IgE to cyclophilins in pollen-allergic children: Epidemiologic, clinical, and diagnostic relevance of a neglected panallergen

BACKGROUND

Cyclophilins are ubiquitous panallergens whose epidemiologic, diagnostic, and clinical relevance is largely unknown and whose sensitization is rarely examined in routine allergy practice.

OBJECTIVE

We investigated the epidemiologic, diagnostic, and clinical relevance of cyclophilins in seasonal allergic rhinitis and its comorbidities.

METHODS

We examined a random sample of 253 (25%) of 1263 Italian children with seasonal allergic rhinitis from the Panallergens in Pediatrics (PAN-PED) cohort with characterized disease phenotypes. Nested studies of sensitization prevalence, correlation, and allergen extract inhibition were performed in patients sensitized to birch pollen extract but lacking IgE to Bet v 1/2/4 (74/1263) or with highest serum level of IgE to Bet v 1 (26/1263); and in patients with sensitization to various extracts (ragweed, mugwort, pellitory, Plantago, and plane tree), but not to their respective major allergenic molecule, profilins, and polcalcins. IgE to cyclophilin was detected with recombinant Bet v 7, and extract inhibition tests were performed with the same rBet v 7.

RESULTS

IgE to rBet v 7 was detected in 43 (17%) of 253 patients. It was associated with asthma (P < .028) and oral allergy syndrome (P < .017) in univariate but not multivariate analysis adjusted for IgE to profilins (Phl p 12), PR-10s (Bet v 1), and lipid transfer proteins (Pru p 3). IgE to rBet v 7 was also highly prevalent (47/74, 63%) among patients with unexplained sensitization to birch pollen extract. In patients with unexplained sensitization to ragweed, mugwort, pellitory, Plantago and plane tree pollen, the levels of IgE to those extracts correlated with the levels of IgE to rBet v 7, and they were also significantly inhibited by rBet v 7 (inhibition range 45%-74%).

CONCLUSIONS

IgE sensitization to cyclophilin is frequent in pollen-allergic patients living in temperate areas and can produce "false" positive outcomes in skin prick and IgE tests to pollen extracts. Molecular diagnostic guidelines should include this panallergen family.

IgE to cross-reactive carbohydrate determinants (CCD) in childhood: Prevalence, risk factors, putative origins

BACKGROUND

IgE antibodies to cross-reactive carbohydrate determinants (CCD) are usually clinically irrelevant but they can be a cause of false positive outcomes of allergen-specific IgE tests in vitro. Their prevalence and levels have been so far cross-sectionally examined among adult allergic patients and much less is known about their origins and relevance in childhood.

METHODS

We examined CCD with a cross-sectional approach in 1263 Italian pollen allergic children (Panallergen in Paediatrics, PAN-PED), as well as with a longitudinal approach in 612 German children (Multicenter Allergy Study, MAS), whose cutaneous and IgE sensitization profile to a broad panel of allergen extracts and molecules was already known. The presence and levels of IgE to CCD were examined in the sera of both cohorts using bromelain (MUXF3) as reagent and a novel chemiluminescence detection system, operating in a solid phase of fluorescently labelled and streptavidin-coated paramagnetic microparticles (NOVEOS, HYCOR, USA).

RESULTS

IgE to CCD was found in 22% of the Italian pollen allergic children, mainly in association with an IgE response to grass pollen. Children with IgE to CCD had higher total IgE levels and were sensitized to more allergenic molecules of Phleum pratense than those with no IgE to CCD. Among participants of the German MAS birth cohort study, IgE to CCD emerged early in life (even at pre-school age), with IgE sensitization to group 1 and 4 allergen molecules of grasses, and almost invariably persisted over the full observation period.

CONCLUSIONS

Our results contribute to dissect the immunological origins, onset, evolution and risk factors of CCD-sIgE response in childhood, and raise the hypothesis that group 1 and/or 4 allergen molecules of grass pollen are major inducers of these antibodies through an antigen-specific, T-B cell cognate interaction.

The impact of neonatologist performed echocardiography in an Italian neonatal unit

BACKGROUND

The main goal of neonatologist performed echocardiography is to timely assess hemodynamic changes in order to properly manage unsteady neonates. Detailed structural heart assessment remains the domain of pediatric cardiologists. Nonetheless, many neonatologists take on an additional role in diagnosis of congenital heart defects, mostly compelled by the lack of in-house pediatric cardiology services. The experience of neonatologist performed echocardiography in an Italian neonatal unit was reported and the risk benefit profile of this practice was discussed.

MATERIAL AND METHODS

We retrospectively reviewed the echocardiograms undertaken by the neonatologist on infants admitted to the neonatal unit and postnatal ward of the Hospital San Pio in Benevento, over a 2-year period. Details of scans and concordance between neonatologist and cardiologist were analyzed.

RESULTS

A total of 160 echocardiographic studies were done by the neonatologist on 136 infants. The ECG was requested in a minority of infants. The most common reason for performing the echocardiogram was admission to the neonatal care unit. Around half of the echocardiograms were normal. The remaining scans resulted in functional and structural abnormalities, transitional changes, and doubtful findings. Cardiac anomalies were significantly more likely found in cases of echocardiograms performed for fetal indications. Only 28 patients were eventually referred to the cardiology services. The inter-rater agreement was satisfactory.

CONCLUSIONS

The hemodynamic assessment of sick infants, as well as triaging and referral of neonates with structural heart diseases are valuable advantages of the echocardiography run by neonatologists.Collaboration with pediatric cardiologists and robust training and accreditation programs are essential to ensure safety and quality service.

Oxidative Stress in Cerebral Small Vessel Disease Dizziness Patients, Basally and After Polyphenol Compound Supplementation

Background:

Leukoaraiosis (LA) is a common radiological finding in elderly, frequently associated with several clinical disorders, including unexplained dizziness. The pathogenesis of LA is multifactorial, with a dysfunction of cerebral microcirculation resulting in chronic hypoperfusion and tissue loss, with oxidative stress involved in this cascade.

