Ultrasound and Clinical Alterations in the Foot of Children with Obesity and Diabetes

BACKGROUND

Alterations in plantar soft tissues are often reported in adults with diabetes, whereas data on children are conflicting. Also, the extent of foot damage caused by excess body fat in children has not been fully characterized yet. This study aimed to address the relationship between body mass and structural changes of the foot in children and adolescents with and without diabetes.

METHODS

In a case-control study, 43 participants (age 13 ± 2.6 years) were recruited, 29 (67%) with type 1 diabetes (T1D) and 14 (33%) controls. Anthropometric parameters [body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR)], foot posture index-6 (FPI-6) for static foot posture, and navicular drop test (NDT) for medial longitudinal arch height (MLA) were measured in all participants. The thickness of the midfoot plantar fascia (MPF) and medial midfoot fat pad (MMFP) were quantified using ultrasound.

RESULTS

No differences in clinical and ultrasonographical parameters were observed between the study groups. MMFP thickness was correlated with MPF thickness (p = 0.027). MMFP and MPF thicknesses were positively associated with BMI (p < 0.001 and p = 0.013, respectively), WC (p < 0.001 and p = 0.013), and WHtR (p < 0.001 and p = 0.026). The NDT measured on the right and left foot correlated with WHtR (p = 0.038 and p = 0.009, respectively), but not with WC and BMI.

CONCLUSIONS

Children with T1D show structural alterations of plantar soft tissues which seem related to body mass increase rather than diabetes pathology. Ultrasound is a valuable tool to assess early structural changes of the foot in young people with an elevated BMI.

Disorders/Differences of Sex Development Presenting in the Newborn With 46,XY Karyotype

Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions, resulting in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. The management of a newborn with suspected 46,XY DSD remains challenging. Newborns with 46,XY DSD may present with several phenotypes ranging from babies with atypical genitalia or girls with inguinal herniae to boys with micropenis and cryptorchidism. A mismatch between prenatal karyotype and female phenotype is an increasing reason for presentation. Gender assignment should be avoided prior to expert evaluation and possibly until molecular diagnosis. The classic diagnostic approach is time and cost-consuming. Today, a different approach may be considered. The first line of investigations must exclude rare life-threatening diseases related to salt wasting crises. Then, the new genetic tests should be performed, yielding increased diagnostic performance. Focused imaging or endocrine studies should be performed on the basis of genetic results in order to reduce repeated and invasive investigations for a small baby. The challenge for health professionals will lie in integrating specific genetic information with better defined clinical and endocrine phenotypes and in terms of long-term evolution. Such advances will permit optimization of counseling of parents and sex assignment. In this regard, society has significantly changed its attitude to the acceptance and expansion beyond strict binary male and female sexes, at least in some countries or cultures. These management advances should result in better personalized care and better long-term quality of life of babies born with 46,XY DSD.

Peripheral Arterial Tonometry (EndoPAT)-measured Endothelial Dysfunction in Migraine with Aura children

BACKGROUND

The association between Migraine with Aura (MA) and vascular disease has been previously reported. We investigated whether pre-clinical vascular alterations, such as Endothelial Dysfunction, are already present in children and adolescents with Migraine with Aura.

METHODS

We retrospectively enrolled 27 patients having Migraine with Aura, aged9 -18 years, and 31 age matched healthy control subjects to evaluateEndothelial Function by Peripheral Arterial Tonometry. This technique measures finger pulse wave amplitude, before and during reactive hyperaemia, and calculates the Augmentation Index (AI) and the Reactive Hyperaemia Index (RHI). We also set-up an Aura Severity Scale to assess disease severity and its relationship with AI and RHI alterations.

RESULTS

Also if the case-control study resulted only partially as significant, we found there is an inversely proportional relationship between the severity of the migraine measured with Aura Severity Scale and the values of the endoscore (a significantly reduced levels of AI (p-value <0,03) and a marginal reduction of RHI levels (p-value <0,07).

CONCLUSION

Further studies should explore the impact of pre-clinical vascular alterations in children and adolescents with Migraine with Aura.

