injury requiring renal replacement therapy is a serious complication following cardiac surgery associated with poor clinical outcomes. Until now no drug showed nephroprotective effects. Fenoldopam is a dopamine-1 receptor agonist which seems to be effective in improving postoperative renal function. The aim of this paper is to describe the design of the FENO-HSR study, planned to assess the effect of a continuous infusion of fenoldopam in reducing the need for renal replacement therapy in patients with acute kidney injury after cardiac surgery.

METHODS

We're performing a double blind, placebo-controlled multicentre randomized trial in over 20 Italian hospitals. Patients who develop acute renal failure defined as R of RIFLE score following cardiac surgery are randomized to receive a 96-hours continuous infusion of either fenoldopam (0.025-0.3 µg/kg/min) or placebo.

RESULTS

The primary endpoint will be the rate of renal replacement therapy. Secondary endpoints will be: mortality, time on mechanical ventilation, length of intensive care unit and hospital stay, peak serum creatinine and the rate of acute renal failure (following the RIFLE score).

CONCLUSIONS

This trial is planned to assess if fenoldopam could improve relevant outcomes in patients undergoing cardiac surgery who develop acute renal dysfunction. Results of this double-blind randomized trial could provide important insights to improve the management strategy of patients at high risk for postoperative acute kidney injury.

Total intravenous anesthesia/target-controlled infusion and auditory-evoked potentials in day surgery mammoplasty

Total intravenous anesthesia and the new parameter for administering the most recent drugs, target-controlled infusion, as well as the introduction of new short half-life molecules that do not accumulate have made anesthesia in day surgery safer. In this study, the use of auditory-evoked potentials monitoring made it possible to determine the target plasma concentration of propofol that induces a narcosis sufficiently deep and strictly necessary for effectiveness, thus minimizing the anesthesiologic risk linked to the use and the dosing of the drug, reducing the hospitalization time, and decreasing the side effects for patients undergoing day surgery mammoplasty.

Lymphoproliferative disorders and chemokines

Chemokines are low molecular weight cytokines specialized in leukocyte recruitment. Recent studies have shown that tumor cells of hematopoietic and non hematopoietic origin express different chemokine receptors that may be involved in neoplastic cell growth, metastasis and angiogenesis. Human lymphoproliferative disorders arise from the malignant transformation of normal lymphoid cells frozen at discrete maturational stages. Studies performed with acute or chronic lymphoproliferative disorders have shown that CXCR4, the unique receptor for CXCL12, is up-regulated in many B and T cells malignancies and may be involved in metastatic localization of the neoplastic elements. Additional chemokine receptors are expressed in the individual lymphoproliferative disorders, but some of these are often non functional. Here we shall review the state of the art on chemokine receptor expression and function in human lymphoproliferative disorders, stressing the potential value of chemokines receptors as novel therapeutic targets. In this respect, small antagonistic peptides are being produced by pharmaceutical companies and hold great promise for clinical application.

Blepharoplasty and otoplasty: comparative sedation with remifentanil,propofol, and midazolam

Three different methods of sedation or sedoanalgesia using remifentanil, Propofol, or midazolam to increase intra- and postoperative comfort and to reduce neuroendocrine stress in patients who had undergone typical ambulatory cosmetic surgery under local anesthesia were studied. A sample of 90 patients who underwent upper and lower eyelid blepharoplasty to correct baggy eyelids or otoplasty to correct protruding ears was selected according to standard criteria for the study. Remifentanil provided the best tolerability profile and the most effective perioperative pain control among the substances studied, demonstrating it to be a valid drug for modern sedoanalgesia aimed at increasing the well-being of patients undergoing ambulatory cosmetic surgery.

The use of recombinant human erythropoietin stimulating factor in plastic surgery

Erythropoietin is the most important factor in the regulation of erythropoiesis. This study aimed to evaluate the efficacy of rhuESF for patients undergoing plastic surgical procedures during which notable blood loss is expected (reduction mammoplasty in cases of macromastia and abdominoplasty obese patients) to improve the full blood count and reduce the need for transfusion. The levels of hemoglobin were significantly greater for patients pretreated with erythropoietin and iron than for the control group.

