Anti-asthmatic prescription variability in children according to age

INTRODUCTION

There is little research in the Spanish paediatric population about the consumption of anti-asthmatic agents. The aim of this study was to describe the current pattern of anti-asthmatic drug prescription in the paediatric population from a region of Spain, using the prescribed daily dose as a unit of measurement.

METHODS

We analysed the requirements of R03 therapeutic subgroup (anti-asthmatic agents) in children less than 14 years of age in the Public Health System of Castilla y León from 2005 to 2010. Consumption data are presented in prescribed daily doses per thousand inhabitants per day (PDHD) and compared with defined daily doses per thousand inhabitants per day (DHD).

RESULTS

394 876 prescriptions of anti-asthmatics were given to a population of 1 580 229 persons/year. Bronchodilators, leukotriene receptor antagonists, single inhaled corticosteroids (ICS) and long-acting β2-adrenergics associated with inhaled corticosteroids were the most commonly prescribed drugs: 7.5, 5.2, 4.9 and 2.2 PDHD, respectively. The maximum prescription of bronchodilators (15.9 PDHD/9.8 DHD) occurred in children under 12 months, with montelukast (8.9 PDHD/3.6 DHD) and single inhaled corticosteroids (7.9 PDHD/2.9 DHD) at one year of age.

CONCLUSIONS

Between 2005 and 2010, children under four years received a high prescription of anti-asthmatic drugs. The use of maintenance therapy was poorly aligned with the recommendations of asthma guidelines. The PDHD was more accurate for measuring consumption than DHD, especially in younger children.

Is acetaminophen use associated with atopic eczema and other allergic diseases in adolescents?

Atopic Eczema (AE) is a chronic inflammatory skin disease that affects children and adults, and alters quality of life. Previous studies have suggested several socio-demographic and environmental factors related to the prevalence of AE and other allergic diseases, including acetaminophen use. In the present study, we report the rates of isolated AE, AE associated with asthma and AE associated with rhinitis among 13- to 14-year-old Spanish adolescents and the level of association of these conditions with the use of acetaminophen. We analyzed Spanish data from a cross-sectional Phase 3 study within ISAAC. A total of 28,717 adolescents completed the Phase 3 written questionnaire by answering questions for acetaminophen use and on asthma, rhinitis and AE symptoms.We observed an association between acetaminophen use and AE among the adolescents who had used acetaminophen in the previous month. Furthermore, the prevalence rate increased with the number of allergic processes: for AE alone, the adjusted Prevalence Ratio (aPR) was 1.81 and for AE associated with rhinitis or with asthma, aPRs were 2.20 and 3.03, respectively.We conclude that acetaminophen use in childhood may be an important factor associated with development and/or maintenance of AE and other allergic diseases.

Ascorbate-dependent decrease of the mucosal immune inflammatory response to gliadin in coeliac disease patients

BACKGROUND

The IL-15/NF-κB axis has an important role in coeliac disease (CD) and may represent a molecular target for immunomodulation. Ascorbate (vitamin C) is known to show inhibitory effects on NF-κB. Therefore, we studied if ascorbate supplementation to gliadin gliadin-stimulated biopsy culture could down-regulate the mucosal immune response to gliadin in CD.

METHODS

Duodenal biopsy explants from treated CD patients were gliadin challenged in vitro (100 μg/ml) with and without 20mM ascorbate. An extra tissue explant in basal culture was used as internal control. Secretion levels of nitrites (3h), and IFNγ, TNFα, IFNα, IL-17, IL-13, and IL-6 (24h) were measured on the supernatants. IL-15 was assayed by western-blot on whole protein duodenal explants.

RESULTS

The addition of ascorbate to in vitro culture gliadin-challenged biopsies blocked the secretion of nitrites (p=0.013), IFNγ (p=0.0207), TNFα (p=0.0099), IFNα (p=0.0375), and IL-6 (p=0.0036) compared to samples from non-ascorbate supplemented culture. Cytokine secretion was downregulated by ascorbate even to lower values than those observed in basal cultures (IFNγ: p=0.0312; TNFα: p=0.0312; IFNα: p=0.0312; and IL-6: p=0.0078). Gliadin-challenge induced IL-15 production in biopsies from treated CD patients, while the addition of ascorbate to culture medium completely inhibited IL-15 production. Moreover, the inhibition of IL-15 by ascorbate took place even in the only treated CD-patient who had basal IL-15 production.

CONCLUSIONS

Ascorbate decreases the mucosal inflammatory response to gluten in an intestinal biopsy culture model, so it might have a role in future supplementary therapy in CD.