Testosterone Therapy and Its Monitoring in Adolescent Boys with Hypogonadism: Results of an International Survey from the I-DSD Registry

It is unclear whether testosterone replacement therapy (TRT) in adolescent boys, affected by a range of endocrine diseases that may be associated with hypogonadism, is particularly common. The aim of this study was to assess the contemporary practice of TRT in boys included in the I-DSD Registry. All participating centres in the I-DSD Registry that had boys between 10 and 18 years of age and with a condition that could be associated with hypogonadism were invited to provide further information in 2019. Information on 162 boys was collected from 15 centres that had a median (range) number of 6 boys per centre (1.35). Of these, 30 (19%) from 9 centres were receiving TRT and the median (range) age at the start was 12.6 years (10.8-16.2), with 6 boys (20%) starting at <12 years. Median (range) age of boys not on TRT was 11.7 years (10.7-17.7), and 69 out of 132 (52%) were <12 years. TRT had been initiated in 20 of 71 (28%) boys with a disorder of gonadal development, 3 of 14 (21%) with a disorder of androgen synthesis, and all 7 (100%) boys with hypogonadotropic hypogonadism. The remainder who did not have TRT included 15 boys with partial androgen insensitivity, 52 with non-specific XY DSD, and 3 with persistent Müllerian duct syndrome. Before starting TRT, liver function and blood count were checked in 19 (68%) and 18 boys (64%), respectively, a bone age assessment was performed in 23 (82%) and bone mineral density assessment in 12 boys (43%). This snapshot of contemporary practice reveals that TRT in boys included in the I-DSD Registry is not very common, whilst the variation in starting and monitoring therapy is quite marked. Standardisation of practice may lead to more effective assessment of treatment outcomes.

[Quality oriented education: the experience of the Prevention Department of the Empoli Local Health Company n 11]

Quality management (QM) is a key issue for the Italian National Health System (NHS). Regione Toscana is currently undertaking a pilot programme to promote QM in Prevention Departments (PD). An introductory training to such programme was devised in the PD of the Local Health Unit no.11 Empoli, since the management was persuaded that all staff should be provided with basic knowledge concerning quality before being enrolled in QM programmes. Managers in charge of PD Units were offered a one-day training,focused on their role in promoting and achieving a QM culture, as an opportunity to be directly involved in the drafting of the DP quality handbook and in improving working procedures. The whole staff took part in a more extensive two-days course, including the basic concepts about QM in health systems, and the illustration of the programme in Regione Toscana; they were also asked to draw up some working procedures according to the draft already used in the Local Health Unit no.11, to be included in the DP quality handbook. The goal of this training programme was to implement a process capable of improving integrated working procedures through the competence, autonomy and responsibility of PD professionals.

[Cohort study of mortality among leather tanners in the Lower Valdarno area]

BACKGROUND

Epidemiological studies of tanners have shown increased risk for a number of cancer sites, namely: lung, bladder, kidney and urinary organs as well as stomach, intestine, pancreas, nose and nasal cavities, together with leukemias and soft tissue sarcomas.

OBJECTIVE

To study cause specific mortality of leather tanners in Tuscany (Valdarno Inferiore area).

METHODS

The cohort included 4874 workers (4150 males and 724 females) employed in 92 tanneries operating in 1996 (Valdarno Inferiore Tanneries Census) which were also operating on 31-12-1970. Ascertainment of vital status was completed for all individuals on 31-12-1998 (end of follow-up), and the cause of death was known for all deceased subjects. Demographic and work history data were obtained from factory payrolls. Regional mortality rates were used for comparison to calculate SMR (Standardised Mortality Ratio) and 90% Confidence Intervals (CI). In addition to the overall cohort analysis, for men only separate analyses were completed for finishers, chrome tanners and vegetable tanners.

RESULTS

The study showed an increased mortality from lung cancer among finishers, Standardised Mortality Ratio (SMR) 145, 19 observed (obs) (90% Confidence Intervals, 90% CI 95-212), from bladder cancer in the overall cohort (SMR 134, 9 obs, 90% CI 70-233) and among finishers (SMR 125, 2 obs, 90% CI 22-393) and from pancreatic cancer among finishers (SMR 120, 2 obs, 90% CI 21-379). Mortality from lymphoemopoietic cancer is above expected, and the increase is mainly due to myeloid leukaemia, both in males (SMR 208, 5 obs, 90% CI 82-437) and females (SMR 599, 2 obs, 90% CI 106-1887). No deaths from soft tissue sarcoma were observed. A new finding of the study was the increased mortality from cancer of the endocrine glands (SMR 566, 4 obs, 90% CI 194-1297), psychiatric disorders (SMR 195, 6 obs, 90% CI 85-385) and blood diseases (SMR 329, 4 obs, IC 90% 112-752).