Objective:

The aim of this study was to analyse some oxidative stress biomarkers in a cohort of LA patients.

Method:

Fifty-five consecutive patients (33 males, median age 75 years) with LA were recruited. In a subgroup of 33 patients with LA and unexplained dizziness, we have then performed an open study to evaluate if 60-day supplementation with a polyphenol compound may modify these biomarkers and influence quality of life, analysed with the Dizziness Handicap Inventory (DHI) scale.

Results:

At baseline, blood oxidative stress parameters values were outside normal ranges and compared to matched healthy controls. After the two months supplementation, we observed a significant decrement of advanced oxidation protein products values and a significant improvement of DHI.

Conclusion:

Oxidative stress biomarkers may be useful to detect redox imbalance in LA and to provide non-invasive tools to monitor disease status and response to therapy.

Prevalence, molecular characterization, and clinical relevance of sensitization to Anisakis simplex in children with sensitization and/or allergy to Dermatophagoides pteronyssinus

Summary

Prevalence of the Anisakis Simplex's (AS) sensitization in children sensitized to Dermatophagoides pteronissynus (DP) is not known, neither it is to which percentage it might be due to cross-reactivity. The primary objective of the present retrospective cross-sectional study is to evaluate the prevalence of sensitization to AS in children sensitized or allergic to DP. Secondary outcomes were the prevalence of cross-reactivity and clinical relevance of the condition. The prevalence of sensitization to AS differs significantly among patients sensitized and not to DP (13.43% vs. 3.80%; p=0.019). The higher prevalence is mainly due to cross-reactivity with Der p10 (OR=8.86; 95% CI=4.33-40.74; p=0.0001). Currently, the sensitization to AS seems to have no clinical relevance in the pediatric population.

Early molecular biomarkers predicting the evolution of allergic rhinitis and its comorbidities: A longitudinal multicenter study of a patient cohort

BACKGROUND

Pollen-related seasonal allergic rhinoconjunctivitis (SAR) is a very frequent pediatric disease in Westernized countries. Risk factors and disease phenotypes have been thoroughly examined in several cross-sectional studies. By contrast, only a few studies have examined disease evolution in patient cohorts. We investigated predictive biomarkers of disease evolution in a large cohort of children with SAR.

METHODS

During 2015-2017 (follow-up), we re-examined 401 patients from those enrolled in 2009-2011 (baseline) by the "Panallergens in Pediatrics" study, a large multicenter survey of Italian children with SAR. Information on clinical history (standard questionnaire, AllergyCARD®; TPS, Italy) and skin prick tests for inhalant and foods extracts (ALK-Abelló, Hørsholm, Denmark) was acquired as at baseline visit. Evolution in clinical and sensitization data of patients was analyzed over time, as well as their association with the main baseline characteristics and atopy risk factors.

RESULTS

The average age of participants was 10.4 ± 3.4 years at baseline and 16.2 ± 3.6 years at follow-up. SAR persisted in 93.3% of patients at follow-up and became more frequently associated with asthma (from 36.7% at baseline to 48.6% at follow-up) and oral allergy syndrome (OAS, from 23.4% to 37.7%). Compared to baseline, the prevalence of skin sensitization to some pollens (Phleum pratense, Corylus avellana, Platanus acerifolia, Artemisia vulgaris) and vegetables (hazelnut, wheat, and apple) significantly decreased at follow-up. Earlier onset of SAR and polysensitization at baseline were associated with incident asthma at follow-up. The presence at baseline of serum IgE to the following allergen molecules was identified as biomarkers of clinical evolution: (a) Phl p 1, for persistence of SAR; (b) Phl p 5, for persistence of both rhinitis and asthma; (c) Pru p 3, for new onset of asthma; (d) Bet v 1, for persistence of OAS.

CONCLUSIONS

Seasonal allergic rhinoconjunctivitis is clinically heterogeneous in its evolution from childhood to adolescence. The detection of serum IgE to specific molecules (Phl p 1, Phl p 5, Bet v 1, Pru p 3) may be useful as biomarkers to predict SAR persistence and future onset of comorbidities, such as asthma and/or OAS.

aEEG in preterm infants

Over the last decade, the survival of premature babies has improved dramatically. Such infants, especially those with extremely low birth weight, are still affected by dangerous complications occurring during the neonatal period that often cause brain damage. Intraventricular-intraparenchymal haemorrhage (IVH-IPH), periventricular leukomalacia (PVL), seizures, meningitis and hypoxic-ischaemic encephalopathy are the most common complications. Such problems require more specialized monitoring of brain function during this critical period. In recent years, many studies on very premature infants have shown that aEEG has a high predictive value for both short-term and long-term outcome. In fact, it has been proven that some types of background activity patterns, the absence of a sleep-wake cycle, and seizure activity are related to the onset of early complications such as IVH-IPH and PVL. Most recent studies have shown that an aEEG performed in the early hours or during the first days of life can predict the neurobehavioural development of preterm infants at 2 years and 3 years (Bayley Scale). In particular our study demonstrates that loss of sleep-wake cycling, shown by aEEG, has a high positive predictive value for the development of posthaemorrhagic hydrocephalus (PPH) in preterm infants with IVH; therefore, the study of cerebral background activity and in particular of sleep-wake cycling can be used as an early prognostic tool in patients at risk of PPH.

Neonatal thrombosis

Thrombosis is a special problem of the neonatal period, particularly in premature sick neonate, where it occurs with greater frequency than at other times of childhood. The aim of this article is to review the recommendations for the diagnosis and treatment of neonatal thrombosIs.

