Bronchoalveolar lavage cytology in children with chronic unexplained cough and severely neurologically impaired children

OBJECTIVE

We aimed to compare the cellular composition of bronchoalveolar lavage (BAL) fluids in children with chronic unexplained cough (group 1) and severely neurologically impaired children with chronic or recurrent respiratory problems (group 2) with the BAL cytology of children without pulmonary or systemic diseases (group 3).

METHODS

Bronchoscopy with BAL fluid analysis was performed in all subjects. Children with respiratory symptoms underwent 24-hour multichannel intraluminal impedance monitoring.

RESULTS

A significant difference was found between the groups in the total number of cells in BAL fluid cytology (191 [range, 24-12,747], 747 [range, 53-13,000], and 105 [range, 41-233] cells/μL, P = .015), in the percentage of neutrophils (21.2 [SD = 32.4], 49.4 [SD = 36.6], and 3.6 [SD = 2.4], P < .001), and in the percentage of lipid-laden macrophages (10.3 [SD = 11.4], 13.7 [SD = 15.8] and 0.44 [SD = 1.0], P < .001).

CONCLUSION

The BAL fluid cytology provides useful data for determining the cause of chronic unexplained cough and chronic or recurrent respiratory problems in severely neurologically impaired children.

Weakly Hard Real-Time Model for Control Systems: A Survey

The concept of weakly hard real-time systems can be used to model real-time systems that may tolerate occasional deadline misses in a bounded and predictable manner. This model applies to many practical applications and is particularly interesting in the context of real-time control systems. In practice, applying hard real-time constraints may be too rigid since a certain amount of deadline misses is acceptable in some applications. In order to maintain system stability, limitations on the amount and distribution of violated deadlines need to be imposed. These limitations can be formally expressed as weakly hard real-time constraints. Current research in the field of weakly hard real-time task scheduling is focused on designing scheduling algorithms that guarantee the fulfillment of constraints, while aiming to maximize the total number of timely completed task instances. This paper provides an extensive literature review of the work related to the weakly hard real-time system model and its link to the field of control systems design. The weakly hard real-time system model and the corresponding scheduling problem are described. Furthermore, an overview of system models derived from the generalized weakly hard real-time system model is provided, with an emphasis on models that apply to real-time control systems. The state-of-the-art algorithms for scheduling tasks with weakly hard real-time constraints are described and compared. Finally, an overview of controller design methods that rely on the weakly hard real-time model is given.

INVASIVE FUNGAL INFECTIONS IN CHILDREN TREATED FOR HEMATOLOGIC MALIGNANCIES - A FIVE-YEAR SINGLE CENTER EXPERIENCE

Invasive fungal infections (IFI) are life-threatening complications of intensive chemotherapy treatment, with the incidence in pediatric patients ranging from 2% to 21%. In this article, we describe our 5-year experience of IFI in pediatric oncology patients and its clinical manifestations with radiological findings, treatment and outcome. A retrospective and descriptive survey of IFI in children with hematologic neoplasms was conducted at the Department of Oncology and Hematology, Zagreb Children's Hospital. Medical charts of children 0-17 years of age, of both sexes, treated for leukemias and lymphomas from January 2016 to December 2020 were reviewed. In a 5-year period, 60 patients were treated for hematologic malignancy, acute lymphoblastic leukemia (ALL) being the most prevalent diagnosis. IFI was verified in 9 (15%) children, predominantly in patients with ALL (75%). The specific causative agent was detected in one child, whereas other infections were classified as probable pulmonary aspergillosis. All the patients received standard prophylaxis with fluconazole and treatment with liposomal amphotericin B and voriconazole. The majority of our patients achieved recovery. IFI prevention, diagnosis and treatment remain a challenge. Uniform prophylaxis and therapy protocols, as well as environmental control are of vital importance for the development of better strategies in the prevention, early detection and treatment of IFI in pediatric hematology patients.

The onset of ulcerative colitis upon Helicobacter pylori eradication in a 72-year-old woman: report of a rare case with a 3-year follow-up

BACKGROUND

Epidemiological studies suggest an inverse association between H. pylori infection/exposure and inflammatory bowel disease prevalence/incidence, however, there are no reports of individual patients who developed a "non-transient" ulcerative colitis (UC) following H. pylori eradication.

CASE PRESENTATION

We report a case of a 72-year-old female with an elderly-onset UC developed upon H. pylori eradication and a 3-year follow-up of the progression to steroid-dependent colitis complicated with enteropathic arthritis and final containment of the disease with golimumab. In our patient, H. pylori eradication was associated with the development of pancolitis that evolved into clinically, endoscopically, and pathohistologically confirmed UC.

CONCLUSIONS

The case of our patient provides a unique clinical context for a growing body of literature suggesting molecular mechanisms involved in the interaction of genes, environment, and microbiota to be of critical importance in the etiopathogenesis of UC, and thus, provides a valuable set of complementary translational information for preclinical and epidemiological research on the topic.

The Role of Combined Multichannel Intraluminal Impedance-pH Monitoring in Infants with Brief, Resolved, Unexplained Events

PURPOSE

Data on the relationship between gastroesophageal reflux (GER) and brief resolved unexplained events (BRUE) in infants is scarce. The aim of this study was to identify the characteristics of combined multichannel intraluminal impedance-pH (MII-pH) monitoring in infants who have experienced BRUE.

METHODS

We conducted a prospective study of infants who were hospitalized on account of BRUE and required 24-hour MII-pH monitoring.