Interferon gamma and tumour necrosis factor alpha are overexpressed in bone marrow T lymphocytes from paediatric patients with aplastic anaemia

Twelve paediatric patients with aplastic anaemia and two groups of normal control subjects underwent flow cytometric analysis for intracytoplasmic expression of gamma interferon (gamma-IFN) and tumour necrosis factor alpha (TNF-alpha) in bone marrow and peripheral blood CD4+ and CD8+ cells. The same cytokines were tested, by immunoassay, in culture supernatants from unstimulated bone marrow mononuclear cells (MNCs). Marrow CD4+ and CD8+ cells expressing gamma-IFN and TNF-alpha were significantly increased in the patients in comparison with normal control subjects (P from < 0.05 to < 0.0001 in the different cellular subsets). Patients' marrow CD4+ and CD8+ cells containing gamma-IFN and TNF-alpha were significantly increased when compared with the same cell fractions from paired peripheral blood samples (P from < 0.05 to < 0.0001 in the various cellular subsets). In the supernatant of marrow MNCs, gamma-IFN and TNF-alpha were detected in four out of eight and five out of eight cases, respectively, whereas neither cytokine was traceable in the control subjects. Patients' peripheral blood CD4+ and CD8+ cells containing gamma-IFN and TNF-alpha were not significantly increased in comparison with those from normal control subjects. Whereas patients with favourable and unfavourable outcomes had no significantly different proportions of marrow gamma-IFN+/CD4+ and gamma-IFN+/CD8+ cells, the percentages of marrow CD4+ and CD8+ cells containing TNF-alpha were significantly lower in subjects with favourable than in those with unfavourable outcome. Overall, these findings show that, in aplastic patients, T cells overexpressing gamma-IFN and TNF-alpha concentrate in the bone marrow and that intracytoplasmic expression of TNF-alpha in marrow CD4+ and CD8+ cells is associated with an unfavourable clinical course.

Cytokine gene expression in neoplastic B cells from human mantle cell, follicular, and marginal zone lymphomas and in their postulated normal counterparts

Cytokines may promote tumor growth by paracrine and/or autocrine pathways. Little information is available because malignant cells differ from their normal counterparts for the cytokine repertoire they express. Here we have investigated by reverse transcription-PCR the expression of 22 cytokine genes in neoplastic B lymphocytes from six patients with mantle cell lymphoma, 10 with follicular lymphoma, and 5 with marginal zone lymphoma and in their normal counterparts, i.e., naive, germinal center, and memory B cells, purified from tonsils. The overall profiles of cytokine gene expression in neoplastic B cells and in the corresponding normal B-cell subsets were similar, but some "holes" in the repertoire of malignant versus normal B lymphocytes were detected. Different "hole" combinations were identified consistently in mantle cell lymphoma, follicular lymphoma, and marginal zone lymphoma, thus representing molecular fingerprints of each individual lymphoma entity.

Expression and function of IL-12 and IL-18 receptors on human tonsillar B cells

IL-12 activates murine and human B cells, but little information is available as to the expression and function of IL-12R on human B lymphocytes. Here we show that the latter cells, freshly isolated from human tonsils, expressed the transcripts of both beta1 and beta2 chains of IL-12R and that beta2 chain mRNA was selectively increased (4- to 5-fold) by incubation with Staphylococcus aureus Cowan I bacteria or IL-12. B cell stimulation with IL-12 induced de novo expression of the transcripts of the two chains of IL-18R, i.e., IL-1 receptor-related protein and accessory protein-like. Functional studies showed that both IL-12 and IL-18 signaled to B cells through the NF-kappaB pathway. In the case of IL-12, no involvement of STAT transcription factors, and in particular of STAT-4, was detected. c-rel and p50 were identified as the members of NF-kappaB family involved in IL-12-mediated signal transduction to B cells. IL-12 and IL-18 synergized in the induction of IFN-gamma production by tonsillar B cells, but not in the stimulation of B cell differentiation, although either cytokine promoted IgM secretion in culture supernatants. Finally, naive but not germinal center or memory, tonsillar B cells were identified as the exclusive IL-12 targets in terms of induction of NF-kappaB activation and of IFN-gamma production.

Stromal cell-derived factor-1 as a chemoattractant for follicular center lymphoma B cells

BACKGROUND

Follicular center lymphoma displays widespread lymph node involvement at diagnosis. The chemoattractants that control the locomotion of follicular center lymphoma B cells have not been established. Stromal cell-derived factor-1 (SDF-1) is a CXC-class chemokine that enhances the migration of normal human B cells and is expressed in peripheral lymphoid tissues. Here we have investigated 1) whether SDF-1 stimulates the in vitro locomotion of follicular center lymphoma B cells and of their presumed normal counterparts (i. e., germinal center B cells) and 2) whether the same cells express SDF-1 transcripts.