CONCLUSIONS

The observations of increased lung cancer mortality among finishers, of bladder cancer in the overall cohort and among finishers, as well as an increase in pancreatic cancer among the latter, confirm previous epidemiological findings among tanners. The increase in myeloid leukemia mortality for both males and females, and the absence of deaths from cancer of the connective tissue, which includes soft tissue sarcomas, are worthy of note. The results should be valued with caution, given the small number of cases and the novelty of some observations.

Cancer mortality of art glass workers in Tuscany, Italy

OBJECTIVES

This study considers the cause-specific mortality from cancer among art glass workers employed in 17 industrial facilities in Tuscany, Italy.

METHODS

A cohort of 3390 workers, 3180 men and 210 women, employed at least 1 year, was taken from company payrolls. It was followed between the year each factory started operation, mostly the mid-1950s, and 31 December 1993. The cause-specific expected mortality from cancer was computed for men relative to Tuscany rates, specified for gender, 5-year age groups, and calendar year. Separate analyses were carried out for the job title of maker and former and for batch mixers.

RESULTS

For 3180 men, the observed mortality was above the expected for larynx [standardized mortality ratio (SMR) 166, 90% confidence interval (90% CI) 90-282], lung (SMR 123, 90% CI 100-151), stomach (SMR 105, 90% CI76-142), and brain (SMR 150, 90%CI 71-282) cancer. Increases for these causes were also found for the makers and formers. Mortality from larynx and lung cancer increased with latency, and significantly increased SMR values were observed for > or =21 years since first exposure. The increasing pattern was also present after adjustment for smoking.

CONCLUSIONS

The results showed consistently increased mortality from larynx and lung cancer in the overall cohort and among makers and formers. Stomach and brain cancer was also increased in the overall cohort and among the makers and formers.

Cohort study of art glass workers in Tuscany, Italy: mortality from non-malignant diseases

This investigation studies cause-specific mortality of art glass workers employed in 17 industrial facilities in Tuscany, Italy. A cohort of 3,390 workers employed for at least 1 year was enumerated from company payrolls. Follow-up was between the start of employment in each factory and 31 December 1993. The cause-specific expected mortality was computed relative to Tuscany rates and specified for gender, 5-year age groups and calendar year. Separate analyses were carried out for the jobs of makers and formers and for batch mixers. Among males (3, 180 individuals) observed mortality for non-cancer causes was higher than expected for hypertensive disease [standardized mortality ratio (SMR) = 178, 90% confidence interval (90% CI) = 96-301], pneumoconiosis (SMR = 200, 90% CI = 94-376) and diseases of the genitourinary system (SMR = 169, 90% CI = 95-279). Increases for the above causes were shown also among makers and formers: hypertensive disease (SMR = 182, 90% CI = 85-341), pneumoconiosis (SMR = 250, 90% CI = 109-493) and diseases of the genitourinary system (SMR = 224, 90% CI = 121-380). For batch mixers an increase was present for cerebrovascular disease. The observed mortality for cancer causes was above the expected for cancers of the larynx, lung, stomach and brain. This study points to the existence for Tuscan glass workers of health effects in addition to cancer; previously observed carcinogenic effects were also confirmed.