RESULTS

Twenty-one infants (mean age, 4.7 months; range, 0.9-8.9 months; male/female, 11/10) participated in this study. BRUE symptoms associated with GER were found in 10 infants (47.6%). Based on the RI on pH-metry alone, only 7 (33.3%) infants were diagnosed with GERD. More than 100 GER episodes detected by MII were found in 10 (47.6%) infants. Nineteen percent of infants were diagnosed with GERD based on both pH and MII.

CONCLUSION

Both acid and non-acid reflux seem to play a significant role in the pathogenesis of GER-related BRUE in infants.

Hallmarks of senescence and aging

The complex process of biological aging, as an intrinsic feature of living beings, is the result of genetic and, to a greater extent, environmental factors and time. For many of the changes taking place in the body during aging, three factors are important: inflammation, immune aging and senescence (cellular aging, biological aging). Senescence is an irreversible form of long-term cell-cycle arrest, caused by excessive intracellular or extracellular stress or damage. The purpose of this cell-cycles arrest is to limit the proliferation of damaged cells, to eliminate accumulated harmful factors and to disable potential malignant cell transformation. As the biological age does not have to be in accordance with the chronological age, it is important to find specific hallmarks and biomarkers that could objectively determine the rate of age of a person. These biomarkers might be a valuable measure of physiological, i.e. biological age. Biomarkers should meet several criteria. For example, they have to predict the rate of aging, monitor a basic process that underlies the aging process, be able to be tested repeatedly without harming the person. In addition, biomarkers have to be indicators of biological processes, pathogenic processes or pharmacological responses to therapeutic intervention. It is considered that the telomere length is the weak biomarker (with poor predictive accuracy), and there is currently no reliable biomarker that meets all the necessary criteria.

Filaggrin and atopic march

There is an increasing number of experimental, genetic and clinical evidence of atopic dermatitis expression as a pre-condition for later development of other atopic diseases such as asthma, food allergy and allergic rhinitis. Atopic dermatitis is a heterogeneous, recurrent childhood disease, also present in the adult age. It is increasingly attributed to systemic features and is characterized by immunological and skin barrier integrity and function dysregulation. To maintain the protective function of the skin barrier, in particular the maintenance of pH, hydration and antimicrobial functions, the filaggrin, among others, plays a significant role. Filaggrin is a multifunctional, histidine-rich, insoluble protein. The lack of filaggrin is associated with various cutaneous (e.g. ichthyosis vulgaris, allergic contact dermatitis) and non-cutaneous (e.g. diabetes, inflammatory conditions of the gastrointestinal tract) diseases and may be a result of genetic, immunological factors combined with environmental factors. In this review we summarised (emphasized) recent findings in understanding the role of filaggrin in atopic dermatitis and other diseases, participants in the atopic march.

Comparison of Obesity Prevalence and Dietary Intake in School-Aged Children Living in Rural and Urban Area of Croatia

The aim of this study was to explore the differences in nutritional status and dietary intakes in 12~17 year-old children living in urban (Zagreb) and the rural (Sinj and Drniš) area of Croatia. A validated food frequency questionnaire was used to assess dietary intake. For each participant, body weight and body height were measured and bioelectrical impedance was used to estimate the body fat percentage. There was an overall of 310 children included: 105 (33.9%) from urban area and 205 (66.1%) from rural area; 191 (61.6%) were female with a mean age 14.9 (range 12~17) years. When adjusted for age and gender, there was no statistically significant difference in body mass index for age Z-scores between urban and rural parts (0.23±0.07 vs. 0.30±1.15; P=0.650) or in average daily energy intake (2,479.2±1,111.2 kcal vs. 2,338.2±920.2 kcal; P=0.702). There was a statistically significant difference in nutritional status between genders, with a higher percentage of boys being overweight or obese compared to girls. When combined, 'Fast food' and 'Snacks' were major contributors to the total energy intake for both areas. The mean contribution of 'Fast food' to total energy intake was significantly higher in the urban area. The prevalence of obesity among Croatian children is high and unrelated to the urban/rural setting, which could be partially explained by the high intake of 'Fast food' and 'Snacks'.

ACUTE RESPIRATORY DISTRESS SYNDROME IN A FOUR-YEAR-OLD BOY WITH DIABETIC KETOACIDOSIS - CASE REPORT

SUMMARY – Among many disease states as known initiators of acute respiratory distress syndrome (ARDS), diabetic ketoacidosis (DKA) is the rarest one. We present a 4-year-old boy with DKA as the first manifestation of insulin-dependent diabetes mellitus who developed ARDS, required tracheal intubation and mechanical ventilation, and survived without significant sequels. To improve survival of patients with ARDS as a complication of DKA, physicians should be aware of this rare pulmonary complication and its appropriate management.

Growth of Children with Food Allergy

BACKGROUND

The prevalence of food allergy in children is increasing worldwide. Strict avoidance of identified allergens from the diet is still the cornerstone of the management of food allergies. There are widespread concerns that food allergy and elimination diet may predispose children to nutrient deficiencies and growth failure.

AIM

The aim of this paper was to review the current evidence on growth of children suffering from food allergy. Summarised is literature on the effects of the number and type of offending allergens, the child's age and affected organ system, as well as the importance of supervision by a dietician/nutritionist.