METHODS

B cells were purified by immunomagnetic bead manipulation. Messenger RNA was detected by reverse transcription-polymerase chain reaction. Migration was assessed by the filter and collagen invasion assays. All P values were two sided.

RESULTS

Follicular center lymphoma B lymphocytes showed a statistically significant migratory response to 300 ng/mL SDF-1, both in the filter and in the collagen assays (P =.002 for each). Such response was mediated by the SDF-1 receptor, CXCR4. CD40 monoclonal antibody (MAb) and tonsillar germinal center B cells treated with CD40 MAb and recombinant interleukin 4, but not freshly isolated, migrated statistically significantly faster in the presence than in the absence of SDF-1 (P =.002 in both filter and collagen assays). Freshly isolated follicular center lymphoma and germinal center B cells expressed SDF-1 transcripts.

CONCLUSIONS

This study shows that SDF-1 substantially enhances the migration of follicular center lymphoma B cells but not the migration of freshly purified germinal center B cells. This difference may be related to the extended survival of follicular center lymphoma versus germinal center B cells. SDF-1 produced in follicular center lymphoma lymph nodes may play a role in the local dissemination of tumor cells.

Flow cytometric and functional characterization of AC133+ cells from human umbilical cord blood

AC133+ cells may represent an alternative source of transplantable haemopoietic progenitor cells to CD34+ cells. Here, we have addressed the characterization of umbilical cord blood (UCB) AC133+ cells and compared their immunophenotypic and functional features with those of UCB CD34+ cells. UCB AC133+ and CD34+ cell fractions were purified by magnetic cell sorting, analysed by flow cytometry, tested for their content in blast cell colony-forming units (CFU-Bl), erythroid and granulocyte-macrophage colony-forming units before and after expansion in the presence of various haemopoietic growth factor combinations. Median AC133+ cell yield was 62.3%, and median AC133+ population purity was 97.9%. AC133+ cells were found to contain significantly more CFU-Bl than CD34+ cells; furthermore, the replating efficiency, i.e. the number of CFU-Bl capable of generating secondary colonies, was higher in the former than in the latter cells. Both AC133+ and CD34+ cells displayed an increased ability to give rise to committed progenitors after 7-day expansion in liquid cultures. These data suggest that the AC133+ cell subset is a heterogeneous pool of immature and more differentiated cells that can be maintained and expanded in well-defined culture conditions. In comparison with CD34+ cells, UCB AC133+ cells appear to contain a higher number of early haemopoietic progenitors.

rC5a directs the in vitro migration of human memory and naive tonsillar B lymphocytes: implications for B cell trafficking in secondary lymphoid tissues

Human C5a is a potent chemoattractant for granulocytes, monocytes, and dendritic cells. In mice C5a has been shown to be chemotactic for germinal center (GC) B cells. To date, no information is available on the effects of C5a on human B cell locomotion. Here we demonstrate that rC5a increases polarization and migration of human tonsillar B cells. The locomotory response was due to both chemokinetic and chemotactic activities of rC5a. Moreover, memory and, at a lesser extent, naive B cell fractions from purified tonsillar populations displayed rC5a-enhanced migratory properties, whereas GC cells did not. Flow cytometry revealed C5aR (CD88) on approximately 40% memory and 10% naive cells, respectively, whereas GC cells were negative. Immunohistochemistry showed that a few CD88+ cells were of the B cell lineage and localized in tonsillar subepithelial areas, where the majority of memory B cells settle. Pretreatment of memory B cells with the CD88 mAb abolished their migratory responsiveness to rC5a. Finally, the C5 gene was found to be expressed in naive, GC, and memory B lymphocytes at both the mRNA and the protein level. This study delineates a novel role for C5a as a regulator of the trafficking of human memory and naive B lymphocytes and supports the hypothesis that the B cells themselves may serve as source of C5 in secondary lymphoid tissues.