Nicergoline in the treatment of dizziness in elderly patients. A review

In elderly patients, dizziness occurs very frequently with significant effects on the patient's life. Its frequency increases with age, and may arise from a variety of causes. Chronic dysequilibrium in elderly patients is most probably related to disturbances within the central nervous system, due either to altered neuronal functions or to an underlying vascular disease. Nicergoline, a drug used in the treatment of cognitive disturbances in geriatric patients, improves dizziness in elderly demented and non-demented patients. In a double blind,placebo controlled trial the drug improved (i) the severity of symptoms, measured by the dizziness assessment rating scale (DARS), (ii) the overall clinical conditions revealed by global impression scale, and (iii) the perceived quality of life estimated by the dizziness handicap inventory (DHI). These results indicate a possible positive effect also on posturographic measures. Moreover, the improvement occurred at no expense of the established strategy of postural control suggesting that the effect is mediated by a substitute compensatory mechanism allowing the patient to preserve consolidated postural strategies. The results of previous open clinical studies in about 3000 patients are in agreement with those findings. Overall, severity of symptoms decreased by 68 % (57 % in the control study). Globally, the results indicate a beneficial effect of nicergoline on symptoms related to balance disorders of central origin. Animal studies show that the drug displays a broad spectrum of actions on cellular and molecular mechanisms. Moreover, animal research specifically aimed at vestibular pathophysiology has revealed that nicergoline improves vestibular compensation in models of vestibular lesion. Chronic treatment with nicergoline improved the time-course of behavioral recovery in old rats after hemi-labyrinthectomy and counteracted the regulation of cholinergic receptors observed after lesion in old rats. Nicergoline interacts at several levels by various mechanisms, from the molecular level to cognitive function, probably enhancing spontaneous plasticity phenomena underlying the central vestibular compensation. This effect is not dependent from the interaction with a single-transmitter-identified neural pathway, but from anatomical, functional and neurochemical synergistic adjustments in several brain areas.

[Diagnostic evaluation of "acute" vertigo]

Numerous studies of outpatients have been effected with the object of evaluating the role of the different causes of vertigo, and these have clearly evidenced the importance of the individual disciplinary sectors and, consequently, of the clinicoinstrumental exams necessary in order to reach the correct etiopathogenetic interpretation of the dizzy syndrome. We report the experience of a retrospective study carried out in 310 patients suffering from dizziness who were sent to us from the Emergency Room with a generic diagnosis of "acute vertigo". A detailed medical history was taken in every case, after which the patients underwent a series of otoneurological examinations which enabled us to situate each in the ambit of a vestibular pathology (central and/or peripheral) or to schedule him for a series of specialized exams, the indication of which was drawn directly from the characteristics of the clinical examination and medical history associated with the vertigo symptomatology. Of the 157 cases (50.6%) with otoneurological signs compatible with a vestibular involvement, 77 presented positional paroxysmal vertigo, 34 had an acute peripheral vestibulopathy, and 32 manifested sufferance of the central vestibular structures. In 137 patients, the otoneurological exam was negative and further investigations led to the identification of a psychogenic form in 54 cases, a cardiovascular disease in 31 cases, and a neurological disorder in 24 cases. Our data highlights the fundamental role of the anamnestic approach and the objective examination with particular reference to the search for nystagmic evidence that enabled us to make a definitive diagnosis in an elevated number of cases. In the remainder, we proceeded to perform various instrumental examinations, at times upon the request of the other specialists involved in the management of the vertigo patient. By means of a structured and detailed medical interview, it was possible to obtain useful information that directed our investigation towards a clear distinction between extravestibular and vestibular forms. In this way, furthermore, the same information was able to supply a whole series of clinical indicators of fundamental importance in identifying the most suitable specialist for the clinical picture under examination. A detailed knowledge of the different pathologies (vestibular and extravestibular) capable of causing acute vertigo appears to us to be of fundamental importance if the patients sent from the Emergency Room is to be properly evaluated. From the above, one may see how fundamental a multidisciplinary approach is in appraising the vertigo patients, enabling the correct diagnosis to be reached rapidly and economically, as demonstrated by the results obtained by our group, in which we failed to reach a precise diagnostic conclusion in only 5% of the cases.

Alternobaric oxygen therapy in long-term treatment of Ménière's disease

Hyperbaric oxygen therapy (HBQ) has been used for several years as a treatment for Ménière's disease, particularly in Sweden. In this study continuous variations in pressure (from 1.7 to 2.2 ATA; alternobaric oxygen therapy: ABOT) were used to decrease endolymphatic hydrops, the typical histopathological substrate of Ménière's disease by increasing hydrostatic pressure and mechanical stimulation of the endolymphatic flow toward the duct and the endolymphatic sac, which produces a consequent increase in the dissolved O2 content in the labyrinth liquid, which should contribute to recovering cell metabolism and restoring cochlear electrophysiological function to normal. An experimental group of 20 patients suffering from unilateral Ménière's disease received a total of 15 ABOT treatment sessions during the acute episodes. Treatment foresaw two days without therapy every five days of application. Maintenance treatment consisted of one session per day for five consecutive days every month for one year. Thereafter, during the second, third, and fourth years of treatment, patients were submitted to one session per day for five consecutive days every three months. A control group of 18 patients suffering from Ménière's disease was treated with 10% glycerol i.v. (during the acute episodes) and with betahistine (8 mg x 3/day) in the periods in between. Mean pure tone average (PTA in dBHL) hearing thresholds at octave frequencies from 500 to 3,000Hz, and frequency of episodes of vertigo and tinnitus, both after 15 days of treatment and at the end of a four-year follow-up, were compared for both groups according to the 1995 Committee on Hearing and Equilibrium criteria. No statistically significant differences were found between the two groups at the end of the first 15 days of treatment. However, at the end of the follow-up period, patients treated with ABOT had significantly fewer vertiginous episodes and improved PTAs and tinnitus compared to the controls. The results support the use of ABOT as a valid alternative to drugs in the long-term treatment of Ménière's disease.