CONCLUSION

Children suffering from food allergy are stunted at the time of diagnosis and during the elimination diets, irrespective whether or not their nutritional requirements were fulfilled, and/or were under the control of a dietician. This underscores the need for further studies to obtain more precise insight into and better understanding of the mechanisms contributing to growth failure in children suffering from food allergy.
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Combined multichannel intraluminal impedance-pH monitoring should be used to diagnose reflux-related otitis media with effusion in children

AIM

This study investigated the diagnostic usefulness of combined multichannel intraluminal impedance-pH monitoring (MII-pH) in children with suspected reflux-related otitis media with effusion (OME) as existing data were scarce.

METHODS

This was a prospective study that included children up to seven years of age who underwent MII-pH due to OME lasting more than three months. The study was conducted in the Children's Hospital Zagreb, Croatia, from January 2014 to August 2016.

RESULTS

The study comprised 63 children (63% male) with a mean age of 4.7 years. Gastroesophageal reflux (GER) disease was detected by impedance in 22 (35%) of the children and by pH-metry in nine (14%). In children with OME, MII-pH found a median number of 24 proximal GER episodes, of which a median of nine was acidic and a median of 11 was weakly acidic. There was a significant positive correlation between the number of GER episodes and the presence of eosinophils in nasal swabs.

CONCLUSION

Both acidic and weakly acidic refluxes seemed to play a significant role in the pathogenesis of OME. Localised nasal eosinophilia may serve as a marker of extraoesophageal reflux in children with suspected reflux-related OME.

European shortage of purified protein derivative and its impact on tuberculosis screening practices

SETTING

In June 2014, we became aware that shortages of purified protein derivative (PPD), the test substance used for the tuberculin skin test (TST), had occurred in several European health care institutions providing care for children with tuberculosis (TB).

OBJECTIVE

To establish the extent of the shortage, a survey was performed.

DESIGN

Survey conducted over a 1-month period (June-July 2014) among members of the Paediatric Tuberculosis Network European Trials Group (ptbnet).

RESULTS

Thirty-five physicians from 23 European countries contributed data. The most commonly used PPD product was RT23 (Statens Serum Institut; n = 22, 63%). Twenty-one (60%) participants reported that their institution was experiencing a PPD shortage. The majority (n = 17, 81%) of those reporting a shortage were using RT23. Thirteen (37%) participants reported changes in screening practices resulting from the shortage, including sourcing PPD from alternative manufacturers, restricting remaining supplies to patients at greatest risk or replacing TST by an interferon-gamma release assay.

CONCLUSIONS

The data show that a PPD shortage occurred in 2014, affecting multiple European countries. The shortage resulted in changes in TB screening capabilities and practices, potentially compromising both patient care as well as public health efforts. Appropriate actions to prevent future PPD shortages should be explored urgently by public health agencies and key stakeholders.

The importance of combined 24-hour multichannel intraluminal impedance-pH monitoring in the evaluation of children with suspected laryngopharyngeal reflux

OBJECTIVE

The aim of this study was to investigate the diagnostic usefulness of combined multichannel intraluminal impedance-pH (MII-pH) monitoring in children with suspected laryngopharyngeal reflux (LPR).

DESIGN, SETTING AND PARTICIPANTS

A prospective study including children in whom, due to LPR suggestive symptoms, MII-pH monitoring was performed at tertiary medical centre from February 2012 to July 2015.

INTERVENTIONS

All included children underwent same diagnostic protocol which included examination by single pulmonologist and ENT specialist and underwent 24-hour MII-pH monitoring.

MAIN OUTCOMES

Primary outcome was to determine MII-pH characteristics of the children in whom LPR was suspected based on symptoms and ENT examination.

RESULTS

One hundred and four patients (mean age 8.9 years; range 0.4-17.9 years; male/female 57/47) participated in the study. In children with signs and symptoms suggestive of LPR, MII-pH monitoring found the median incidence of proximal gastro-oesophageal reflux (GER) of 15 (range 0-129), proximal acidic GER of 6.5 (range 0-66) and weakly acidic GER of 5 (range 0-102). There were significant positive correlations between the number of GER (proximal total, acidic and weakly acid) with Reflux Finding Score, Reflux Symptom Index and presence of eosinophils in nasal swabs. The only endoscopy ENT finding which significantly correlated with total proximal GER, acid proximal GER and weakly acidic proximal GER was arytenoid hyperaemia.

CONCLUSION

Both acid and non-acid reflux seem to have a significant role in the pathogenesis of LPR.

The role of combined 24-h multichannel intraluminal impedance-pH monitoring in the evaluation of children with gastrointestinal symptoms suggesting gastro-esophageal reflux disease

BACKGROUND

The aim of this study was to determine the role of multichannel intraluminal impedance-pH (pH-MII) monitoring in the diagnosis of gastro-esophageal reflux disease (GERD) in children who presented with gastrointestinal (GI) symptoms in comparison with the results of pH-metry alone and endoscopy.

METHODS

All children who underwent pH-MII monitoring due to GI symptoms, suggestive of GERD, from October 2013 to October 2015 in Children's Hospital Zagreb, were retrospectively enrolled in the study. The cohort was divided into three groups according to age - group 1: children <1 year of age; group 2: 1-9 years of age; and group 3: ≥9 years of age.

