P242 ADVANCED HEART FAILURE: ENHANCEMENT OF INTEGRATED MANAGEMENT IN THE METROPOLITAN AREA OF FORLÌ

 

The aim of this study is to assess the effectiveness of a multi–professional home care (HC) model – cardiologist, general practitioner, cardiology nurse – which has been active in the metropolitan area of Forlì since 1999. In May 2021, 14 patients were enrolled (mean age=75.43). Inclusion criteria: heart failure (HF) in NYHA class III–IV, recurrent hospitalizations for HF and difficulties to reach the clinic. 4 out of 14 patients had been followed by the cardiologic HC program since 2016, 3 patients since 2018, 1 patient since 2019, 1 patient since 2020, 5 patients since 2021.

Outcome Measures

Rate of hospital admissions for HF 6 and 12 months before and after admission in HC pathway, quality of life (Minnesota Test), functional residual capacity (Palliative Performance Scale, PPS), compliance to the therapeutic program (Morisky Test). Questionnaires were administered when patients were included in HC and repeated at the time of enrollment and after 6 months. 3 patients were excluded from the analysis after enrollment because they died (n = 2) or were admitted in nursing homes (n = 1). It was observed that hospitalizations due to HF decreased from 1.64 during the 6 months preceding the admission in HC to 0.36 in the following 6 months (–78.05%, p = .002); furthermore, patients included in HC for more than 12 months (n = 9) decreased their hospitalizations from 1.78 in the year before their inclusion in the HC pathway to 0.33 in the year after (81.46%, p = .012). Since the cost of an average hospitalization for HF has been evaluated to be € 3,265.90 (DRG 127 Emilia–Romagna Region 2020), it was estimated a reduction in costs per patient of € 4,180.36 in 6 months and € 4,735.55 in 12 months. During the follow–up period, patients experienced a clinically significant improvement in psychophysical and social well–being and in the performance of daily activities. The mean Minnesota Test score improved (p = .001) from 62.86 (at the admission in HC) to 44.21 (at the enrollment) and 40.09 (at 6 months); the PPS score increased (p = .0021) from 56.43% (at the admission in HC) to 61.43% (at the enrollment) and 67.27% (at 6 months). Good therapeutic adherence was maintained, with a Morisky Test score ≥ 10.

In conclusion, these preliminary results are consistent with recent ESC guidelines for the multi–professional care of patients with chronic HF and show the efficacy of this approach in order to prevent hospital admissions and to improve quality of life.

Abstract P6-11-19: Efficacy and patient acceptability of the DigniCaP ScalpCooler to prevent hair loss in breast cancer patients receiving adjuvant chemotherapy

Background: Alopecia is a common and distressing adverse effect in breast cancer (BC) patients (pts) receiving adjuvant chemotherapy. The aim of the study was to assess the effectiveness and safety of this device to prevent chemotherapy-induced alopecia in early breast cancer patients (EBCP) receiving adjuvant treatment. The quality of life of pts was also evaluated.

Patients and methods: From January to December 2016, a sensor-controlled scalp cooling system (DigniCap:Sysmex Europe GmbH, Norderstedt, Germany) was proposed to a consecutive group of EBCP submitted to adjuvant chemotherapy at the Breast Unit of Spedali Civili Hospital of Brescia. Degree of hair loss was assessed by two nurse using Dean's alopecia scale by digital photographs at baseline and each chemotherapy cycle. EORTC QLQ-C30 questionnaire and self-reported visual analogical scale (VAS) of symptoms (anxiety, tone of mood, fatigue, nausea,well-being, activity) were collected at baseline and after the first two cycles of chemotherapy.

Results: 70 pts were enrolled and 49 (70%) completed the chemotherapy plan and were evaluable. Median age was 51 years, 8 pts (16%) received neoadjuvant and 41 pts (84%) adjuvant chemotherapy, 21 (43%) were treated with 4 cycle of chemotherapy (TC, EC or paclitaxel alone), and 28 (57%) with sequential chemotherapy with antracycline and taxane +- trastuzumab. Fifteen pts (30%) stopped the treatment because of loss of hair in 9 pts, for headache in 4 pts and for other problems in 2 pts. At the end of chemotherapy, 13 pts (27%) had no loss of hair (Dean score 0), 25 pts (51%) had a minimal loss of hair (Dean score 1), 9 pts (18%) had a 50% hair loss (Dean score 2), 2 pts (4%) had a 75% hair loss (Dean score 3). No pts reported hair loss more than 75% (Dean score 4). There wasn't a significant difference between mean score value of QLQ-C30 at baseline and after chemotherapy and between the groups with and without hair loss. VAS documented an increase of fatigue and decrease of anxiety from baseline to final evaluation. The side effects presented with the use of DigniCap were the following: headache in 32% of pts and cold feeling in 57 % of pts.

Conclusion: Scalp cooling with cold caps appears to be effective in preventing CIA among the majority of women undergoing treatment chemotherapy. The quality of life did not change in scalp-cooled patients.