Contribution of cerebellum and brainstem in the control of eye movement: evidence from a functional study in a clinical model

The idiopathic cerebellar ataxias (IDCA) comprise a wide spectrum of neurodegenerative diseases with heterogeneous neuropathology, characterized by the negativity of search for any known genetic mutation. On the basis of both their clinical presentation and their magnetic resonance imaging pattern, patients with IDCA can be subdivided into patients with a purely cerebellar syndrome and atrophy of the cerebellum (IDCA-C) and patients with additional noncerebellar symptoms and atrophy of both cerebellum and brainstem (IDCA-P). The aim of the present study was to evaluate the disaggregated contribution of brainstem and cerebellum in the control of eye movements, by means of an extensive battery of quantitative tests covering most oculomotor subfunctions related to lesions of the cerebellum and the brainstem. The smooth-pursuit movement analysis showed a decrease in gain and magnitude in both subgroups of IDCA with respect to normal controls, without any significant differences in the prevalence pattern between the two subgroups; the mean values of these parameters, however, were significantly lower in IDCA-P than in IDCA-C subjects in both gain (P < 0.01) and magnitude (P < 0.001). No statistically significant difference was observed between the two subgroups in the analysis of saccadic movements or in the other parameters investigated. The distinction between IDCA-P and IDCA-C subgroups has clinical implications, as a poorer prognosis is related to brainstem involvement, which may occur late in the course of the disease. Thus, the possibility to detect the brainstem involvement, also in association with cerebellar impairment, by a relatively simple eye-movement analysis, potentially useful mainly in follow-up investigations, needs to be evaluated further.

Sudden hypoacusis treated with hyperbaric oxygen therapy: a controlled study

The term sudden hypoacusis describes a hearing loss of rapid onset and unknown origin that can progress to severe deafness. Of the many therapeutic protocols that have been proposed for treating sudden hypoacusis, hyperbaric oxygen therapy (HOT) plays a leading role. We studied 50 patients who had been referred to our ENT unit within 48 hours of the onset of sudden hypoacusis. We randomly assigned 30 of these patients to undergo once-daily administration of HOT for 10 days; the other 20 patients were treated for 10 days with an intravenous vasodilator. Response to therapy in all patients was evaluated by calculating the mean hearing threshold at frequencies between 500 and 4,000 Hz and by assessing liminal tonal audiometry results recorded at baseline and 10 days after the cessation of treatment. These results, plus the findings of other audiologic and otoneurologic examinations, revealed that the patients in the HOT group experienced a significantly greater response to treatment than did those in the vasodilator group, regardless of age and sex variables. Significantly more patients in the HOT group experienced a good or significant response. In both groups, patients with pantonal hypoacusis responded significantly better than did those with a milder condition. Based on our findings, coupled with the fact that oxygen therapy is well tolerated and produces no side effects, we conclude that HOT should be considered the preferred treatment for patients with sudden hypoacusis.

Hemostatic alterations in patients with acute, unilateral vestibular paresis

OBJECTIVES

The etiopathogenesis of acute unilateral peripheral vestibulopathy (APV) still remains a matter of debate; ischemic changes in the circulation of the labyrinth may play a role. We consequently looked for possible hemostasis alterations in a group of patients with APV of an unknown nature.

METHODS

We evaluated blood parameters known to be involved in circulation disorders, including total and HDL cholesterol, triglycerides, apolipoprotein A and B, lipoprotein(a), homocysteine, folate, prothrombin time, activated partial thromboplastin time, fibrinogen, D-dimer, antithrombin III, protein C, protein S, activated protein C resistance, and anticardiolipin IgG and IgM antibodies. A series of 23 patients affected with APV were consecutively referred to our department, in the acute phase, before treatment, and in the follow-up phase after 4 to 6 weeks of pharmacologic washout. The aforementioned blood parameters were also measured in a series of 15 patients with Menière's disease.

RESULTS

The patients with APV in the acute phase compared with the patients with Menière's disease in the acute phase exhibited increased plasma levels of fibrinogen (mean, 338.3 +/- 135.9 SD vs 271.3 +/- 69.8 SD mg/dL, P = 0.05), increased plasma levels of D-dimer (mean, 320 +/- 207.8 SD vs 226.7 +/- 138.7 SD NG/mL), enhanced plasma levels of lipoprotein(a) (41.4 +/- 38.6 SD vs 16 +/- 18.2 SD mg/dL, F = 5.67, P = 0.02), high leukocyte count (9.1 +/- 2.7 SD vs 6.5 +/- 1.3 SD x 10(3)/microL; F = 8.42, P < 0.006), and low serum folate concentration (5.3 +/- 1.8 SD vs 7.1 +/- 2.7 NG/mg; F = 4.34, P = 0.04). During follow-up the prothrombin time was prolonged (F = 4.34, P = 0.04) and leukocyte count decreased (F = 7.39, P < 0.019) in the APV patients, whereas fibrinogen, D-dimer, lipoprotein(a), and folate were unchanged.

CONCLUSION

Our results provide evidence suggesting an involvement of the hemostatic system in APV.

[Oxygen therapy in the long term treatment of Meniere's disease]

Endolymphatic hydrops is the hystopathological substrate characteristic of Ménière's disease. Besides the classical treatment with diuretics and/or osmotic drugs for some time, now treatment in a "pressure chamber" (OTI) has also been applied. The oxygen administered in the hyperbaric chamber can reduce the hydrops both by increasing the hydrostatic pressure and by mechanically stimulating the flow of endolymph toward the duct and endolymphatic sac. In addition, an increase is seen in the amount of O2 dissolved in the labyrinthine fluids and this contributes to recovering cell metabolism and restoring normal cochlear electrophysiological functions. Between 1992 and 1996 40 patients with monolateral Ménière's disease were studied: 15 underwent oxygen therapy at a constant pressure (2.2 ATA) (HOT), 25 with a continuous variation in pressure (from 1.7 to 2.2 ATA) (Alternobaric therapy, AOT). During the acute phase the patients underwent daily OTI treatment for 15 days in a row. The maintenance treatment called for one treatment cycle (one session a day for 5 days in a row) a month for 1 year, followed by for one treatment cycle (one session a day for 5 days in a row) every three months during the 2nd, 3rd and 4th years. The controls consisted of a group of 18 patients treated with 10% glycerol i.v. (during the acute phase) and betahystine (8 mg x 3/die) between episodes. A comparison was made of the average hearing threshold for the frequencies 500-3000 Hz (PTA), how frequently episodes of dizziness arose and extent of hearing loss in the three groups after the initial 15 days of treatment and at the end of the 4-year follow-up, in compliance with the criteria laid down by the Committee on Hearing and Equilibrium in 1995. At the end of the first 15 days of treatment, there were no statistically significant differences between the three groups. At the end of the follow-up, on the other hand, hyperbaric treatment, and in particular alternobaric therapy, enabled a significant reduction in the episodes of dizziness as compared to the control group. PTA and deafness also improved significantly in the patients who had undergone hyperbaric treatment. The results of the present work show that HOT, and in particular AOT, offer a valid alternative to drugs in the treatment of Ménière's disease.