KEY RESULTS

One hundred thirty-three patients met our inclusion criteria (73 female/60 male; mean age 9.2 years [0.19-18.0]). Gastro-esophageal reflux disease was determined in 44 of 133 patients (33.1%) by pH-MII and only in 21 of 133 patients (15.8%) by pH-metry alone. Endoscopy was performed in 77 (57.9%) children and esophagitis was found in 32/77 (41.6%). The finding of esophagitis significantly correlated with the number of total reflux episodes (coef. 0.42, p < 0.001), acidic (coef. 0.26, p = 0.02), weakly acidic (coef. 0.3, p = 0.008) and non-acidic (coef. 0.26, p = 0.02) reflux episodes detected by pH-MII; but, no correlation was found to reflux episodes detected by pH-metry alone (coef. 0.21, p = 0.07).

CONCLUSIONS & INFERENCES

Compared with pH-metry alone, pH-MII performed significantly better in the detection of GERD in all age groups. On the basis of our data, pH-MII had a strong correlation with endoscopically confirmed esophagitis.

Discordance Between Tuberculin Skin Test and Interferon-γ Release Assay in Children Younger Than 5 Years Who Have Been Vaccinated With Bacillus Calmette-Guérin

BACKGROUND

Interferon-γ release assays (IGRAs) offer the possibility of improved detection of latent tuberculosis infection (LTBI).

OBJECTIVE

To analyze discordant tuberculin skin testing (TST) and IGRA results in ethnic Croatian children as old as 5 years for whom there is documented exposure to an adult with active tuberculosis (TB) and who have been vaccinated with Bacillus Calmette-Guérin.

METHODS

In specimens from our cohort individuals, we tested the performances of the QuantiFERON-TB Gold In-Tube (QFT-GIT) test and TST and analyzed discordant results.

RESULTS

At the TST cutoff value of 10 mm or greater, the estimated prevalence of M. tuberculosis infection was 18.1% (31/171) using TST and 15.2% (26/171) using QFT-GIT. The results of these 2 tests showed an overall concordance of 87.7%. There was no evidence that subjects' age correlated with discordant results.

CONCLUSIONS

The reasons for discordant results in young children are still unclear, which highlights the importance of further longitudinal studies to better understand the interpretation and any possible clinical implications of the results of these tests.

The Relationship Between Gastroesophageal Reflux and Chronic Unexplained Cough in Children

The aim of this study was to assess the association between chronic cough and acid or weakly acid gastroesophageal reflux (GER) determined by 24-hour multichannel intraluminal impedance-pH monitoring and to assess whether the association is age dependent. Overall 150 children (mean age 7.5 years; range 0.3-18.0 years; male/female 90/60) were enrolled. Median of 87.5% (0% to 100%) of all cough episodes were associated with reflux; 9% (0% to 100%) with acidic and 60% (0% to 100%) with weakly acidic episodes. In 52 children (34.7%), all cough episodes were associated with GER (100% association). Children younger than 2 years had significantly higher number of cough episodes associated with total (P = .03) and weakly acidic GER (P = .01). Binary logistic regression confirmed that only increase in age decreases the risk for complete (100%) association between cough episode and GER. Cough is significantly associated with weakly acidic GER and children of younger age are at higher risk.

[Which tuberculin skin test hyperreactive child should be treated with -our experience]

Since persons with latent tuberculosis infection (LTBI) represent a huge reservoir of potential tuberculosis (TB) disease, accurate diagnosis and treatment of LTBI is essential for TB control and eradication. The aim was to assess the diagnostic value of determination of interferon-gamma release assay in school children with hyperreactive tuberculin skin test (TST) reaction. A total of 120 BCG-vaccinated children were investigated due to a hyperreactive TST results. The QuantiFERON-TB Gold In-Tube test (QFT-GIT) was performed. Fifteen children (12.5%) had positive QFT-GIT and 105 (87.5%) children had negative QFT-GIT. There was no statistically significant difference in TST reaction (21.5 mm u QFT+ vs. 20.9 mm u QFT-group, p=0.458). The children with positive QFT-GIT had a statistically higher level of interferon-gamma (IFN-γ) than children with negative QFT-GIT. There were no statistically significant differences in concentrations of IFN-y either basic or upon stimulation with mitogen phytohemagglutinin. After isoniazid prophylaxis QFT-GIT remained positive in two children (p=0.019). In a difficult procedure for diagnosing LTBI in BCG-vaccinated children determination of IFN-γ could be the key factor in making decision whether to use preventive therapy or not.

The effects of parental smoking on anthropometric parameters, peak expiratory flow rate and physical condition in school children

Passive smoking in children is a considerable health problem, mainly arising from parental smoking. The objectives of the present cross-sectional study were to assess the impact of passive smoking on 1) anthropometric parameters; 2) peak expiratory flow rate (PEFR); and 3) physical condition in school children. The target population included 177 children attending elementary school 5th to 8th grade. Study subjects were divided into two groups according to parental smoking habits. Body weight and height were determined using a digital weighing scale and digital stadiometer; PEFR was measured between 8 a.m. and 10 a.m. using a Peak Flow Meter; and physical condition was assessed by the 6-minute run test. Sixty-six percent of study children were exposed to passive smoking. The children of smoking parents had higher BMI [18.79 (17.50-21.13) kg/m2] than children of nonsmoking parents [17.90 (16.00-20.00) kg/m2; p = 0.036]. There was no statistically significant difference in body height and weight. The children of smoking parents had statistically lower values of PEFR [M(IQR) = 84 (78-88)%, M(IQR) = 94 (89-101)%, respectively; p < 0.0001] and 6-minute run test than children of nonsmoking parents [M(IQR) = 2(1-3), M(IQR) = 4(3-5); respectively; p < 0.0001]. The results of the present study showed that exposure of school children to passive smoking by their parents resulted in an increase of BMI, impairment of lung function, and impairment of physical condition, especially in children of both smoking parents.