Sunny hours and variations in the prevalence of asthma in schoolchildren according to the International Study of Asthma and Allergies (ISAAC) Phase III in Spain

The objective of this study was to estimate the relationship between the prevalence of asthma in schoolchildren aged 6-7 years and 13-14 years and the mean annual sunny hours (MASH) in Spain, and to explore predictive models for asthma prevalence. The prevalence of asthma was obtained from the International Study of Asthma and Allergies (ISAAC) Phase III 2002-2003, and climate and socio-economic variables from official sources. Nine centres were studied and a further four centres, two of which are in ISAAC, to test the predictive models. Logistic regression was used to estimate adjusted prevalence rates of asthma for each centre, and multiple regression models to study the effects of MASH and other meteorological and socio-economic variables. The adjusted prevalence rate of asthma decreased 0.6% [95% confidence interval (CI) 0.4-0.8%] for the 6-7 years group and 1.1% (95% CI 0.8-1.3%) for the 13-14 years group with an increase in the MASH of 100 h. Relative humidity was negatively associated with asthma in the older age group, and gross province product per capita (GPP) was positively associated with asthma in the younger age group. The predictive models, which included MASH, gender, relative humidity, and GPP, anticipated prevalence rates of asthma without significant differences between the levels observed and those expected in 9 of the 11 measurements carried out. The results indicate that sunny hours have a protective effect on the prevalence of asthma in schoolchildren.

Early exposure to paracetamol or to antibiotics and eczema at school age: modification by asthma and rhinoconjunctivitis

The association between early exposure to paracetamol or to antibiotics and eczema is conflicting. This study aims to know whether the early exposure to those drugs is associated with eczema at school age, and whether the strength of the association is modified by the presence of asthma or rhinoconjunctivitis. Children aged 6-7 (n = 13908) from the International Study of Asthma and Allergies in Childhood in Spain provided data about current asthma, rhinoconjunctivitis and eczema. Parent-reported information was also obtained on paracetamol and antibiotic consumption during the first year of life. Logistic regression analysis with eczema as outcome and including exposure to paracetamol or to antibiotics, together with possible confounders, was carried out in the whole sample of children and in five different strata: no respiratory symptom and any respiratory symptom further subdivided into: asthma with rhinoconjunctivitis, asthma without rhinoconjunctivitis and rhinoconjunctivitis without asthma. In the whole sample, exposure to paracetamol was associated with eczema (aOR 1.56 [1.36-1.80]) as was antibiotic consumption (aOR 1.66 [1.43-1.92]). These associations did not substantially change after additionally adjusting for the other drug. A similar pattern was found among children without respiratory symptoms. In children with symptoms, adjusting for the other drug modified the association with paracetamol (aOR from 1.32 [1.03-1.71] to 1.09 [0.83-1.43]) but did not change that with antibiotics (aOR from 1.80 [1.38-2.35] to 1.81 [1.37-2.39]). Early exposure to paracetamol or to antibiotics is associated with an increased prevalence of eczema at school age. Asthma and/or rhinoconjunctivitis substantially modifies this association.

[Interleukin 18 (IL-18) and other immunological parameters as markers of severity in acute pancreatitis]

OBJECTIVE

Our aim was to prospectively compare the behavior of interleukin 18 (IL-18) levels and other immunological parameters during the first week of hospitalization between acute pancreatitis patients with and without severity criteria, as well as between patients with and without late pseudocyst development.

PATIENTS AND METHODS

In 36 patients with acute pancreatis we compared sTNF-RI, IL-1Ra, IL-6, and IL-18 levels at days 1, 2, 3 and 7 after hospitalization between mild pancreatitis, severe pancreatitis, and a "control" group (13 patients) with uncomplicated biliary colic, as well as between patients with and without pseudocyst.

RESULTS

On comparing mild to severe pancreatitis, IL-18 was significantly higher only the first day in severe pancreatitis, while the other parameters were steadily higher after the second day. In patients developing pseudocyst, IL-18 was also noticeably higher the first day.

CONCLUSIONS

IL-18 appears to be the earliest marker of complications and severity in acute pancreatitis at both the systemic and local level (pseudocyst).