Detection and management of diabetic glomerulopathy in children and adolescents with insulin-dependent diabetes mellitus: need for improved knowledge and better care

Current modalities of detection and management of incipient diabetic nephropathy in childhood and adolescence are summarized and the open questions outlined. In particular, the predictive value of microalbuminuria for later nephropathy in adolescents is examined. Microalbuminuria is not as strong a predictor as suggested in earlier studies - recent studies show up to 50% of microalbuminuria can revert to normal. We advocate that the association of well-established risk markers and promoters of renal injury, including degree and tracking of albuminuria, glycemic control, blood pressure changes, incipient retinopathy and genetic background, allow more precise assessment of the individual risk of developing nephropathy and the decision to start pharmacological intervention. The major impact of strict glycemic control to prevent the development and progression of diabetic nephropathy is emphasized, as well as the need for a multidisciplinary team to optimize the care of pediatric diabetic patients. We discuss other therapeutic options, i.e. angiotensin-converting enzyme inhibitors (ACE-Is), moderate dietary protein intake, and other drugs. ACE-Is may provide a second line intervention in a well selected, high-risk subgroup of microalbuminuric diabetic adolescents.

Vestibular disorders in primary thrombocytosis

OBJECTIVE

Balance disturbances are some of the most common symptoms among the clinical manifestations of chronic myeloproliferative disorders (MPDs) with a high platelet count, such as essential thrombocythaemia (ET) and polycythaemia vera (PV). In this study, we evaluated the vestibulo-oculomotor and vestibulospinal reflexes in a group of patients suffering from these diseases.

DESIGN

Evaluation of balance disturbances.

SETTING

Department of Neurosciences, ENT Unit, University of Pisa, Italy.

METHOD

In this study, we evaluated 43 patients suffering from ET and PV who underwent otoneurologic examination, based on a study of the vestibulo-oculomotor and vestibulospinal reflexes.

RESULTS

There was exclusive central vestibular involvement in 26 cases (60.4%), peripheral and central signs were associated in 8 cases (18.6%), and the involvement was purely peripheral in 1 patient. In six patients (14%), the otoneurologic examination revealed no alterations.

CONCLUSIONS

The high percentage of balance disorders in cases of ET and PV probably depends upon disorders of the microcirculation due to platelet dysfunction. We also postulate a full explanation of the involvement of the central vestibular system on the basis of a greater availability of central activated serotonin acting as neuromediator.

Metabolic control in children and adolescents with diabetes: experience of two Italian Regional Centers

A survey on glycemic control in 201 diabetic children and adolescents, aged 0-18 years, was performed in two Italian Centers for Childhood Diabetes (Chieti and Parma). Mean HbA1c was 7.8+/-1.4 (range 4.8-13.3%; median 7.6%). With progression of diabetes duration, deterioration of glycemic control was observed (r=0.20; p< 0.002), more evident in girls than in boys, with peaks at 14 (8.9+/-2.0 vs 6.9+/-1.7%; p<0.05) and 16 years (9.5+/-1.4% vs 8.1+/-1.1; p<0.02). No differences were found in BMI values in boys or girls, or for insulin doses which were increased significantly in both sexes according to age (r= 0.33, p<0.04). The number of insulin injections did not influence glycemic control. Only one severe hypoglycemic episode was reported during the period of observation. This study demonstrates that modern management, continuous education and patient and family empowerment are effective in attaining excellent glycemic control without increasing the risk of hypoglycemia.

Prevention of microvascular complications in diabetic children and adolescents

Diabetes mellitus causes profound alterations in many body tissues. Microvascular diabetic complications include diabetic neuropathy, nephropathy and retinopathy. Nephropathy first becomes manifest with hyperfiltration and microalbuminuria. These functional changes evolve over several years to a stage of marked deterioration of renal function. The possible preventive measures are metabolic control, reduction of dietary protein intake and use of ACE-inhibitors. Metabolic control is also important for the prevention of diabetic retinopathy. In fact, patients with HbA1c higher than 10% have an increased risk of progression of retinopathy. Moreover, an accelerated progression of retinopathy has been observed in patients with systemic hypertension following the onset of microalbuminuria. It has been demonstrated that diabetic neuropathy can also be present during childhood; therefore, it is possible to detect electrophysiological abnormalities in children and adolescents with IDDM. Glycaemic and blood pressure control are, so far, the main means for possible prevention or modification of the natural history of diabetic microvascular complications. Tight glycaemic control may have beneficial effects for diabetic neuropathy. In addition, other preventive measures, such as aldose reductase inhibitors, gangliosides, neurotrophic vitamins, etc., have been studied in the last years. However, no conclusive results have been obtained so far.

Diabetic nephropathy in children and adolescents: a critical review with particular reference to angiotensin-converting enzyme inhibitors

Clinical diabetic nephropathy is a well-recognized cause of increased morbidity and mortality in patients with type 1 diabetes. The finding that microalbuminuria predicts progression to overt nephropathy has allowed early diagnosis and preventive interventions. Several studies have demonstrated that treatment with angiotensin-converting enzyme (ACE) inhibitors slows down the rate of decline of the glomerular filtration rate in type 1 diabetes patients with established proteinuria. The renoprotective properties of the ACE inhibitor captopril extend beyond its antihypertensive effects. ACE inhibitors represent the most appropriate class of antihypertensive drugs for treating type I diabetes patients because of their efficacy and safety. When microalbuminuria is detected and confirmed in a diabetic child or adolescent, and if it persists despite 6-12 months of improved metabolic control, treatment with ACE inhibitors should be started, even if the child is normotensive. Careful follow-up of renal function is essential.