Palisaded neutrophilic and granulomatous dermatitis in association with subcutaneous nodular and systemic sarcoidosis

Palisaded neutrophilic granulomatous dermatitis (PNGD) is a rare entity that has been clearly defined neither clinically nor histopathologically. PNGD has been associated with some immune-mediated disorders such as rheumatoid arthritis, systemic lupus erythematosus, systemic vasculitis, Behçet's disease, as well as with lymphoproliferative conditions, bacterial endocarditis, sarcoidosis, and various drugs. We present a 44-year-old Caucasian woman with roundish erythematous-livid plaque and erythematous papules on the left calf that were present for three months. Histopathology of plaque lesion showed palisading neutrophilic and granulomatous dermatitis. Subsequently, she developed a firm and tender nodule on the right calf. Histopathology of the nodule showed typical naked sarcoid granulomas in the dermis and subcutis. Additionally, the patient developed non-tender subcutaneous nodules on the cheeks, submandibular region and left breast with normal overlying skin, which were histopathologically diagnosed as sarcoid granuloma. Red eyes and lower visual acuity on the right eye were diagnosed as anterior uveitis. Therefore, systemic sarcoidosis was established. This is a case of PNGD described in an adult patient with sarcoidosis with cutaneous, breast, eye and lung involvement established by clinical, radiographic, laboratory, and histopathologic criteria.

Risk factors for acute respiratory tract infections in children

Acute respiratory tract infections (ARTI) are the most common cause of childhood morbidity and an important public health problem. The aim of this study was to identify the significant risk factors for ARTI in children. The study took place in Ivankovo which is a rural area of Eastern Slavonia and with small socio-economic differences. The study population were 159 children who were 3-5 years old at the time of the study, and who were registrated at doctor's office Ivankovo. The study was conducted retrospectively through a questionnaire from January 2008 to December 2008. The risk factors studied were the gender, breastfeeding history, any atopic manifestation in the form of atopic eczema, rhinoconjuctivitis and/or asthma, the size of the family, parents smoking habits and main form of childcare. The number of ARTI requiring the consultation of a doctor throughout 2007 were measured; and whether ARTI had been treated with antibiotic or there were recommendation for symptomatic treatment only. Results of this research show that the risk factor for consulting a doctor because ofARTI in children was passive exposure to cigarette-smoke. For receiving antibiotics because of ARTI in children, the risk factors were passive exposure to cigarette-smoke and atopic manifestation. By giving the available evidence, parents must be told that ceasing smoking offers a significant opportunity to reduce the risk of ARTI in their children.

Influence of passive smoking on functional abilities in children

Passive smoking has been found to be associated with a large number of disorders of passive smokers. It seems that the children are the most susceptible population for harmful effects of passive smoke exposure. The aim of this study was to evaluate the effect of passive smoking on children's functional abilities. The target population was 199 children who were 13-15 years old at the time of the study. For the assessment of motor skills 6-min run test was used. Children exposed to passive smoking by their mothers had statistically significant lower functional abilities (r =-0.7029; 95% CI -0.7707 to -0.6194; p < 0.0001). We also found statistically significant difference if the both parents are smokers (r =-0.3343; 95% CI -0.4595 to -0.1961; p < 0.0001). The results of our study did not show statistically significant difference if the children are exposed to cigarette smoke by their fathers (r = 0.03139; 95% CI -0.1171 to 0.1785; p = 0.6792). Public health preventive actions should go toward minimizing the exposure of children to passive smoking by counseling the smoking parents that quitting smoking provides enormous health benefits not only to them but also to their children.

The influence of mother's active smoking during pregnancy on body mass index of newborns

Many investigations have noted bad influence of smoking during pregnancy. In the present article, the influence of mothers smoking during pregnancy on the body mass index (BMI), birth weight and birth length are examined. This retrospective research included 219 children: Group I: 109 children from rural area of east Slavonia (born in General Hospital-Vinkovci) and group II: 110 children from industrial area (born in Zagreb). The questioned subjects were divided into two groups depending on mothers smoking during pregnancy: newborns of mothers who didn't smoke during pregnancy (subgroup A) and newborns of mother who did smoke 10 or more cigarettes per day during pregnancy (subgroup B). Anthropometric parameters (BMI, birth length and birth weight) in newborns of non-smoking mothers were statistically higher (p < 0.05) than in newborns of smoking mothers. Moderate correlation between birth length and birth weight in newborns of non-smoking and smoking mothers from rural area and from non-smoking mothers in urban area was statistically significant, but correlation in the group in newborns of smoking mothers from Zagreb was not statistically significant. Results of this research show that smoking during pregnancy significantly influences the birth weight and birth length. Further investigation is needed, to investigate the lack of correlation between the birth length and birth weight in newborns of smoking mothers from industrial city.

Indeterminate results of QuantiFERON-TB Gold In-Tube assay in nonimmunosuppressed children

BACKGROUND AND AIMS

QuantiFERON-TB Gold In-Tube (QFT-IT) assay is a highly sensitive and specific test for the diagnosis of latent tuberculosis infection. Data on the use of QFT-IT assay in children are scarce and contradictory. The aim of the study was to assess the rate of indeterminate test results and to identify factors contributing to indeterminate results on routine use of QFT-IT assay in nonimmunosuppressed children.