Acknowledgments: a thank you to the ESA association that donated Dignicap to Oncology Department.

Citation Format: Vassalli L, Pedersini R, Romelli M, Claps M, Fornaro C, Conti E, Tagliani M, Baronchelli A, Ragni D, Lombardi E, Rodella F, Amoroso V, Berruti A, Simoncini EL. Efficacy and patient acceptability of the DigniCaP ScalpCooler to prevent hair loss in breast cancer patients receiving adjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-11-19.

Diagnostic Value of Three Different Latex Extracts

The diagnosis of latex allergy is made on clinical history, but a confirmatory skin prick test (SPT) or a serological assay based on a commercial latex extract is always recommendable. Different raw materials can be used in the preparation of commercial latex extracts. Such extracts can consequently show both different qualitative profiles and a different diagnostic potential. Therefore, the selection of a proper latex extract is essential for in vitro and in vivo diagnosis of latex allergy. In the present study three different latex extracts, prepared from different raw materials (ammoniated -AL-, serum -SL-, or rubber particles -RPE- latex), are compared by in vitro techniques using sera from twenty patients with latex allergy. SDS-PAGE technique was used to compare the antigenic profile of the three latex extracts. Subsequently, their allergenic profiles were evaluated by immunoblotting technique using the individual sera from the twenty latex allergic patients. The diagnostic potential of the three latex extracts was also evaluated using direct Radio-Allergo-Sorbent Test (RAST) as well as skin prick tests (SPTs). In order to establish the more appropriate latex extract in a perspective of in vivo diagnosis of latex sensitization, the same latex extracts were subsequently compared by an in vivo SPT involving ten of the above subjects. The SDS-PAGE profiles of the three latex extracts examined were quite different. SL extract showed numerous bands comprised between 10–100 kDa. RPE extract was characterized by two intense bands at 14 and 20 kDa while AL extract showed the poorer antigenic composition. Analogously, immunoblotting analysis evidenced a different profile in relation to both different patients and extracts. For only two out of the twenty sera, direct RAST results showed a same positive class in relation to the different latex extracts used. SPT with SL extract showed, in respect to the other extracts (AL, RPE), a significantly higher wheal. This study showed that SL extract is able to express the best in vitro and in vivo diagnostic potential. Thus, its use should be preferred for the diagnosis of patients affected by latex allergy.

Antibiotic Allergy

Antibiotics are commonly injected during the perioperative period and are responsible of 15% of the anaphylactic reactions. Anaphylaxis triggered by antibiotics primarily involves penicillin and cephalosporin. The management of patients with histories of allergic reactions to antibiotics is a common situation in clinical practice. The confirmation or invalidation of the allergic nature of the reported reaction is not based on in vitro tests, but on a rigorous allergological work-up based on detailed analysis of clinical history, skin tests and drug provocation test. Considering a possible cross-reactivity between penicillins, once an immediate penicillin allergy has been diagnosed, skin testing with the alternative molecule (cephalosporin, carbapenem, aztreonam) is mandatory and, if negative, the relevant drug should be given in an appropriate setting at increasing doses.

Respiratory impedance and bronchodilator response in healthy Italian preschool children

OBJECTIVE

To define normal values for respiratory resistance (R(rs)) and reactance (X(rs)) and bronchodilator response (BDR) in a population of healthy Italian preschool children using a commercially available forced oscillation device.

METHODS

R(rs) and X(rs) were measured in kindergartens in Viterbo, Italy. Regression analysis was performed taking into account height, weight, age, gender, and reference equations calculated. The coefficient of repeatability (CR) between two tests performed 15 min apart was calculated in a subset of children. BDR was assessed by repeating the measurements 15 min after the administration of 200 µg of inhaled salbutamol and calculated as an absolute change in R(rs) and X(rs) at 8 Hz, as a percent change in baseline, and as a change in Z-score calculated from the reference equations.

RESULTS

Lung function was attempted in 175 healthy children and successful in 163 (81 male, median age 4.8, range 2.9-6.1 years). R(rs) and X(rs) at 6, 8, and 10 Hz were related to height but not other variables. The CR was 1.53 hPa s L(-1) for R(rs8) and 0.91 hPa s L(-1) for X(rs8). The 5th percentile for absolute R(rs8) BDR was -3.16 hPa s L(-1), whereas the 95th percentile for absolute X(rs8) BDR was 2.25 hPa s L(-1). These cut-off values corresponded to a change in the Z-score of -1.88 and 2.48, respectively.

CONCLUSIONS

We have established reference equations for R(rs) and X(rs) in healthy Italian preschool children using forced oscillations. We recommend a change in Z-score of -1.88 for R(rs8) and 2.48 for X(rs8) as cut-off values for a positive BDR.