Late graft failure 8 years after first bone marrow transplantation for severe acquired aplastic anemia

A 14-year-old patient with acquired very severe aplastic anemia (VSAA) underwent bone marrow transplantation (BMT) from his HLA-identical brother. Preparative therapy was cyclophosphamide (CY) 200 mg/kg over 4 days. GVHD prophylaxis was with cyclosporin A (CsA) for a year. After an 8 year follow-up during which the patient was well with normal blood counts, graft failure occurred. At this time marrow chimerism studies demonstrated that 85% of hemopoiesis was of recipient origin. The patient was re-engrafted from the same donor after conditioning with CY 200 mg/kg over 4 days plus rabbit antithymocyte globulin (ATG) 3.5 mg/kg/day for 3 days. After 140 days follow-up he has a normal blood count. The possible causes of the graft failure are discussed. This case demonstrates that, although rarely, very late graft failure may occur after BMT for AA and highlights the need for long-term monitoring even in apparently successfully transplanted patients.

Recombinant tumor necrosis factor enhances the locomotion of memory and naive B lymphocytes from human tonsils through the selective engagement of the type II receptor

Recent studies performed in mice knocked out for the tumor necrosis factor (TNF ), the lymphotoxin-alpha, or the type I TNF receptor (R), genes have shown that these animals display gross defects in germinal center (GC) formation, suggesting that members of the TNF and TNFR superfamilies are involved in the control of B-cell migration. Based on these premises, we have here investigated the effects of human recombinant (r) TNF on the polarization and locomotion of tonsillar B cells. rTNF increased the spontaneous polarization and locomotion of unfractionated tonsillar B lymphocytes in a dose-dependent manner by inducing a true chemotactic response. Memory (IgD-, CD38(-)) and naive (IgD+, CD38(-)), but not GC (IgD-, CD38(+)) B cells purified from total tonsillar B lymphocytes, showed a significantly higher locomotion in the presence than in the absence of rTNF. Accordingly, type I and II TNF receptors (TNFRs) were detected by flow cytometry on the surface of memory and naive, but not GC, B lymphocytes. Blocking experiments with monoclonal antibodies to type I or II TNFR showed that rTNF enhanced the spontaneous chemotaxis of memory and naive B cells through the selective engagement of type II TNFR. Finally, the TNF gene was found to be expressed in memory, naive and GC B lymphocytes; the cytokine was released in culture supernatants from the three B-cell subsets after stimulation. These data may support the hypothesis that human TNF is involved in the paracrine and perhaps autocrine control of B-cell migration in secondary lymphoid tissues.

B-cell-derived granulocyte-colony stimulating factor (G-CSF)

Biologically active granulocyte-colony stimulating factor (G-CSF) was released spontaneously in culture by in vivo activated tonsillar B lymphocytes and, in particular, by the germinal center (GC) B-cell subset. In contrast, mantle zone B cells failed to produce the cytokine under any of the culture conditions tested. A CD40 monoclonal antibody (mAb), recombinant (r) IL4, and the combination of the CD40 mAb and rIL4 all increased G-CSF production by GC B cells. The augmentation of G-CSF release correlated with the increased survival of GC B cells. rG-CSF rescued GC B cells from apoptosis, suggesting that the cytokine may be utilized in autocrine and/or paracrine ways. Neoplastic B cells from follicular center cell lymphoma patients, which are the counterparts of normal GC B lymphocytes, also released G-CSF spontaneously in culture. In contrast, malignant B cells from a subset of chronic lymphocytic leukemia (CLL) patients had to be stimulated with Staphylococcus aureus Cowan I or CD40 mAb in combination with rIL4 or rIL2 to produce G-CSF in vitro. Some B-CLL cell suspensions were rescued from spontaneous apoptosis following culture in the presence of rG-CSF. Taken together, these studies provide the first demonstration that G-CSF (i) is produced by either normal or neoplastic human B lymphocytes and (ii) participates in the modulation of apoptosis of the same cells.