METHODS

This retrospective study included 2173 children with ages ranging from 1 month to 18 years. Determination of interferon-gamma (IFN-γ) in peripheral blood was performed by commercial QFT-IT assay.

RESULTS

Indeterminate test results were recorded in ten (0.46%) subjects with ages ranging from 15 months to 15 years. The value of negative control was >8.0 kIU/L in one subject, whereas in the remaining nine subjects indeterminate results were consequential to positive control (<0.50 kIU/L). None of these subjects had any history data on congenital or acquired immunodeficiency disorders. Bacterial infection (with elevated body temperature and therapy with β-lactam antibiotics) was present in eight subjects with indeterminate results, one subject had exacerbation of asthma (therapy with inhalation corticosteroids), and one subject was clinically healthy. Repeat IFN-γ determination performed in seven subjects did not yield indeterminate results.

CONCLUSIONS

Study results showed the rate of indeterminate QFT-IT results in nonimmunosuppressed children of all age groups to be very low. QFT-IT should preferably be performed upon resolution of acute inflammation in order to avoid repeat testing of indeterminate results in a new blood sample and to reduce the cost of testing.

Exercise-induced anaphylaxis after ingestion of sandwich with soy containing canned tuna: case report

We report a case of a 17-year-old female adolescent who experienced an episode of exercise-induced anaphylactic reaction following ingestion of tuna sandwich (from soy containing canned tuna). Her medical history revealed that she had previously had one episode of urticaria after ingestion of sulfamethoxazole with trimethoprim and anaphylactic reaction after ingestion of sunflower nuts. Skin prick tests and specific immunoglobulin E antibody to tuna were negative, and to soy were positive. Treadmill exercise induced test in fasting state and 1 hour after a fresh tuna meal and meal not containing soy were negative. However, an exercise challenge test one hour after soy ingestion resulted in pruritus of hands, shoulders and back, urticarial lesions of the face and neck with angioedema of the lips and eyelids, hoarseness, tachycardia and anxiety.

Immunologic aspects of atopic dermatitis

Atopic dermatitis/eczema is a chronically relapsing, pruritic, and inflammatory skin disease. The term "atopic eczema/dermatitis syndrome" covers the "extrinsic" and "intrinsic" atopic dermatitis. The pathogenesis of atopic dermatitis includes complex interaction between the genetic background, skin barrier defects, abnormalities in innate and adaptive immunity, abnormalities of humoral and cellular immunity, and environmental influences. Understanding the immunopathogenesis of atopic dermatitis leads to new diagnostic and therapeutic approaches. The targets in atopic dermatitis are innate immunity including improvement of skin barrier defects by supplementing lipids or inhibiting proteases, and regulating antimicrobial peptides, adaptive immunity, and induction of regulatory T cells.

Hierarchical and redundant lymphocyte subset control precludes cytomegalovirus replication during latent infection

Reactivation from latent cytomegalovirus (CMV) infection is often associated with conditions of immunosuppression and can result in fatal disease. Whether the maintenance of systemic CMV latency is mainly governed by factors of the infected cell or by immune control functions is unknown. Likewise, the putative immune control mechanisms which could prevent the induction and spread of recurrent CMV infection are not clearly identified. We took advantage of latently infected B cell-deficient mice and a sensitive method for virus detection to study CMV reactivation after ablation of lymphocyte subsets. A crucial role of both T lymphocytes and natural killer (NK) cells was demonstrated. Within 5 d after depletion of lymphocytes, productive infection occurred in 50% of mice, and 14 d later 100% of mice exhibited recurrent infection. A hierarchy of immune control functions of CD8(+), NK, and CD4(+) cells was established. Reactivation was rare if only one of the lymphocyte subsets was depleted, but was evident after removal of a further subset, indicating a functional redundancy of control mechanisms. The salivary glands were identified as the site of most rapid virus shedding, followed by the detection of recurrent virus in the lungs, and eventually in the spleen. Our findings document a previously unknown propensity of latent CMV genomes to enter productive infection immediately and with a high frequency after immune cell depletion. The data indicate that only the sustained cellular immune control prevents CMV replication and restricts the viral genome to a systemic state of latency.

Functional regions of the human cytomegalovirus protein pUL97 involved in nuclear localization and phosphorylation of ganciclovir and pUL97 itself

In order to identify functional regions of the human cytomegalovirus protein pUL97 (i) different 5' fragments of the UL97 open reading frame (ORF) were fused to the coding region of the green fluorescent protein and (ii) recombinant vaccinia viruses (rVV) were generated carrying two full-length and 11 mutated UL97 ORFs. The results indicated the presence of an N-terminal region within pUL97 which changed the intracellular distribution of the fusion proteins. pUL97 was localized in the nucleus, but not in the nucleoli, and was detected in the nuclear matrix fraction. Expression of all pUL97 mutants could be confirmed by Western blot analysis. pUL97-associated ganciclovir (GCV) phosphorylation in rVV-infected cells, determined quantitatively by HPLC analysis, was abolished completely using individual UL97 deletion mutants. Phosphorylation of full-length and some of the mutated pUL97 was detected in cells infected with the rVVs. The UL97 constructs carrying point mutations from GCV-resistant HCMV isolates at positions 460M, 520H, 594V, and the 4 aa deletion 590AACR593, also resulted in decreased but not abolished phosphorylation of GCV in the rVV system, whereas the phosphorylation of pUL97 itself was not influenced. The rVV system is a suitable method for quantitatively testing the functional relevance of pUL97 mutations.