Reference ranges for interrupter resistance technique: the Asthma UK Initiative

Measuring interrupter resistance (R(int)) is an increasingly popular lung function technique and especially suitable for preschool children because it is simple, quick and requires only passive cooperation. A European Respiratory Society (ERS)/American Thoracic Society (ATS) Task Force recently published empirical recommendations related to procedures, limitations and interpretation of the technique. However, for valid interpretation, high-quality reference equations are required and these have been lacking. The aim of the present study was to collate R(int) data from healthy children in order to produce more robust reference equations. A further aim was to examine the influence of methodological differences on predicted R(int) values. R(int) data from healthy children were collected from published and unpublished sources. Reference equations for expiratory and inspiratory R(int) were developed using the LMS (lambda, mu, sigma) method. Data from 1,090 children (51% males) aged 3-13 yrs were collated to construct sex-specific reference equations for expiratory R(int) and data from 629 children (51% males) were collated for inspiratory R(int). Height was the best independent predictor of both expiratory and inspiratory R(int). Differences between centres were clinically irrelevant, and differences between ethnic groups could not be examined. The availability of a large and generalisable sample and the use of modern statistical techniques enabled the development of more appropriate reference equations for R(int) in young children.

Allergen specific nasal challenge to latex in children with latex allergy: clinical and immunological evaluation

There are no data concerning the significance of allergen specific nasal challenge to latex (ASNCL) in the pediatric population and the effect of mometasone furoate nasal spray (MFNS), topic corticosteroid exerting a potent anti-inflammatory activity in children with latex allergic rhinitis. The aims of this study are: to investigate the clinical and immune pathological effects of ASNCL in children with latex allergy; to study the effects of MFNS pre-medication on the clinical and immune pathological effects of ASNCL in children with latex allergy. Thirteen children: 6 male and 7 female, mean (SD) age 9.6 (2.9) years, with latex allergy and seven children: 3 male and 4 female, mean (SD) age 9.9 (3.8) years, without latex allergy underwent ASNCL. Nasal symptoms were recorded, nasal lavage fluid was collected to measure tryptase, eosinophil cationic protein (ECP), interleukin-5, interferon-gamma levels, and spirometric test was performed for each patient without or with premedication with MFNS. ASNCL induced a clinical allergic response and increased tryptase levels only in children with latex allergy. No serious adverse events occurred after ASNCL. MFNS premedication reduced both tryptase and ECP levels only in children with latex allergy. ASNCL is a simple, reliable and useful tool to make or confirm the diagnosis of nasal symptoms due to latex; it allows us to study both clinical symptoms and local immunological changes. MFNS premedication before an ASNCL may prevent some immunological responses induced by ASNCL without clinical allergic modifications.

Comparison between pulse oximetry and transthoracic impedance alarm traces during home monitoring

OBJECTIVE

To compare transthoracic impedance (TTI/ECG) and pulse oximetry alarm traces detected during home monitoring in infants at risk of apnoea, bradycardia and hypoxaemia.

STUDY DESIGN

A retrospective evaluation of the monitor downloads of 67 infants who had undergone either TTI/ECG or pulse oximetry home monitoring using a device which can detect both parameters.

METHODS

The patients were categorised as: apparent life-threatening events (n = 39), preterm infants (n = 21) and miscellaneous (n = 7). TTI/ECG and pulse oximetry alarm traces were scored as either true or false alarms. Classification criteria were based on visual analysis of the impedance and plethysmographic waveforms captured by the memory monitor every time alarm thresholds were violated.

RESULTS

5242 alarms occurred over 3452 days of monitoring: 4562 (87%) were false and 680 (13%) true. The mean duration of monitoring was 51 days (range 5-220 days). There were 2982 TTI/ECG false alarms (65% of the total) and 1580 pulse oximetry false alarms (35%) (p = 0.0042). Of the 680 true alarms, 507 (74%) were desaturations not attributable to central apnoea and 173 (26%) were true TTI/ECG alarms (p = 0.0013).

CONCLUSIONS

Comparison of pulse oximetry and TTI/ECG alarm traces shows that true events were mostly attributable to desaturations, while false alarms were mainly provoked by TTI/ECG. The total number of false alarms is lower than reported in other studies using TTI/ECG only, thus indicating that monitoring using both pulse oximetry and TTI/ECG is suitable for home use. When the combination of both techniques is not feasible or not required, we recommend the use of motion resistant pulse oximetry alone.

Nitric oxide (NO) inhibits prostaglandin E2 9-ketoreductase (9-KPR) activity in human fetal membranes

Nitric oxide (NO) synthesized by fetal membranes may act either directly inhibiting myometrium contractility or indirectly interacting with tocolytic agents as prostaglandins (PGs). Here we examined if NO could modulate prostaglandin E(2) 9-ketoreductase (9-KPR) activity in human fetal membranes (HFM). 9-KPR is the enzyme that converts PGE(2) into PGF(2alpha), the main PGs known to induce uterine contractility at term. Chorioamnion explants obtained from elective caesareans were incubated with aminoguanidine (AG), an iNOS inhibitor, or NOC-18, a NO donor. NOC-18 (2mM) increased PGE(2) production and diminished PGF(2alpha) synthesis in HFM. AG presented the opposite effect. When we evaluated the activity of 9-KPR by the conversion of [(3)H]-PGE(2) into [(3)H]-PGF(2alpha) and 13,14-dihidro-15-keto prostaglandin F(2alpha) (the PGF(2alpha) metabolite), we found that NOC-18 inhibited 9-KPR activity. Interestingly, AG did not elicit any effect on 9-KPR but l-NAME, a non-selective NOS inhibitor, significantly increased its activity. Our data suggests that exogenous NO inhibits 9-KPR activity in HFM, thus modulating the synthesis of important labor mediators as PGF(2alpha).