Influence of two different geo-climatic zones on the prevalence and time trends of asthma symptoms among Spanish adolescents and schoolchildren

Few studies have focused on the long-term influence of the climate on the prevalence of asthma. The aim of this study is to establish the influence of geo-climatic conditions on the prevalence of asthma symptoms both in adolescents and schoolchildren, and to discover if this influence is associated with their time trends. Eight centres in Spain performed both ISAAC phases I (1994) and III (2002) in children 13-14 years old. Six of them also surveyed children 6-7 years old. For each age group and phase, about 3,000 children were surveyed per centre. This study examines the prevalence of current wheeze and severe current wheeze in two different geo-climatic zones, coast and plateau, considering their relative humidity and temperature range. In both age groups, the mean asthma prevalence on the coast, for phase I and III, was significantly higher than on the plateau. Living on the plateau was an independent protective factor for current wheeze and severe current wheeze for the two age groups. Within the coastal centres, the increase of the annual relative humidity was a statistical significant risk factor for current wheeze, the same trend existing for current severe wheeze. These effects were independent of the sex and of the phase of the study. The prevalence of asthma and severe asthma symptoms is more frequent on the coast of Spain as compared to the inner plateau. This finding was repeated both in 1994 and in 2002.

Higher constitutive IL15R alpha expression and lower IL-15 response threshold in coeliac disease patients

The IL-15 triggering effect of gliadin is not exclusive to coeliac disease (CD) patients, whereas the secondary response is CD specific. We have studied the expression of the IL-15 receptor, and the IL-15 response upon stimulation, in non-CD and CD patients, and the possible existence of a lower immunological threshold in the latter. Forty-two CD patients (20 on a gluten-containing diet, GCD, and 22 on gluten-free diet, GFD) and 24 non-CD healthy individuals were studied. IL15R alpha mRNA expression, and tissue characterization, were assayed in the duodenum. Biopsies from six CD patients on GFD and 10 non-CD individuals were studied in vitro using organ culture in basal conditions, as well as after IL-15 stimulation discarding basal IL-15 production. Secretion of immune mediators was measured in the culture supernatants. IL15R alpha mRNA expression was increased in CD patients, as compared with non-CD controls (on GFD P = 0.0334, on GCD P = 0.0062, respectively), and confirmed also by immunofluorescence. No differences were found between CD patients on GFD and on GCD. After in vitro IL-15 stimulation, IL15R alpha expression was only triggered in non-CD controls (P = 0.0313), though it remained increased in CD patients. Moreover, IL-15 induced a more intense immunological response in CD patients after triggering the production of both nitrites and IFN gamma (P = 0.0313, P = 0.0313, respectively). Gliadin-induced IL15 has a lower response threshold in CD patients, leading to the production of other immune mediators and the development of the intestinal lesion, and thus magnifying its effects within the CD intestine.

How the presence of rhinoconjunctivitis and the severity of asthma modify the relationship between obesity and asthma in children 6-7 years old

BACKGROUND

The association between asthma and obesity in children, and the effect modification of allergy on this association have not been fully established. Aims The objective of the study was to know the effect modification of the severity of asthma and of the coexistence of rhinoconjunctivitis (RC) in the relationship between obesity and asthma.

METHODS

A cross-sectional study of 17 145 schoolchildren 6-7 years old from eight Spanish cities who had completed information on height and weight of the ISAAC phase III questionnaire, which also included questions about asthma and RC symptoms and on various risk factors. Body mass index (BMI) was used to define obesity according to international standards. Two different logistic regressions, using current occasional asthma (COA) and current severe asthma (CSA) as dependent variables, were made stratifying for gender and for the coexistence of RC and controlling for age, older and younger siblings, exercise, mother's education, truck traffic, cat/dog during the first year of life and smoking father or mother.

RESULTS

Obesity was a risk factor of CSA without RC, both for boys (1.92, CI 95% 1.13-3.25) and for girls (2.99, CI 95% 1.68-5.32). Every BMI unit increment increased by 6.7% the risk of CSA without RC in boys and by 12.4% in girls. Obesity was not a risk factor for CSA with RC. The association between COA and obesity was weaker and the coexistence of RC did not modify it greatly.

CONCLUSIONS

Obese schoolchildren are more at risk of suffering from non-allergic asthma than the non-obese subjects.