Flow cytometric analysis of herpes simplex virus type 1 susceptibility to acyclovir, ganciclovir, and foscarnet

We established a quantitative flow cytometric method for determination of herpes simplex virus type 1 (HSV-1) susceptibility to acyclovir (ACV), ganciclovir, and foscarnet in vitro. Susceptibility was defined in terms of the drug concentration which reduced the number of cells expressing HSV-1 glycoprotein C (gpC) with a fluorescence intensity of > or =10(2) by 50% (IC50). Flow cytometry allowed us to use a high (1.0) as well as a low (0.005) multiplicity of infection, and determination of the IC50 was possible after one or more viral replicative cycles. IC50s were dependent on virus input and on time postinfection. In mixture experiments, 1 to 2% resistant viruses added to a sensitive strain could be detected. The results obtained by flow cytometry showed a good qualitative correlation with those achieved by cytopathic effect inhibitory assay. However, flow cytometry might detect more quantitative differences in drug susceptibility, especially among resistant strains, as confirmed also by determination of intracellular drug phosphorylation. The mean IC50s for ACV-sensitive strains were 0.45 to 1.47 microM, and those for ACV-resistant strains were between 140 and 3,134 microM. Flow cytometric analysis was fast and accurate, automatizable, and highly reproducible. Flow cytometry may be a more powerful tool than standard cytopathic effect-based assays and could have advantages for the detection of low levels of drug resistance or mixtures of sensitive and resistant virus strains.

Phosphorylation of aciclovir, ganciclovir, penciclovir and S2242 by the cytomegalovirus UL97 protein: a quantitative analysis using recombinant vaccinia viruses

We used recombinant vaccinia viruses (rVV) containing the UL97 open reading frame (ORF) of the human cytomegalovirus (HCMV) to investigate the UL97-dependent phosphorylation of different nucleoside analogs. The rVV T1 expressed the wild-type UL97 protein whereas rVV A5 contained a 12 bp deletion in the UL97 which had been known to be responsible for resistance of HCMV to ganciclovir (GCV). The rVV T1opal was generated which contained a stop codon at position 1089 of the UL97 ORF and which expressed a truncated UL97 protein. We quantitatively analyzed the capability of these rVVs to phosphorylate GCV, penciclovir (PCV), aciclovir (ACV) and 2-amino-7-[(1,3-dihydroxy-2-propoxy)methyl] purine (S2242) as well as the natural nucleosides deoxycytidine and deoxythymidine. Moreover, we compared their phosphorylating capability with that of herpes simplex virus type 1 strains. In thymidine kinase (TK)-deficient 143B cells infected with rVV T1, the three compounds GCV, ACV and PCV were phosphorylated with different efficiency whereas in cells infected with the rVV A5 a markedly reduced but not completely abolished phosphorylation of these compounds was observed. In rVV T1opal-infected cells no specific phosphorylation of the compounds was detectable at all. Neither S2242 nor the natural substrates of TKs were phosphorylated by any of the vaccinia recombinants. The rVVs proved to be a suitable tool for analysis of UL97-dependent phosphorylation of nucleoside analogs and also allowed to quantitatively study the influence of UL97 mutations on drug phosphorylation.

The UL97 gene product of human cytomegalovirus is an early-late protein with a nuclear localization but is not a nucleoside kinase

The temporal expression of the UL97 gene product during human cytomegalovirus (HCMV) infection of human foreskin fibroblasts (HFF) and subcellular localization of this protein were analyzed by using a polyclonal antiserum raised against a truncated UL97 protein of 47 kDa. The UL97 protein was detectable 16 h after infection by Western blot (immunoblot) analysis. Since only reduced UL97 expression occurred in the presence of two inhibitors of DNA replication, phosphonoacetic acid and ganciclovir, we conclude that UL97 is an early-late gene, requiring DNA replication for maximum expression. By indirect immunofluorescence, the protein could be visualized in the nuclei of virus-infected HFF 22 h after infection. Nuclear localization of the UL97 protein was also detected in thymidine kinase-deficient 143B cells infected with a recombinant vaccinia virus containing the entire UL97 open reading frame (ORF), as well as in HFF transiently expressing the entire UL97 ORF under the control of HCMV major immediate-early promoter. However, transiently expressed 5'-terminal deletion mutants of the UL97 ORF in addition showed a cytoplasmic localization of the UL97 protein, confirming the presence of a nuclear localization site in the N-terminal region of the protein. Our high-pressure liquid chromatography analyses confirmed the ganciclovir phosphorylation by the UL97 protein, but no specific phosphorylation of natural nucleosides was observed, indicating that the UL97 protein is not a nucleoside kinase. During plaque purification of recombinant UL97-deficient HCMV, this virus was growth defective; hence, we presume that UL97 may be essential for the viral life cycle.