Cross-reactivity between IgE-binding proteins from Anisakis simplex and Dermatophagoides pteronyssinus

An association was found between Anisakis simplex (As) and Dermatophagoides pteronyssinus (Dp) sensitization. One recent study shows a cross-reactivity between As and Dp and tropomyosin (tr)is suspected as being one of the proteins responsible of this cross-reaction. The aim of our study was: 1) to confirm the cross-reactivity between Dp and As; 2) to determine the importance of tr in this cross reaction. SDS-PAGE analysis of Dp and As (metabolic and somatic) extracts was carried out. Then an IgE immunoblotting test using serum from a patient who had specific IgE only to Dp and As and immunoblotting inhibition experiments using Dp extract and tr as inhibitors were performed. We found that patients serum reacted: 1) against larval As antigens with a molecular weight (mw) of 25 kilodalton (kD) and a mw > than 100 kD, 2) against various metabolic As antigens with a mw > than 100 kD, a mw ranging approximately from 35 to 50 kD, and a mw around 20 kD, and 3) against Dp proteins with mw between 35 and 55 kD. Preincubation of patient's serum with Dp extract caused the disappearance of reactivity against antigens with a mw > than 100 kD in both larval and metabolic As extracts and against proteins with mw ranging approximately from 35 to 50 kD in the metabolic As extract. Preincubation of patients serum with As extract caused the disappearance of reactivity against antigens with mw between 35 and 55 kD in the Dp extract. Pre-incubation of patients serum with tr did not induce any change in the immunoblotting profile. The results show that 1) cross-reactive components between Dp and As are some proteins with a mw ranging approximately from 35 to 50 kD and with a mw > than 100 kD, and 2) tr is not involved in cross-reactivity between As and Dp.

Mould/dampness exposure at home is associated with respiratory disorders in Italian children and adolescents: the SIDRIA-2 Study

AIMS

To report on the relation between home mould and/or dampness exposure and respiratory disorders in a large sample of children and adolescents in Italy, accounting for age at time of exposure.

METHODS

20,016 children (mean age 7 years) and 13,266 adolescents (mean age 13 years) completed questionnaires on indoor exposures and respiratory symptoms/diseases. Statistical analyses were adjusted for sex, age, questionnaire's compiler, area of residence, season of interview, parental educational status, family history of asthma, rhinitis, eczema, chronic obstructive pulmonary disease, presence of gas water heaters, passive smoking, pets, and active smoking (only for adolescents). Population attributable risk % (PAR) was also computed.

RESULTS

Asthma was more strongly related to only early than to only current exposure, both in children (OR 1.80, 95% CI 1.41 to 2.30) and adolescents (OR 1.89, 95% CI 1.38 to 2.59). The same result was found for rhino-conjunctivitis (OR 1.46, 95% CI 1.17 to 1.82), in children, and for wheeze among adolescents (OR 1.56, 95% CI 1.15 to 2.11). In children, wheeze (OR 1.98, 95% CI 1.47 to 2.66) and eczema (OR 1.44, 95% CI 1.09 to 1.91) were more strongly related to mould/dampness when exposed both early and currently; the same occurred in adolescents for rhino-conjunctivitis (1.78, 95% CI 1.30 to 2.45). Although persistent cough/phlegm was significantly related to mould/dampness exposure in children, regardless of exposure timing, no significant association between mould/dampness exposure and eczema or cough/phlegm was found among adolescents. PAR estimates were higher for only early than only current exposures. Avoiding early only exposure would abate wheeze by 6%, asthma or cough/phlegm by 7%, rhino-conjunctivitis in children by 4%, and in adolescents, asthma by 6%, and wheeze by 4%.

CONCLUSIONS

Respiratory disorders such as wheeze and asthma can often be explained by exposure to home mould/dampness, especially early in life. The association seems more evident in children than in adolescents. These findings may suggest the need for environmental prevention strategies.

[Factors associated with postoperative mortality following gastric adenocarcinoma surgery at the Edgardo Rebagliati Martins Hospital]

OBJECTIVES

This study is a retrospective, descriptive and observational evaluation aimed at defining the factors associated with postoperative mortality due to gastric adenocarcinoma and evaluating postoperative morbidity at the Edgardo Rebagliati Martins Hospital.