[A cohort study of art glass workers in the Empoli area]

The investigation aimed at studying cause-specific mortality of art glass workers employed in 17 industrial facilities in Tuscany, Italy. A cohort of 3390 workers employed for at least 1 year was obtained from company payrolls. Follow-up was between the year each factory started operations, mostly in the mid-fifties, and the end of 1993. The cause specific expected mortality was computed relative to Tuscany rates, specified for gender, 5-year age groups and calendar year. Separate analyses were carried out for the job titles of makers, batch mixers and grinders. For males, 3180 individuals, the observed mortality for cancer causes was above the expected for the lung [standardized mortality ratio (SMR) 123, 10 observed (Obs)], larynx (SMR 166, 10 Obs), stomach (SMR 105, 30 Obs) and brain (SMR 150, 7 Obs). For non-cancer causes observed mortality was above expected for hypertensive diseases (SMR 178, 10 Obs) and diseases of the genitourinary system (SMR 169, 11 Obs). Increases for the above listed causes were shown also among makers. Mortality for larynx and lung cancer increased with time since first exposure and significantly increased SMRs were observed for 21 or more years since first exposure: this pattern was still present with smoking adjustment. The results showed consistently increased mortality for lung and larynx cancer in the overall cohort and among makers. Stomach cancer, brain cancer, hypertensive diseases and diseases of the genitourinary system were also increased in the overall cohort and among makers.

Effect of antiorthostatic hypokinetic/hypodynamia on urinary endothelin-1 and N-acetyl-beta-D-glucosaminidase excretion in rats

In an experimental model with rats in head-down suspension, plasma levels and urinary excretion of endothelin-1 (ET-1) and urinary excretion of N-acetyl-beta-D-glucosaminidase (EC 3.2.1.30; NAG) were determined. Significant variations in time in the effective plasma ET-1 levels in the superior and inferior cava vessel blood of animals maintained for 6 days in hypogravity with respect to controls were observed. We not only found a transient increase in urinary NAG activity but also that the levels of U-ET-1 increased during head-down suspension. The simultaneous evaluation at urinary level of these two parameters could be an indication that there are different sites of renal parenchymal involvement or injury during antiorthostatic hypokinesis.

[Repetitive movements of the upper limbs: results of exposure evaluation and clinical investigation in the production and packaging of ice cream]

An evaluation was made of the degree of exposure to risk and the frequency of disorders attributable to biomechanical overload of the upper limb in workers employed on packaging in an ice cream factory. The risks were first evaluated against a checklist, then subsequently an assessment was made of the tasks found to feature the highest risks, using an ergonomic analysis method. The method identified several jobs, such as placing ice cream coupes and such like in boxes, as requiring a large number of actions per minute (> 30) and considerable muscular strength. The 59 female workers performing the packaging operations were given a risk-targeted physical examination. The clinical test detected an extremely high frequency of carpal tunnel syndrome, (7.1%) epicondylitis (5.2%) and scapulo-humeral periarthritis (3.5%) in the over 35 years age group, with respect to a control population not exposed to risk. The authors conclude that the repetitiveness of the actions, the use of gloves due to prolonged contact with frozen products and the effects of the low temperatures themselves, may have favoured the spread of the disorders that appeared in this population of workers. These findings must be further supported by more in-depth epidemiological studies.

Art glassware and sinonasal cancer: report of three cases

In a multicenter study on the occupational etiology of sinonasal cancer (s.n.c.) carried out in Italy, we collected information about three cases which had arisen among glass workers: an adenocarcinoma, a melanoma, and a squamocellular carcinoma. The three men worked many years as mixers and/or batchers in artistic glass factories in Tuscany (Italy). We propose a possible etiological role of arsenic dust.

Cardiovascular and organ responses and adaptation responses to hypogravity in an experimental animal model

The head-down suspension (i.e. antiorthostatic hypokinesia) rat is used to simulate weightlessness. However, little is known about cardiovascular and organ adaptation responses which, over a long time, can become pathologically significant. The purpose of this study was therefore to evaluate regional changes in the hematology parameters. Endotheline-1 (ET-1) concentration and urinary excretion of N-acetyl-beta-D-glucosaminidase (EC 3.2.1.30) (NAG) in an experimental antiorthostatic rat model. The data indicate significant variations in the plasma ET-1 level in time, in the superior and inferior cava vessel blood of animals maintained for 10 days in hypogravity with respect to controls. These changes do not seem to be due to hemoconcentration. The increase in urinary NAG was observed during the first 24h of experiment, indicating renal stress, probably due to adverse blood flow variations within the organ. We conclude that the plasma ET-1 level changes could be responsible, overall for the blood flow variations in the kidney and renal stress could be the consequence of extended antiorthostatic hypokinesia. The ET-1 behaviour and urinary NAG excretion in rats exposed to antiorthostatic hypokinetic hydynamia offer possibilities for understanding if these changes might be reversible or when they become pathological. This could give some relevant information about the effects of prolonged hypogravity during the space voyage.