Expression of granulocyte colony-stimulating factor and granulocyte colony-stimulating factor receptor genes in partially overlapping monoclonal B-cell populations from chronic lymphocytic leukemia patients

B lymphocytes were purified from the peripheral blood of 30 B-cell chronic lymphocytic leukemia (B-CLL) patients and tested for the ability to produce granulocyte colony-stimulating factor (G-CSF) in vitro. Fifteen Staphylococcus aureus Cowan I (SAC)-stimulated, but not unstimulated, B-cell suspensions produced G-CSF in short-term cultures. Accordingly, G-CSF mRNA was detected only in SAC-stimulated B cells. Five CLL B-cell fractions that released G-CSF following exposure to SAC were also incubated with CD40 or anti-mu antibodies in the presence or absence of recombinant (r) interleukin-2 (IL-2) or IL-4. The 5 cell suspensions produced G-CSF only on culture with CD40 monoclonal antibody in combination with rIL-2 or rIL-4. CD5+ B lymphocytes, which represent the normal counterparts of most B-CLL proliferations, did not produce G-CSF under any of the above culture conditions. G-CSF produced by leukemic B lymphocytes was biologically active, because conditioned media of SAC-stimulated cells supported the in vitro growth of myeloid colonies from normal bone marrow progenitors. The colony stimulating activity of CLL B-cell supernatants was ascribed to both G-CSF and granulocyte-macrophage colony stimulating factor. G-CSF receptors (G-CSFRs) were detected on freshly isolated B lymphocytes from 7 of 11 B-CLL patients; 5 of these cell suspensions produced G-CSF in culture, whereas 2 did not. rG-CSF rescued 3 of the 7 G-CSFR+ cell fractions from spontaneous apoptosis but had no effect on their in vitro proliferation.

Relationships between B cell cytokine production in secondary lymphoid follicles and apoptosis of germinal center B lymphocytes

In vivo or in vitro activated human B lymphocytes can produce a wide spectrum of cytokines which are involved in the regulation of hematopoiesis and of the inflammatory and immune responses. Three major B cell subsets have been identified in peripheral lymphoid organs: the germinal center (GC), the mantle zone (MZ) and the marginal zone B lymphocytes. GC and MZ B cells can be isolated as CD39- surface (s)IgD- or CD39+ sIgD+ cells, respectively. Therefore, it is now possible to investigate the cytokine producing potential of purified GC and MZ B lymphocytes. In this article, the optimal conditions for the assessment of cytokine production by human B cells are first discussed; thereafter, the spectrum of B lymphocyte-derived cytokines is described together with their possible physiological meaning. Next, data concerning the cytokines released in vitro by either GC or MZ B cells are presented. Some cytokines, such as granulocyte colony stimulating factor (G-CSF) or granulocyte-macrophage CSF (GM-CSF), are produced only by GC or MZ B lymphocytes, respectively, whereas other cytokines, such as tumor necrosis factor-alpha (TNF-alpha), interleukin 6 (IL-6) or IL-10 are synthesized by both B cell subsets. Finally, the relationships between B cell-derived cytokines and apoptosis of GC B lymphocytes are discussed, and a hypothetical model of the cytokine networks in secondary lymphoid follicles is presented. It is expected that these notions will help to clarify the pathophysiology of lymphoproliferative and autoimmune diseases.

Spontaneous production of granulocyte colony-stimulating factor in vitro by human B-lineage lymphocytes is a distinctive marker of germinal center cells

The ability of human B lymphocytes to produce granulocyte (G)-CSF in vitro was investigated. Highly purified tonsillar B cells were fractionated into large and small cells by a Percoll density gradient, cultured, and tested for G-CSF gene expression. Large B cells spontaneous produced G-CSF mRNA and protein, whereas small B cells did not, even after incubation with various stimuli. Immunophenotypic analyses showed that large B lymphocytes contained approximately 60 to 70% of cells with the characteristic surface markers of germinal center (GC) B cells (CD38+, CD10+, and surface IgG+). The remaining cells expressed CD39, CD23, and surface IgD and were presumably in vivo-activated follicular mantle zone B cells. Fractionation of the large B lymphocytes into CD39+, surface IgD+, and CD39-, surface IgD- cells showed that the latter, but not the former, cell type produced G-CSF spontaneously in culture. Stimulation of purified (CD39-, surface IgD-) GC B cells with a CD40 mAb alone or in combination with IL-4 increased G-CSF production. Because these stimuli rescued a large fraction of GC cells (up to 50%) from spontaneous apoptosis in vitro, the finding may suggest that prevention of apoptotic death resulted in an increased G-CSF production or that CD40 mab and/or IL-4 increased G-CSF gene expression in G-CSF-producing GC B cells. Malignant B cells purified from the invaded lymph nodes of three patients with follicular center cell lymphoma and three Burkitt lymphoma cell lines, which had an immunophenotype identical with that of normal GC B cells, spontaneously produced G-CSF in vitro, thus confirming the GC origin of the cytokine. Incubation of normal purified GC B cells with rG-CSF resulted in the rescue of GC B cells from apoptosis, suggesting that G-CSF may be used by GC B cells in an autocrine manner. This autocrine loop of production and response to G-CSF by GC B cells may be activated by stimuli such as those delivered via the surface CD40 molecule, that participate in the rescue of GC B cells from apoptosis.