Immunohistochemical localisation of tear lipocalin in human nasal mucosa

Lipocalins are low molecular weight soluble proteins, a sub-class of this family are the odorant binding proteins (OBPs) which are postulated as having an important role in the perireceptor events of olfactory transduction, though their specific physiological function has yet to be defined. From the nasal mucus of normal subjects we recently isolated a 19kDa protein, the amino-acid sequence of which, limited to the first 20 residues, is identical to that of tear lipocalin. In this study we performed an immuno-histochemical investigation on the nasal localisation of this protein, using tissue specimens taken from the inferior (27 samples), middle (7 samples) and superior turbinates (6 samples) in 27 patients undergoing septoplastic surgery. The protein was detected in the sub-epithelial tubulo-acinar glands of the nasal mucosa, particularly in the mucoserous glands, in 74% of the specimens taken from the inferior turbinate, in 71.4% of those from the middle turbinate and in 66.6% of the samples of superior turbinate tissue. The homogeneous distribution of this protein in the nasal mucus could imply that it functions as a general protection agent rather than as an odour carrier or transducer.

A new collection method for the evaluation of nasal mucus proteins

BACKGROUND

Different sampling techniques for collecting nasal mucus have been used. The eosinophil and its granule toxin proteins, especially the eosinophil cationic protein (ECP), is an important inflammatory cell.

OBJECTIVE

In the healthy subjects (with no acute or chronic disease of the respiratory tract), no detailed quantitative data on mucus nasal proteins have been reported, so the aim of the study is to demonstrate a simple and reliable method for the collection of nasal mucus and for measuring nasal ECP.

METHODS

Our method consists in collecting two specimens of mucus from each nasal fossa, using a square of sterile pre-humidified gauze, centrifuged at 2000g for 20 min and stored at -20 degrees C until tested. To evaluate the reproducibility of the technique, 30 healthy subjects were retested after 24 h.

RESULTS

The amounts of secretion gathered in the 89 collections did not show any statistical difference between the sexes. In the pooled subjects (n=59), the mean levels of ECP were 108 ng/mL and 325 ng/g and total protein (TP) levels were 701 mg/dL and 2.5 mg/g (expressed in absolute concentration and concentration related to the weight in grams). In the classes, according to age, no statistical differences were found on analysis of the groups by: sex, recovery rate, and ECP and TP concentrations. The Reproducibility Index was very good for the recovery rate (0.78), ECP (ng/mL=0.95, ng/g=0.83) and TP (mg/dL=0.89, mg/g=0.76).

CONCLUSION

With our method, the sample collections were taken with minimal stimulation of the mucosa and it was well tolerated by the subjects; the low known dilution factor is also adequate for analysing small quantities of mucus recovered, and the protein concentration can be measured as an absolute value.

Positional vertigo and ageotropic bidirectional nystagmus

A strong paroxysmal positional horizontal nystagmus accompanied by symptoms similar to those of paroxysmal positional vertigo (PPV) can be observed in a small fraction of patients who have positional vertigo. This nystagmus may be a lateral canal variant of PPV. We evaluated nine patients who had episodes of prolonged, intense positional vertigo provoked by lateral movements of the head while in the supine position. The nystagmus appeared as horizontal and was directed toward the uppermost ear (ageotropic) when the head was rotated to either side (bidirectional). The duration of nystagmus lasted more than 1 minute in all the cases, although it presented a progressive decrease in the velocity of the slow component. The clinical and electronystagmographic features of this syndrome lead us to propose a different form of horizontal canal PPV associated with a paroxysmal positional ageotropic and bidirectional nystagmus, probably caused by a "heavy cupula" as a result of deposits of extraneous bodies (otolithic?) or by a cupula denser than the endolymph.

Acoustic neuroma: correlations between morphology and otoneurological manifestations

Forty-two patients with acoustic neuroma (AN) were studied to determine whether different types of neuroma could be correlated with specific signs and symptoms of the disease. Based on gadolinium-enhanced TI-weighted MRI sequences, the 42 cases of AN could be divided into three groups, either by size (small: 11.9%, medium: 50%, and large: 38.1%) or by site of origin of the tumour (lateral: 16.7%, intermediate: 69%, and medial: 14.3%). Relations were found between the size and the site of origin of the neuromas and certain clinical, audiological and vestibular findings. The clinical presentation seemed to vary with the site of origin and the size of the tumour: patients with lateral neuromas generally had small tumours, sometimes only located in the internal auditory canal (IAC), and presented early subjective hearing loss while patients with medial neuromas had larger tumours which grew without causing significant audiological symptoms. Normal hearing function was seen only in the patients with medial ANs; however, a significant relation between the size or the site of origin of the AN and the average hearing threshold was not demonstrated. The sensitivity of the stapedial reflex test (SR) was higher for lateral ANs. Anomalies in the brainstem auditory evoked potentials (BAEPs) did not seem to be related to either the size or the site of origin of the AN. The vestibular tests demonstrated a higher frequency of central vestibular involvement in the large tumours, while normal function was more frequent in the lateral tumours. In the group studied the combination of BAEPs and vestibular tests allowed us to identify all the ANs with an optimal level of sensitivity.

Alternobaric and hyperbaric oxygen therapy in the immediate and long-term treatment of Menière's disease

Forty-five patients suffering from Menière's disease were submitted to pressure chamber therapy: 20 with constant pressure (2.2 ATA, hyperbaric treatment) and 25 with continuous variations in pressure levels (from 1.7 to 2.2 ATA, alternobaric treatment). Oxygenation therapy consisted of one session per day lasting 90 minutes for 15 days during the acute attacks followed by five consecutive sessions per month during a follow-up of two years. For a control group we used 18 patients treated with 10 per cent intravenous glycerol during the acute episode and 8 mg tid of betahistine thereafter. We compared hearing loss, vertigo and tinnitus in the three groups 15 days after starting treatment and at the end of the follow-up, according to the criteria suggested by the 1995 Committee on Hearing and Equilibrium. We found no statistically significant differences in recovery from the cochlear-vestibular symptoms in the three groups at the end of the first 15 days of therapy, whereas hyperbaric and, in particular, alternobaric treatment permitted a significant control of the principal attacks of vertigo during the follow-up period. Hearing loss also showed a more significant and more persistent improvement in the patients treated with alternobaric oxygenation compared to the patients in the other two groups.