Lack of MHC class I complex expression has no effect on spread and control of cytomegalovirus infection in vivo

It has been claimed that MHC class I proteins serve as receptors for murine cytomegalovirus (MCMV) and that this interaction is the most important mechanism for virus entry in most cells. This claim is based on the observation that the MHC haplotype contributes to the susceptibility to cytomegalovirus (CMV) infection in vivo. Results from in vitro studies support the concept that stable expression of correctly folded MHC class I molecules contributes to infection, since the individual properties of MHC class I alleles, the availability of beta 2-microglobulin (beta 2m) and also the degree of peptide charging of the MHC class I heavy chain beta 2m heterodimers determined the infection phenotype of cell lines. To assess the biological relevance of proper MHC class I expression we investigated CMV infection in beta 2m-deficient mice which fail to express ternary MHC class I complexes and lack peripheral CD8+ T lymphocytes. We found that organ virus titres and virus clearance kinetics were not altered in beta 2m mutant mice. In addition, there was no indication of diminished virus propagation in beta 2m-/- embryonic fibroblasts. beta 2m-/- mice suffered from the lack of CD8+ T lymphocytes that was partially compensated for by the function of CD4+ T lymphocytes. An organ-specific anti-virus function of natural killer (NK) cells was observed, independent from the beta 2m deletion. The immune control unique for salivary gland infection was maintained. From the data presented here, we confirm the role of MHC class I molecules in the immune surveillance of CMV infection but question the biological impact of correct MHC class I complexes for productive infection.

Antibodies are not essential for the resolution of primary cytomegalovirus infection but limit dissemination of recurrent virus

Virus shedding from the epithelial cells of the serous acini of salivary glands is a major source for the horizontal transmission of cytomegalovirus. These cells are, different to other tissues, exempt from CD8 T lymphocyte control. CD4 T lymphocytes are essential to terminate the productive infection. Here, we prove that T-B cooperation and the production of antibodies are not required for this process. For the infection with murine cytomegalovirus, mutant mice were used which do not produce antibodies because of a disrupted membrane exon of the immunoglobulin mu chain gene. Also, in these mice the virus clearance from salivary glands is a function of CD4 T lymphocytes. However, these mice clear the virus and establish viral latency with a kinetics that is distinguishable from normal mice. Reactivation from virus latency is the only stage at which the absence of antibodies alters the phenotype of infection. In immunoglobulin-deficient mice, virus recurrence results in higher virus titers. The adoptive serum transfer proved that antibody is the limited factor that prevents virus dissemination in the immunodeficient host.

The conditions of primary infection define the load of latent viral genome in organs and the risk of recurrent cytomegalovirus disease

Recurrence of cytomegalovirus (CMV) from latency is a frequent cause of disease in immunocompromised patients. To date, there is no explanation for the diversity in the clinical manifestations. Primary infection can occur perinatally or later in life, and inevitably results in latent infection. Seropositivity for antibodies against CMV is indicative of latent infection, but is insufficient as a predictor for the risk of recurrence. As a model for this important medical problem, we compared the risks of murine CMV recurrence from latency established after neonatal primary infection and after infection at adult age. The risk of CMV recurrence was high only after neonatal infection. The copy number of latent viral genome in tissues was identified as the key parameter that determines the overall and organ-specific risks of recurrence. Latent CMV burden and risk of recurrence were related to the extent of virus multiplication during primary infection. The presence of latent CMV in multiple organs provides the molecular basis for stochastic events of recurrence in single organs or in any combination thereof. These findings are discussed as a concept of multifocal CMV latency and recurrence. It provides a rationale for the diversity in the clinical outcome of CMV disease.

Participation of endogenous tumour necrosis factor alpha in host resistance to cytomegalovirus infection

Interferon gamma (IFN gamma) represents an essential cytokine involved in murine cytomegalovirus (MCMV) clearance from the salivary gland and the control of horizontal transmission. Because IFN gamma cannot be responsible for all cytokine effects during recovery from MCMV infection we have now tested the potential participation of tumour necrosis factor alpha (TNF alpha) in the antiviral defence. Neutralization of endogenous TNF alpha abolished the antiviral activity of CD4 T cells in immunocompetent as well as in CD8 subset-deficient mice. These data suggest that the antiviral effect of the CD4 subset requires the presence of at least two cytokines, namely IFN gamma and TNF alpha. Depletion of endogenous TNF alpha in adoptive cell transfer recipients diminished the antiviral function of CD8 T lymphocytes suggesting that TNF alpha also participates in CD8 T cell effector functions. Furthermore, endogenous cytokines were found to be required for survival after infection with lethal doses of MCMV, whereas immunotherapy with recombinant TNF alpha and IFN gamma could not limit virus replication in vivo. The results suggest that, similar to IFN gamma, TNF alpha is an integral part of the protective mechanisms involved in cytomegalovirus clearance.

Gamma interferon-dependent clearance of cytomegalovirus infection in salivary glands

Cytomegalovirus (CMV), similar to other members of the Herpesviridae family, can establish both persistent and latent infections. Each of the CMVs that are found in many animal species replicates in the salivary gland, and oral secretion represents a source of horizontal transmission. Locally restricted replication characterizes the immunocompetent individual, whereas in the immunocompromised host, protean disease manifestations occur due to virus dissemination. The virus is cleared by immune surveillance, and CD8+ T lymphocytes play a major role. Remarkably, certain cell types of salivary gland tissues are exempt from CD8+ T-lymphocyte control of murine CMV infection and require the activity of CD4+ T lymphocytes. The results presented here suggest that this activity is a function of Th1 cells. Neutralization of endogenous gamma interferon abrogated the antiviral activity of Th1 cells but not that of CD8+ T lymphocytes in other tissues. Neutralization of endogenous gamma interferon did not interfere with the induction of the cellular and humoral immune response but acted during the effector phase. Recombinant gamma interferon could not replace the function of Th1 cells in vivo and had limited direct antiviral activity in vitro. The results therefore suggest that gamma interferon represents one, but not the only, essential factor involved in salivary gland clearance, establishment of CMV latency, and, eventually, the control of horizontal transmission.