METHODS

The study included 282 patients, which had undergone surgery between January 1, 1996 and December 31, 1999 and the evaluation involved filiation, background, tumor location, Bormann and Early Cancer classifications, histological classification, number of resected lymphatic nodes, extragastric compromise, type of surgery and reconstruction, TNM classification, clinical stage and medical and surgical complications.

RESULTS

Patients were divided in two groups: Survivors (n=251) and deceased (n=31) evidencing 31.56% morbidity and 10.99% mortality. The factors associated with mortality were: age, hypertension (AHT), cardiopathy, tumor location in the stomach, extragastric compromise of the liver, T3 and T4 tumors, N1, distant metastases, clinical stage IV, pneumonia and other surgical complications.

CONCLUSIONS

These results lead us to conclude that proper preoperative staging of the disease is necessary and so is special care with patients suffering of hypertension, diabetes and cardiopathy.Finally, we consider it pertinent to bear in mind the postoperative complications, for proper management of them.

Atopy and serum eosinophil cationic protein in 110 white children with vernal keratoconjunctivitis: differences between tarsal and limbal forms

BACKGROUND

A predominance of Th2 response has been suggested in vernal keratoconjunctivitis (VKC), and a high prevalence of IgE-sensitized (IgE-S) patients has been reported (positive skin prick test or serum-specific-IgE). Palpebral and bulbar VKC are considered to be expressions of the same disease and only occasional racial and histopathological differences are described between the two forms. Tear levels of eosinophil cationic proteins have been correlated with the severity of ocular symptoms; however, there is no published study that demonstrates the presence of serum markers of disease activity.

OBJECTIVE

This study was performed to evaluate the prevalence of IgE-sensitization in palpebral, bulbar and mixed VKC and to determine possible useful markers of disease activity in peripheral circulation.

METHODS

A total of 110 white VKC patients (mean age 8.3 years, range 3.2-18 years) were evaluated for ocular score in the active phase of the disease. Skin prick tests and serum-specific IgE for common allergens, serum-total IgE, peripheral blood eosinophil counts (PBECs) and serum eosinophil cationic protein (s-ECP) were determined. Fifteen age-matched non-IgE-S control children underwent the same determinations.

RESULTS

s-ECP, PBECs and s-total IgE were significantly higher in IgE-S than in non-IgE-S VKC patients and in non-IgE-S VKC patients than in controls. A lower prevalence of IgE-S patients was found in bulbar vs. tarsal (P = 0. 050) or mixed forms (P = 0.002). The score of giant papillae was strongly correlated with s-ECP levels (P < 0.001) and with PBECs (P = 0.001).

CONCLUSIONS

Our data suggest that an overall eosinophilic response is present in VKC independently of IgE-sensitization; bulbar forms, unlike tarsal and mixed forms, were associated with a low prevalence of IgE-sensitization. Serum ECP was a useful marker of disease activity in tarsal and mixed forms.

Reference values of interrupter respiratory resistance in healthy preschool white children

BACKGROUND

Interrupter respiratory resistance (Rint) is reported to be useful in evaluating lung function in poorly collaborating patients. However, no reference values are available from large samples of preschool children using the standard interrupter method. The aim of this study was to define reference Rint values in a population of healthy preschool children.

METHODS

Rint was assessed without supporting the cheeks in children with no history of wheeze from six kindergartens. To evaluate the effects of upper airway compliance on Rint in healthy children, an additional group of preschool children with either no history of wheeze or no respiratory symptoms at the time of testing underwent Rint measurements in our lung function laboratory with and without supporting the cheeks. Short term (about 1 minute apart) and long term (mean 2.5 months apart) repeatability of Rint measurements (2 SDs of the mean paired difference between measurements) was also assessed in children referred for cough or wheeze.

RESULTS

A total of 284 healthy white children (age range 3.0–6.4 years) were evaluated. Mean inspiratory and expiratory Rint (Rinti and Rinte) did not differ significantly in boys and girls. Age, height, and weight showed a significant inverse correlation with both Rinti and Rinte in the univariate analysis with linear regression. Multiple regression with age, height, and weight as the independent variables showed that all three variables were significantly and independently correlated with Rinti, whereas only height was significantly and independently correlated with Rinte. Supporting the cheeks had no significant effect on Rinti (n=29, median 0.673 v0.660 kPa/l.s, p=0.098) or Rinte (n=39, median 0.702v 0.713 kPa/l.s, p=0.126). Short term repeatability was 0.202 kPa/l.s for Rinti (n=50) and 0.242 kPa/l.s for Rinte (n=69). Long term repeatability was 0.208 kPa/l.s for Rinte (n=26).

CONCLUSIONS

We have reported reference Rint values in preschool white children and have demonstrated the usefulness of this technique in assessing lung function in this age group.

Reference values of interrupter respiratory resistance in healthy preschool white children

BACKGROUND

Interrupter respiratory resistance (Rint) is reported to be useful in evaluating lung function in poorly collaborating patients. However, no reference values are available from large samples of preschool children using the standard interrupter method. The aim of this study was to define reference Rint values in a population of healthy preschool children.