Interleukin 18 maintains a long-standing inflammation in coeliac disease patients

Dietary gluten induces an early response in the intestine of coeliac disease patients (CD), within a few hours, and this is driven by high levels of proinflammatory cytokines, including IFNgamma and IL-15, as has been thoroughly shown by gluten stimulation of biopsy explants. Our aim was to identify the immune mediators involved in the long-standing inflammation in untreated CD patients at diagnosis. mRNA and protein levels of TNFalpha, IL-12(p35), IL-12(p40), IL-15, IL-18 and IL-23(p19) were quantified in biopsies from active CD patients, CD patients on a gluten-free diet (GFD), healthy controls, and patients with non-CD inflammation and mild histological changes in the intestine. Biopsies from CD patients on a GFD were also stimulated in vitro with gliadin, and protein expression of IL-15 and IL-18 was analysed. Levels of IL-12 and IL-23 mRNA are nearly absent, and TNFalpha levels remain unchanged among different groups. Both the active and inactive forms of IL-18 protein have been found in all samples from active CD, and protein expression was only localized within the crypts. Levels of IL-15 mRNA remain unchanged, and protein expression, localized within the lamina propria, is found in a small number of samples. In vitro stimulation with gluten induces the expression of IL-15 and IL-18. In active CD, the early response following gluten intake characterized by high IFNgamma levels is driven by IL-18, and probably IL-15, and this alternates with periods of long-standing inflammation with moderate IFNgamma levels, maintained by IL-18 alone.

Common variable immunodeficiency. Old questions are getting clearer

Common variable immunodeficiency (CVID) is a heterogeneous entity characterized by an impaired ability to produce antibodies. The failure is localized in partially mature B lymphocytes, though T lymphocyte abnormalities are occasionally present. This deficiency affects antibody synthesis and class switch from IgD and IgM, to IgG and IgA. CVID is related to selective IgA deficiency, and both abnormalities may coincide in one same family, and evolve from one to another in the same patient. The symptoms generally manifest in adults, but can occur at any age, even in infancy. Recurrent bacterial infections or pneumonias are frequent, and may be complicated by gastrointestinal problems, granulomas, autoimmune disorders or malignancies. A defect in memory B cells seems to condition the clinical severity. Recently, several mutations in genes encoding for molecules (CD19, TACI, ICOS) involved in B cell survival and isotype switch have been identified in patients with CVID. Nevertheless, genetic abnormalities have been found in less than 25 % of cases with CVID; the underlying mechanism thus remains unknown in the majority of CVID patients, and research in this field must continue.

[Geographic variation in the prevalence of asthma symptoms in Spanish children and adolescents. International Study of Asthma and Allergies in Childhood (ISAAC) Phase 3, Spain]

OBJECTIVE

To analyze geographic variations in the prevalence of symptoms related to asthma in Spanish children and adolescents.

POPULATION AND METHODS

In 2001 and 2002, the Spanish arm of the International Study of Asthma and Allergies in Childhood (ISAAC) Phase 3 collected information on 28 445 children in the age bracket of 6-7 years in 10 metropolitan areas (A Coruña, Asturias, Barcelona, Bilbao, Cartagena, Castellón, Madrid, Pamplona, San Sebastián, and Valencia) and on 31 257 adolescents in the bracket 13-14 years in 11 areas (the previously named areas plus Valladolid). An asthma symptom questionnaire was filled in by parents or the adolescents themselves. Differences in symptoms between geographic areas were analyzed by fitting a logistic regression model. The relationship between symptoms and age was analyzed by linear correlation.

RESULTS

The prevalence of recent wheezing (last 12 months) ranged from 7.1% to 12.9% among 6-7-year-olds and from 7.1% to 15.3% among the 13-14-year-olds. The greatest risk of recent wheezing was observed for children in A Coruña (odds ratio [OR] =1.96 in comparison with the area of lowest prevalence; 95% confidence interval [CI], 1.65-2.33) and Bilbao (OR=1.83; 95% CI, 1.54-2.18) and for adolescents in A Coruña (OR=2.38; 95% CI, 2.04-2.79) and Asturias (OR=2.37; 95% CI, 2.03-2.77). A strong correlation (r=0.72) was observed between the prevalence of recent wheezing and age in each of the geographic areas.

CONCLUSIONS

Considerable geographic variation in the prevalence of asthma symptoms can be seen in Spain even among young children. Symptoms are more frequent in children and adolescents who live on the Spain s northern Atlantic coast.