Acupuncture treatment for balance disorders following whiplash injury

In this study, by means of computerized static posturography, we evaluated the postural changes after acupuncture treatment in a group of 15 patients with balance disorders caused by cervical torsion due to Whiplash Injury (WI). The acupuncture treatment consisted of 3 sessions (one weekly session for 3 weeks) during which the acupuncture points Bladder 10 (Bl.10) and Gall Bladder 20 (G.B.20). VB were stimulated by means of piercing with needles, and manipulating the needles for 20 seconds. Each patient underwent posturographic evaluations before and just after each session of acupuncture. The posturographic tests were performed with open eyes (OE), closed eyes (CE) and closed eyes with retroflexed head (CER). As a control group, we used 17 patients complaining of the same symptoms as the study group due to WI, but treated with drugs (FANS and myorelaxing) and physiotherapy only. The patients of the control group also underwent posturographic tests once a week for three weeks. We observed a significant difference between the two groups regarding the reduction of the CER Length of the statokinesigram just before each session of acupuncture and reduction of the frequency oscillations (FFT) of the patients on the sagittal plane in the study group, in CER, whereas in the control group we observed a progressive increase in these values. The high percentage of positive results in our WI patients leads us to advocate the therapeutic efficacy of acupuncture for balance disorders due to cervical pathology, where it can be associated with or be a valid alternative to pharmacological treatment.

Menière's disease: role of antibodies against basement membrane antigens

Recently, high levels of anti-collagen II (CII) antibodies have been found in a significant percentage of patients with Menière's disease (MD). An immune response against other collagens (C) present in the basal membranes has also been suggested by the presence of anti-CIV and anti-laminin antibodies in a number of instances of progressive systemic sclerosis (PSS) and Raynaud's phenomenon (RP). The aim of the present study was to measure the levels and frequency of anti-CI, -CII, -CIV, -CV, and anti-laminin antibodies by enzyme-linked immunosorbent assay (ELISA) in 45 patients affected by MD, 24 patients with PSS, 24 patients with RP, and 25 normal subjects. Immunoglobulin G (IgG) anti-CII antibodies were detected in 15.5% of MD sera, and 6.6% of MD sera were positive on CV, 11.1% were positive on laminin, 4.4% were positive on CI, and 4.4% were positive on CIV. A low incidence of anti-CI, -CII, -CIV, -CV, and antilaminin antibodies was found. Positive sera did not react on immunoblot with peptides obtained by cyanogen bromide (CNBr) digestion of CII. These results contrast with those of Yoo, et al.; differences in the washing procedure used and in the ethnic background of the patients may explain this divergence. Our results would seem to indicate that autoimmune responses do not play a role in the pathogenesis of MD.

[An update on the treatment of otitis media with effusion in children. The indications for transtympanic drainage]

Otitis media with effusion (O.M.E.) is a frequent child's condition, with generally spontaneous recovery. Only a few cases, with some complications and chronic-O.M.E., present hearing loss and later verbal and academic delayed performances. We report our experience on treatment by tympanostomy tubes for O.M.E., at the Clinic of otolaryngology of the University of Pisa, since 1981 to 1993, resulting a progressively reduced number of these operations in the last period. We believe that both the inflamed upper airways care, and first choice adenoidectomy can explain the trend. Ventilation tubes must be placed only for persistent picture of O.M.E. and possibility of invalidity.

[Delayed endolymphatic hydrops: an analysis of 12 cases]

Delayed Endolymphatic Hydrops (DEH) is a clinical entity which is characterized by an early phase with a profound sensorineural hearing loss in one ear. After a prolonged period of time (from 1 to 68 years) a late phase of the disease appears with different otologic symptoms. The ipsilateral type of endolymphatic hydrops appears in the deaf ear with consequent episodic vertigo. The contralateral type develops symptoms of endolymphatic hydrop in the previously normal ear, with the onset of fluctuating hearing loss and/or episodic vertigo. This paper is a review of 12 cases of DEH (7 ipsilateral and 5 contralateral, age ranging from 19 to 79 years). Diagnosis was established on the basis of clinical history and the results of audio-vestibular investigations, specifically designed to detect signs of endolymphatic hydrops (including the glycerol-test and neuroradiological imaging of the cerebello-pontine angle). In 8 patients the levels and frequency of anti-collagen I-II-IV-V, anti-laminin autoantibodies, complement, Ig and immuno-complexes were measured. Viral infections (measles, mumps, influenza) were thought to have caused the early phase in 6 cases. In the entire group of 12 patients the delay between the onset of the ear loss and vertigo averaged 12 years. In the group of the ipsilateral DEH, caloric tests showed in 5 cases a reduced or absent response of the deaf ear. About contralateral DEH, caloric tests showed bilateral reduced response in 2 cases, and, in 3 cases, a decreased response only in the previously normal ear. Regarding immunological study, an abnormal level of Ig and Complement was detected in 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of the head shaking test in the posturographic diagnosis]

This study on equilibrium disturbances employed the Head Shaking Test (HST), with manoeuvres similar to those used in studying the Vestibule Oculomotor Reflex (VOR) as well as the Vestibule Spinal Reflex (VSR), following a posturographic technique. Two hundred and forty-eight patients suffering of equilibrium disturbance of peripheral (168 cases) and central (80 cases) origin underwent study in four different conditions: Open Eyes (OE), Closed Eyes (CE), Open Eyes with Head Retroflection (OER) and Closed Eyes and HST (CE-HST). The results obtained (47.9% positive results to the test) confirm the high sensitivity and specificity of the CE-HST. The correlation with posture alterations, peripheral as well as central, resulted highly significant (P less than 0.0001), with a notable reduction of false negatives. A positive correlation between CE-HST and HST-Ny was not detectable thus confirming two distinct patterns for VOR and VSR. Furthermore, no correlation between CE-HST and postural pathology of cervical or positional origin was documented.