Spontaneous production of granulocyte colony-stimulating factor in vitro by human B-lineage lymphocytes is a distinctive marker of germinal center cells

The ability of human B lymphocytes to produce granulocyte (G)-CSF in vitro was investigated. Highly purified tonsillar B cells were fractionated into large and small cells by a Percoll density gradient, cultured, and tested for G-CSF gene expression. Large B cells spontaneous produced G-CSF mRNA and protein, whereas small B cells did not, even after incubation with various stimuli. Immunophenotypic analyses showed that large B lymphocytes contained approximately 60 to 70% of cells with the characteristic surface markers of germinal center (GC) B cells (CD38+, CD10+, and surface IgG+). The remaining cells expressed CD39, CD23, and surface IgD and were presumably in vivo-activated follicular mantle zone B cells. Fractionation of the large B lymphocytes into CD39+, surface IgD+, and CD39-, surface IgD- cells showed that the latter, but not the former, cell type produced G-CSF spontaneously in culture. Stimulation of purified (CD39-, surface IgD-) GC B cells with a CD40 mAb alone or in combination with IL-4 increased G-CSF production. Because these stimuli rescued a large fraction of GC cells (up to 50%) from spontaneous apoptosis in vitro, the finding may suggest that prevention of apoptotic death resulted in an increased G-CSF production or that CD40 mab and/or IL-4 increased G-CSF gene expression in G-CSF-producing GC B cells. Malignant B cells purified from the invaded lymph nodes of three patients with follicular center cell lymphoma and three Burkitt lymphoma cell lines, which had an immunophenotype identical with that of normal GC B cells, spontaneously produced G-CSF in vitro, thus confirming the GC origin of the cytokine. Incubation of normal purified GC B cells with rG-CSF resulted in the rescue of GC B cells from apoptosis, suggesting that G-CSF may be used by GC B cells in an autocrine manner. This autocrine loop of production and response to G-CSF by GC B cells may be activated by stimuli such as those delivered via the surface CD40 molecule, that participate in the rescue of GC B cells from apoptosis.

Heterogeneity of the erythropoietic defect in two cases of Aase-Smith syndrome

Here we report two children with Aase-Smith syndrome (triphalangeal thumbs and congenital red cell plasia). In vitro growth of erythroid colonies was normal in the first patient and totally absent in the other. In both patients, treatment with glucocorticoids induced remission of anemia. Our results suggest that the different growth patterns of erythroid colonies observed in the two patients could reflect the defect of erythroid differentiation occurring at discrete maturational levels.

Transforming growth factor beta-1 (TGF-beta 1) released by an Epstein-Barr virus (EBV) positive spontaneous lymphoblastoid cell line from a patient with Kostmann's congenital neutropenia inhibits the growth of normal committed haemopoietic progenitors in vitro

This study reports the characterization of a spontaneous lymphoblastoid cell line (LCL) raised from the peripheral blood of a patient with Kostmann's congenital neutropenia. The LCL was composed of EBV-infected polyclonal B cells and displayed surface markers and pattern of growth in vitro typical of normal LCLs. The supernatant of the LCL contained a colony inhibiting activity (CIA) that decreased the cloning efficiency of normal committed haemopoietic progenitors and was identified as immunoreactive transforming growth factor beta 1 (TGF-beta 1) by neutralization experiments with a specific antiserum. Control studies with a panel of LCLs spontaneously derived from the peripheral blood of patients seropositive for Epstein-Barr virus (EBV) infections showed that 5/30 LCLs produced a CIA. This CIA was not identifiable as TGF-beta 1 but rather was due to the combined effects of tumour necrosis factor alpha (TNF alpha), tumour necrosis factor beta (TNF beta) and interferon alpha (IFN alpha), that were present in the LCL supernatants. The hypothesis that the B cells latently infected by EBV in vivo and possibly expanded as a consequence of the infection may have contributed to the inhibition of the patient granulopoiesis by releasing TGF-beta 1 will be discussed.