Prognostic utility of the semi-quantitative procalcitonin test, neutrophil count and C-reactive protein in meningococcal infection in children

The aim was to determine whether semi-quantitative procalcitonin (PCT-Q) measurements on admission can identify the severity of meningococcal infection in children. A total of 65 children (mean age 2.4 years) with meningococcal disease were included in a prospective study. All patients were treated with antibiotics, rehydration, inotropic drugs and mechanical ventilation if presenting with shock or respiratory failure. On admission, blood was drawn for routine laboratory analyses including absolute neutrophil count (NC), C-reactive protein (CRP) and PCT-Q (immunochromatographic test). A total of 33 patients presented with septic shock on admission of whom 18 developed multiple organ dysfunction syndrome (MODS) and 9 died. Forty-three patients showed a very high PCT-Q level (>or=10 ng/ml), 12 showed values between 2-9.9 ng/ml and the remaining 10 patients showed PCT-Q levels<2 ng/ml. All patients with a PCT-Q level<10 ng/ml survived, whereas all those who developed MODS or died had PCT-Q levels>or=10 ng/ml. Receiver operator curve analysis showed that PCT-Q and NC had a high predictive value for MODS and death. PCT-Q showed a sensitivity of 100%, a negative predictive value of 100% and a negative likelihood ratio of 0.0 for MODS and death.

CONCLUSION

semi-quantitative procalcitonin levels under 10 ng/ml predict good outcome of children with meningococcal infection. It is a highly sensitive method to identify patients with an increased risk of multiple organ dysfunction syndrome or death.

Interleukin-13 is involved in the survival of children with sepsis

Forty-eight children with sepsis were studied. Interleukin-13 (IL-13) levels were lower in patients who died at admission (p=0.014) and at 6 h (p=0.037), and in patients with refractory shock at 0 (p=0.03) and particularly at 6 h (p=0.0009). IL-13 levels did not correlate with other cytokines (IL-1b, IL-10, IL-12, TNFr), CRP or neutrophil count. Low IL-13 levels in the early hours of sepsis are associated with poor prognosis.

CONCLUSION

IL-13, a Th-2 cytokine fundamental in the pathogenesis of atopy, might also have a protective role against severe infections in children.

Tachyphylaxis to beta2-agonists in Spanish asthmatic patients could be modulated by beta2-adrenoceptor gene polymorphisms

BACKGROUND

The study of determinants of asthma is a subject of much interest currently, especially the pharmacogenetic aspects of asthma management. Genetic polymorphisms affecting amino-acids at positions 16 and 27 within beta(2)-adrenoceptor (beta(2)AR) gene have been implicated in the asthma phenotypes and influence on the variability observed in response to use of bronchodilator agents used in the treatment of asthma. Whether these polymorphisms alter the bronchoprotection response to beta(2)-agonist treatment in Spanish asthmatic population is unknown. The aim of this study was to investigate whether genetic polymorphisms within beta(2)AR gene modulate the clinical outcomes of the individual response to beta(2)-agonist therapy and the development of desensitization in Spanish asthmatic patients.

METHODS

In a prospective, case-control study were included 80 asthmatic patients. Based on the standard criteria, patients were classified into two groups: patients with tachyphylaxis and good responders to beta(2)-agonist therapy. DNA samples were genotyped for the Arg(16)Gly and Glu(27)Gln alleles within the beta(2)AR gene as well as in 64 control samples from blood donors.

RESULTS

Arg(16) allele was slightly more frequent within the group with tachyphylaxis (P=0.039), whereas Gly(16) allele carriers were overrepresented within the group of good responders (59.7%, P=0.028). On the other hand, the allele frequency of Gln(27) and the proportion of Gln(27) carriers was higher within the group with tachyphylaxis (P=0.010 and 0.049, respectively) and Glu(27) allele carriers were overrepresented within the group of good responders (P=0.026). The Arg(16) and Gln(27) alleles were in strong linkage disequilibrium across this locus, resulting in the occurrence of disease haplotype.

CONCLUSIONS

The predisposition to develop tachyphylaxis in our population seems to be linked to the Arg(16) and Gln(27) alleles and to the Arg(16)/Gln(27) risk haplotype (positive association between the presence of the Arg(16) and Gln(27) alleles and tachyphylaxis). The Arg(16) allele is perhaps overrepresented due to the strong linkage disequilibrium between both polymorphisms. The presence of the Glu(27) allele seems to be a protective factor against tachyphylaxis in this cohort study.

IL6, IL10 and TGFB1 gene polymorphisms in coeliac disease: differences between DQ2 positive and negative patients

Predisposition to coeliac disease (CD) might be partially due to an individual pattern of hyper-inflammatory biased immune response. One of these patterns of intense response may be linked to the haplotype carrying HLA-DQ2 alleles and TNF -308A allele. However, 10 % of CD patients do not express the DQ2 heterodimer and these do not usually carry the TNF -308A allele. A similar response might be achieved by genes codifying other cytokines.