[Use of SPECT in the diagnosis of vertigo syndromes of vascular nature]

Dizziness is doubtlessly one of the most common symptoms to arise in ischemia of the brainstem. In such cases the circulatory deficit can not only cause a direct lesion of the vestibular structures but it may also block the compensatory process. There are, however, significant difficulties in establishing whether such dizziness can be attributed to a brainstem insufficiency (BI). In fact, both CAT and NMR provide data only in the case of permanent CNS tissue lesions and tests such as the Doppler examination of neck blood vessels are unable to establish the true state of cerebral blood flow. In order to obtain semi-quantitative data regarding cerebral blood flow 99mTc-HMPAO-S.P.E.T. (Single Photon Emission Tomography) was used in 18 patients suffering from dizziness and for whom there was strong indication that the underlying cause could be vascular. There was a discrepancy between the Doppler and S.P.E.T. findings in 50% of the cases. CAT, however, proved negative in all but one of the cases. These data indicate that Doppler testing of the neck blood vessels can provide useful information regarding the status of the cerebral-afferent vessels but that these cannot be correlated to the level of cerebral blood flow. On the other hand, with S.P.E.T., in 15 of the 18 patients, it proved possible to identify significant alterations in cerebral blood flow in the absence of any permanent tissue lesions as those revealed by CAT and NMR. In the light of the present results cerebral S.P.E.T. appears to be a highly valid tool when, faced with dizziness for which a vascular origin is suspected, one must evaluate cerebral prognosis and therapy.

[Posturography in unilateral peripheral vestibular deficiency]

A thorough study of vestibular function cannot be limited to the evaluation of VOR alone; it must also include the study of VSR which serves to control erect stance under both static and dynamic conditions. In unilateral peripheral vestibular lesions (UVL) computerized stabilometry makes it possible to perform a more accurate evaluation of the VSR complex through the quantification of "postural sway". Furthermore, the diagnostic potential of stabilometry can be further fine-tuned by introducing a sensitization test, in particular the head retroflexion (OCR) and head shaking (OC-HST) tests. In the present study 61 patients with UVL of various etiology (viral, toxic, vascular, idiopathic) were studied. Besides electrooculography, stabilometry was performed under base conditions (eyes open and closed) and with sensitizing tests (OCR, OC-HST). L and S were used as statokinesigram parameters while frequency and oscillation amplitude on the sagittal and transverse planes were used as stabilogram parameters. Of the 61 UVL patients, 47.5% showed VOR compensation while static postural alterations were found in 31.1%; this raised to 50.8% when the sensitization test was introduced. Apparently the compensation phenomena became manifest more quickly for VOR than for VSR. The introduction of the sensitization test, however, markedly reduced this variance. The two sensitization, maneuvers used provided quantitatively equivalent results although in the absence of reciprocal agreement. Agreement was not even recorded between stabilometric HST and the head shaking test. This confirms the presence of two different routes for VOR and VSR. Nonetheless, the introduction of the sensitization test made it possible to identify those "false negative" VSR cases which were really pathological, thus making it possible to properly identify the patients' condition and arrange for adequate treatment.

[Benign paroxysmal positional vertigo: clinical aspects and medico-legal considerations]

Benign paroxysmal positional vertigo (BPPV) is quite frequently found as an otological consequence of cranial traumas; thus leading to medico-legal implications. An attempt has herewith been made to evaluate these implications on the basis of data available. Therefore, 158 patients suffering from BPPV were examined between 1984-1986. Of these 23% of the total were post-traumatic forms (of medico-legal interest). Among patients suffering from post-traumatic vestibular disturbances in the broad sense, the incidence of BPPV proved to be greater in the ages ranging from 50 to 70. In those under 30 years of age BPPV was hardly ever present (5% of the total) although when it was its origin was always post-traumatic. The temporal evolution of paroxysmal positional vertigo, which tends to spontaneously disappear, is paralleled in BPPV patients whether it is of post-traumatic origin or not. On the other hand, the subjective sensation of positional vertigo takes longer to clear up in post-traumatic BPPV patients, most likely due to factors stemming from the so-called "compensation syndrome". Any medico-legal evaluation of BPPV must, therefore, take into account its natural favorable evolution. This makes it necessary to examine the patient several times over a period of at least six months from the moment of trauma. In medico-legal terms, the features of BPPV (i.e. position setting it off, duration of vertigo, frequency with which it appears when that position is assumed, presence and duration of the positional nystagmus) lead to inability to work in from 2 to 10% of the cases.

Assessment of head shaking test in neuro-otological practice

The head shaking test (HST) is an important test in neuro-otological diagnosis. In our study of 277 patients complaining of dizziness we verified this importance. The results thus obtained were compared with the results recorded in 73 normal subjects. Head shaking nystagmus was observed in 73 patients. Of these 73 cases, 42 involved central diseases and 31 cases involved peripheral diseases. Head shaking nystagmus was observed in 7 subjects of the control group. A highly significant correlation was noted between head shaking nystagmus and positional nystagmus, between head shaking nystagmus and the caloric test and between head shaking nystagmus and all the other spontaneous types of nystagmus that were investigated (eyes open in light/gaze straight ahead; eyes open behind Frenzel's glasses; eyes closed; eyes open in darkness). No correlation was found between head shaking nystagmus and cervical nystagmus and positioning nystagmus. The sensitivity of head shaking nystagmus, in comparison with other types of spontaneous nystagmus, was found to be slightly higher in cases with peripheral lesions than in those with central lesions. These data confirm the diagnostic importance of this simple test. It is also important to keep in mind that the HST has no importance for topodiagnostic purposes.