METHODS

Rint was assessed without supporting the cheeks in children with no history of wheeze from six kindergartens. To evaluate the effects of upper airway compliance on Rint in healthy children, an additional group of preschool children with either no history of wheeze or no respiratory symptoms at the time of testing underwent Rint measurements in our lung function laboratory with and without supporting the cheeks. Short term (about 1 minute apart) and long term (mean 2.5 months apart) repeatability of Rint measurements (2 SDs of the mean paired difference between measurements) was also assessed in children referred for cough or wheeze.

RESULTS

A total of 284 healthy white children (age range 3.0-6.4 years) were evaluated. Mean inspiratory and expiratory Rint (RintI and RintE) did not differ significantly in boys and girls. Age, height, and weight showed a significant inverse correlation with both RintI and RintE in the univariate analysis with linear regression. Multiple regression with age, height, and weight as the independent variables showed that all three variables were significantly and independently correlated with RintI, whereas only height was significantly and independently correlated with RintE. Supporting the cheeks had no significant effect on RintI (n=29, median 0.673 v 0.660 kPa/l.s, p=0.098) or RintE (n=39, median 0.702 v 0.713 kPa/l.s, p=0.126). Short term repeatability was 0.202 kPa/l.s for RintI (n=50) and 0.242 kPa/l.s for RintE (n=69). Long term repeatability was 0.208 kPa/l.s for RintE (n=26).

CONCLUSIONS

We have reported reference Rint values in preschool white children and have demonstrated the usefulness of this technique in assessing lung function in this age group.

Changes in mental health and service use after termination of SSI benefits

OBJECTIVE

Supplemental Security Income (SSI) benefits for a substance abuse disability were terminated by federal legislation as of January 1, 1997. This study examined the changes in mental health and in the use of mental health services two years after the legislation was implemented among individuals who had been receiving benefits under this classification.

METHODS

From a random sample of 400 SSI beneficiaries in Los Angeles, 253 were interviewed at the time the legislation took effect and again at 12-month, 18-month, and 24-month follow-ups. The study subjects were characterized by income source after the legislation and by probable mental health diagnosis. Their use of mental health services was also measured.

RESULTS

The mental health status of the participants remained unchanged between baseline and 24-month follow-up. The proportion who reported any use of mental health services decreased, primarily among those who continued receiving SSI benefits under a different classification. Among those who lost SSI benefits, emergency department visits and hospitalizations did not increase, and rates of outpatient visits remained the same.

CONCLUSIONS

Contrary to expectations, the mental health status of individuals who had been receiving SSI benefits for a substance abuse disability did not worsen after the benefits were terminated. Local safety nets and reclassification under another disability may have mitigated the effects of the policy change. The results of this study underscore the need for longitudinal data to inform policy decisions.

Clinical features of acute anaphylaxis in patients admitted to a university hospital: an 11-year retrospective review (1985-1996)

BACKGROUND

Although anaphylaxis is considered a life-threatening event, there is a lack of information on the clinical characteristics at presentation, both in adults and in children.

OBJECTIVE

To describe in a nonselected population the clinical characteristics and the treatments of acute anaphylaxis triggered by different agents.

METHODS

This is a retrospective review of the clinical features of 113 episodes of acute anaphylaxis resulting in admission to a university hospital. Initially, the 107 patients visited the emergency room and were then admitted to the hospital.

RESULTS

Most anaphylactic events (63%) occurred at home. The most frequent symptoms involved the respiratory system (78%) and the skin (90%). Drugs, especially nonsteroidal anti-inflammatory drugs and antibiotics, were the most frequent cause of anaphylaxis in adults (49%). Patients with drug-induced anaphylaxis were older and more often had cardiovascular symptoms (hypotension and tachycardia) (P = 0.0064). Hymenoptera venom was the second most frequent cause of anaphylaxis (29%). Most of the patients with hymenoptera venom anaphylaxis were male (80%) and more frequently they had no history of atopy (P = 0.012). In food-induced anaphylaxis, the cardiovascular system was less likely to be involved (P < 0.05) (39%). Seafood seems to be frequently involved in food-induced anaphylaxis in our area. Specific immunotherapy-induced anaphylaxis occurred more often in younger patients (P = 0.032). Epinephrine seems to be underused in Italy (only 15% of patients received it), especially for respiratory symptoms.

CONCLUSIONS

Anaphylaxis triggered by different agents may have different clinical presentations and may occur in different types of patients. In Italy, the inadequate use of epinephrine for anaphylaxis treatment needs to be publicized to both physicians and the general population.

Enhancing transgender health care

As awareness of transgender men and women grows among health care educators, researchers, policymakers, and clinicians of all types, the need to create more inclusive settings also grows. Greater sensitivity and relevant information and services are required in dealing with transgender men and women. These individuals need their identities to be recognized as authentic, they need better access to health care resources, and they need education and prevention material appropriate to their experience. In addition, a need exists for activities designed to enhance understanding of transgender health issues and to spur innovation.