Local and systemic immune response to inactivated Candida albicans in mice

To improve our understanding of the role natural-immunity cells play in regulating the immune response to Candida albicans (CA) we compared local versus systemic effects of intraperitoneal inoculations with inactivated CA cells in mice. Peritoneal exudate cells (PECs) and spleen cells (SCs) were recovered from CD2F1 mice after 5 intraperitoneal CA injections (2 x 10(7) cells/mouse on days -14, -10, -7, -3 and 0 (CA-5d) with respect to in vitro assays performed at 2 h, 24 h, 3 days and 5 days). Northern blot analysis revealed that 2 h after CA-5d, PECs expressed a high level of IL-2, IFN-gamma, IL-1 beta and a low level of IL-10 and TNF-alpha mRNAs, while IL-4 and IL-5 mRNAs were absent, suggesting the development of TH1 subset. At 24 h, while IL-2 mRNA remained high, IL-1 beta and IFN-gamma expression had decreased and IL-10 and TNF-alpha mRNAs were no longer detectable. Instead, in spleens of CA-treated mice, examined up to 5 days after CA-5d, only IL-2 and IL-1 beta mRNAs were detectable, but the expression level was similar to that of untreated control mice. CA-5d induced a high level of natural-killer (NK)/lymphokine-activated-killer (LAK) activity in the peritoneal cavity but did not affect spleen NK activity. After CA-5d, the proliferative response of PECs to mitogens and CA antigens was also different from that of SCs. Unfractionated PECs were unable to proliferate in response to concanavalin A (Con A), IL-2, CA cells and CA cell wall mannoprotein, but after removal of the nylon-wool-adherent fraction, the nonadherent peritoneal cells (Nad-PECs) showed a significant proliferative response to mitogens. After depletion of NK cells by anti-asialo-GM1 antibody plus complement, the proliferative response of Nad-PECs to Con A and CA increased further. Contrary to the PEC response, unfractionated SCs from the same animals responded very well to mitogens and CA antigens and the proliferative response was significantly higher compared to that of SC from control mice. In conclusion, these results cast some light on the mechanisms by which NK cells and macrophages regulated the development of the local specific response to CA: activated NK cells, by producing IFN-gamma, favor the development of TH1 subset, while suppressor macrophages keep proliferation of T lymphocytes under control because of the presence of highly activated NK cells.

Cohort mortality study of rock salt workers in Italy

A cohort mortality study of rock salt workers was carried out in Volterra, Italy. The occupational risk factors identified during environmental hygiene surveys were high noise levels and exposure to dusts and to chrysotile asbestos. The cohort consists of 487 subjects (367 males and 120 females) employed in the mine between 1/1/1965 and 12/31/1989. At the end of follow-up, 387 individuals were alive (295 males and 92 females), and 100 were decreased (72 males and 28 females). For two decedents, the cause of death was unknown. Regional rates were used for the computation of standardized mortality ratios (SMRs). In the entire cohort, observed mortality for all causes was similar to expected (SMR = 98, 100 obs); SMR for all cancer was 127 (41 obs); for lung cancer, the SMR was 146 (10 obs). Two cases of pleural mesothelioma, both in males, resulted in a statistically significant elevation of this cause (SMR = 741, 90% confidence interval (CI) 131-2,332). Two malignant brain tumors were detected (SMR 328, 90% CI 58-1,032); one of these was identified as a secondary neoplasm with consideration of additional clinical information. Among males, mortality for all cancers was significantly increased (SMR = 140, 90% CI 106-192). The observed mortality for malignant tumors of the digestive and the respiratory systems was higher than expected. In women, two cases of malignant ovarian cancer were observed vs. 0.42 expected on the basis of the regional rates. Increased mortality from lung and pleural tumors was consistent with the exposure to asbestos, which has also been shown to play a role in the development of ovarian tumors. The main limitations of this study were the small number of subjects and the definition of exposure solely in terms of duration of employment. Further studies of rock salt workers are needed to elucidate our findings.