The health and mental health of disabled substance abusers

In 1996 Congress terminated Supplemental Security Income (SSI) benefits to individuals disabled by substance abuse. Although most were expected to continue benefits under another disability category, 64% were not reclassified. This article examines data from a longitudinal study of individuals in Los Angeles County affected by the legislation. While poor physical health predicted both continued SSI benefits and receipt of public income assistance, many individuals reporting significant mental and physical health problems were not reclassified and did not receive public income assistance, raising concern for their welfare. Local safety nets may become increasingly important for this population.

[Pseudoallergies]

Pseudo-allergic-reactions (PAR) are clinical manifestations including urticaria, angioedema, conjunctivitis, rhinitis, asthma, and anaphylaxis. The prevalence of PAR ranges from 0.1% to 75% according to various studies. The pathogenetic mechanism of these diseases is not immunologically mediated. Food, additives, and drugs are the main responsibilities for PAR. The diagnosis of PAR is characterized by the absence of specific IgE for the suspected products. The absence of immunological mechanisms is confirmed by in vitro and in vivo tests. The treatment of PAR is similar to that of allergic diseases (antihistamine drugs, steroids, B2 agonists, epinephrine).

Nonsteroidal progesterone receptor ligands with unprecedented receptor selectivity

We have characterized a series of nonsteroidal progesterone receptor ligands, the tetrahydropyridazines. Compounds in this series, exemplified by RWJ 26819, demonstrate high affinity and unprecedented specificity for the progesterone receptor relative to other steroid hormone receptors. Like steroidal progestins, RWJ 26819 induces binding of the receptor to a progesterone response element in vitro, and stimulates gene expression in and proliferation of T47D human breast cancer cells. When administered to rabbits orally or subcutaneously, the compound induces histological changes in the uterine lining comparable to those induced by levonorgestrel. It also inhibits ovulation in monkeys. Though less potent in cells and in animal models than would be predicted from binding affinity alone, their enhanced selectivity suggests that they could be effectively used in a clinical setting. Most of the tetrahydropyridazines synthesized are progestin agonists or mixed agonists and antagonists in vitro; however, one compound with antagonist activity in the rabbit uterine transformation assay has been identified.

Is the paternal mononuclear cells' immunization a successful treatment for recurrent spontaneous abortion?

PROBLEM

Alloimmunization as a treatment for recurrent spontaneous abortion (RSA) is still controversial due to the lack of enough controls to evaluate its effectiveness. The present study was conducted to compare the live birth rate in the presence or absence of immunotherapy.

METHOD OF STUDY

Ninety-two women with RSA (79 primary [PA] and 13 secondary aborters[SA]) received immunotherapy. Thirty-seven RSA couples not receiving paternal alloimmunization, constituted the "control" group.

RESULTS

The pregnancy rate in alloimmunized was 58 vs 46% in the control group. The live birth increased from 71% in the controls to 88% after immunotherapy. The alloimmunization induced mixed lymphocyte reaction blocking factors (MLR BFs) in 79% of women. However, they were also present in 83% of immunized women experiencing a new abortion.

CONCLUSION

These results indicate that alloimmunization may be useful in the treatment of RSA.

Rabbit corpus cavernosum smooth muscle shows a different phosphodiesterase profile than human corpus cavernosum

PURPOSE

Cyclic nucleotide phosphodiesterases (PDEs) are important regulators of cAMP/cGMP secondary messenger systems. Fluctuations in the level of cyclic nucleotides control the smooth muscle tone of corpus cavernosum. It had been shown that milrinone, a PDE3 inhibitor, was as potent as sildenafil, a PDE5 inhibitor, in relaxing human corpus cavernosum. However, milrinone is much less effective in relaxing rabbit corpus cavernosum than sildenafil. PDEs in rabbit corpus cavernosum were characterized and organ bath experiments were carried out in an attempt to search for the biochemical basis of this species difference.

MATERIALS AND METHODS

In a biochemical study, PDE isozymes from rabbit corpus cavernosum were isolated by FPLC and characterized by PDE assay. In organ bath experiments, rabbit corpus cavernous tissue strips were precontracted and increasing doses of various inhibitors were added.

RESULTS

The major PDE in rabbit corpus cavernosum is PDE5. There are small amounts of PDE2 and PDE1. PDE3, which contributes significantly to the total PDE activity in human corpus cavernosum, is apparently lacking in rabbit corpus cavernosum. Organ bath experiments with isotype-specific inhibitors confirm this conclusion.

CONCLUSION

The distribution of PDE isozymes in corpus cavernosum is different in human and in rabbit. This could be the biochemical basis for the differential effects of milrinone in relaxing rabbit and human corpus cavernosum. Our study emphasizes the importance of a more complete understanding of the tissue distribution of targeted proteins in an animal model before applying the results to humans.

Treatment of recurrent glioblastoma multiforme using fractionated stereotactic radiosurgery and concurrent paclitaxel

Despite the progress in neurosurgery and radiotherapy, almost all patients treated with malignant gliomas develop recurrent tumors and die of their disease. Eighty-eight patients (median age 56 years) with recurrent glioblastoma (median tumor volume 32.7 cm3) were treated with noninvasive fractionated stereotactic radiosurgery and concurrent paclitaxel used as a sensitizer. The median interval between diagnosis of primary glioblastoma and salvage radiosurgery was 7.8 months. Four weekly treatments (median dose: 6.0 Gy) were delivered after the 3-hour paclitaxel infusion (median dose: 120 mg/m2). Survival was calculated by the Kaplan-Meier method from radiosurgery treatment. Overall median survival was 7.0 months, and the 1-year and 2-year actuarial survival rates were 17% and 3.4%, respectively. When grouped by performance status, there was no difference in survival between the patients with low and high Karnofsky score. Patients with tumor volume less than 30 cm3 survived significantly longer than those with tumor greater than 30 cm3 (9.4 vs. 5.7 months, p = 0.0001). Their 1-year survival rate was 40% and 8%, respectively. Eleven patients (11%) had reoperation because of expanding mass. Stable disease was seen in 40% of patients (n = 34), and increase in radiographically detected mass was observed in 41 patients (48.8%). Although the treatment of recurrent GBM is mostly palliative, the fractionated radiosurgery offers a chance for prolonged survival, especially in patients with a smaller tumor volume.

Urinary eosinophil protein X and serum eosinophil cationic protein in infants and young children with atopic dermatitis: correlation with disease activity

BACKGROUND

Eosinophil cationic protein (ECP) and eosinophil protein X (EPX) or eosinophil-derived neurotoxin (EDN) are released by eosinophil granulocytes in allergic diseases. Serum ECP (s-ECP) levels have been correlated with disease activity in atopic dermatitis (AD) in adults and young patients, and high urinary EPX (u-EPX) levels in asthmatic patients seem to reflect active disease. A relationship between AD severity and u-EPX concentration in young children has not been previously studied.

OBJECTIVE

This study was performed to evaluate whether the severity of AD in infants and young children was correlated with s-ECP and u-EPX levels.

METHODS

Fifty-four infants and children (mean age, 17.7 months; range, 4-48 months) with AD and without other allergic conditions were evaluated. The severity of AD was measured by using the SCORAD index. S-ECP, serum total IgE, serum-specific IgE for common allergens, and peripheral blood eosinophil counts (PBECs) were determined. In forty-two children u-EPX was also measured. Seven age-matched control patients underwent the same determinations.

RESULTS

S-ECP and u-EPX were significantly higher in children with AD than in control children (mean, 23.9 vs 3.5 microg/dL [P <.001] and 57.7 vs 6.0 microg/mmol creatinine [P <.001]). A significant correlation was found between SCORAD and s-ECP (P =.002), u-EPX (P =.01), and PBECs (P =.01) and between symptom index and uEPX (P =.0004). PBECs were strongly correlated to s-ECP and u-EPX (P <.0001). However, 5 patients with moderate and severe AD (11.9%) showed low levels of s-ECP, u-EPX, and PBECs.

CONCLUSION

S-ECP and u-EPX were useful markers of AD activity in infants and young children. When taken together, the two determinations could give more information about the clinical course of the illness. Some patients seemed to have clinical exacerbations without an involvement of eosinophils and their products.

Changes in mesenteric blood flow response to feeding: conventional versus fiber-optic phototherapy

OBJECTIVE

To evaluate whether fiberoptic phototherapy influences the postprandial increase in mesenteric blood flow velocity similarly to conventional phototherapy in preterm infants.

PATIENTS AND METHODS

With the use of Doppler color ultrasonography, blood flow velocity in the superior mesenteric artery was measured both preprandially and postprandially in 19 preterm infants during and after conventional phototherapy, and in 20 preterm infants during and after fiber-optic phototherapy. The mean arterial blood pressure/mean flow velocity ratio was calculated as an estimate of relative vascular resistance of the superior mesenteric artery.

RESULTS

The study shows that conventional phototherapy blunts the postprandial mesenteric blood flow response to feeding in preterm infants. Furthermore, it shows that the postprandial increase in intestinal blood flow is not attenuated when fiber-optic phototherapy is administered, and that such postprandial increase of blood flow is significantly greater than in infants receiving conventional phototherapy. During and after fiber-optic phototherapy, a significant reduction in postprandial relative vascular resistance was found; such reduction was significantly greater than during conventional phototherapy.

CONCLUSIONS

Fiber-optic phototherapy is preferable to conventional phototherapy for the treatment of hyperbilirubinemia in preterm infants because it does not affect the physiologic postprandial redistribution of blood flow from the periphery to the gastrointestinal system as does conventional phototherapy.