OBJECTIVES

To study biallelic polymorphisms in genes codifying for TNFalpha, IL10, IL6 and TGFbeta1 in DQ2 negative CD patients and to compare the results with DQ2 positive patients and healthy controls, in order to establish whether any of these polymorphisms have a role in CD susceptibility.

METHODS

TNF -308 (G > A), IL-6 -174 (G > C) and TGFB1 codon 10 (+ 869, T > C) and codon 25 (+ 915, G > C) polymorphisms and IL-10 haplotype of polymorphisms in positions -1082 (G > A), -819 (C > T) and -592 (C > A) were typed by a SSP-PCR technique.

RESULTS

The distribution of allele frequencies for TNF -308 is different between DQ2 positive CD patients and controls and the same occurs for haplotype frequencies of the IL10 promoter (-1082, -819, -592): The frequencies of the TNF -308A allele (p = 0.027), TNF -308A carriers (p = 0.031) and of IL10GCC haplotype are increased (p = 0.013) in DQ2 positive CD patients. However, the IL6 -174 allele G is more frequent in DQ2 negative patients than in healthy controls (p = 0.018), DQ2 negative controls (p = 0,018), and DQ2 positive patients (p = 0.008).

CONCLUSIONS

DQ2 negative CD patients show an increased frequency of genotypes associated to IL6 high production. These were mainly allele G homozygous for the IL6 gene (-174) polymorphism. The IL6 -174GG genotype (homozygous) may be an additional risk marker for CD in DQ2 negative patients, representing an alternative susceptibility factor for CD when TNF -308A is negative.

[Time trends in prevalence of symptoms of allergic rhinitis in 13-14 year-old schoolchildren in 8 areas of Spain between 1993-1994 and 2001-2002 according to the International Study of Asthma and Allergies in Childhood (ISAAC)]

BACKGROUND AND OBJECTIVE

Our goal was to estimate the time trends in the prevalence of symptoms of allergic rhinitis (AR) and its geographic variations.

POPULATION AND METHOD

During 2001-2002, the phase 3 of ISAAC study was carried out, and a comparison with the phase 1 (1993-1994) was done. This cross sectional study included 30,046 schoolchildren 13-14 years-old from 9 centers (Asturias, Barcelona, Bilbao, Cartagena, Castellon, Madrid, Pamplona, Valencia, and Valladolid). A questionnaire about rhinitis symptoms self-administered to schoolchildren was used at schools and institutes with a participation rate of 100% to 75.8%.

RESULTS

A divergent time trend of AR prevalence symptoms was observed with a decrease in Barcelona and Bilbao, a stabilization in Cartagena, Pamplona, and Valencia, and an increase in Castellon; Madrid and Valladolid; however, there was an overall increase in nasal allergy. The prevalence of rhinoconjunctivitis in the past year (Prevalence Ratio [PR] = 1,13; 95% Confidence Interval [CI], 1.07-1.19) and nasal allergy ever (PR = 1.22; 95% CI, 1.15-1.30) increased after adjusting for gender, center and season change. The prevalence of rhinoconjunctivitis and nasal allergy varied according to centres, Madrid, Asturias, Cartagena and Bilbao exhibiting the higher prevalence. Taken as a whole, these data indicate a middle prevalence of AR when compared with other countries following an ISAAC methodology.

CONCLUSIONS

Two patterns of time trend of prevalence of symptoms of AR were observed. The investigation of risk factors at local level could be important in order to undertake preventive measures.

High cord blood IL-10 levels in preterm newborns with respiratory distress syndrome

BACKGROUND

The development of respiratory distress syndrome (RDS) is closely related to fetal immaturity, although the participation of inflammatory mechanisms also seems to be likely. We previously reported high interleukin-10 (IL-10) levels in cord blood from preterm infants. In the present study, we investigate the possible role of IL-10 and IL-12 in preterm newborns with RDS, a disease that is also closely related to gestational age.

PATIENTS AND METHODS

Cord blood levels of IL-10 and IL-12 (p70 + p40) were determined by ELISA in 20 preterm infants who later developed RDS, in 21 preterm infants without RDS and in 31 full term newborns. In 11 patients follow-up samples could be also obtained between 2 and 14 days of life.

RESULTS

Preterm infants with RDS showed higher IL-10 (27 vs 10.8 pg/mL; p: 0.0003) and lower IL-12 (188 vs 384; p: 0.002) levels in cord blood than premature infants without RDS and full term newborns (IL-10: 3.2 pg/mL, p: 0.0001; IL-12: 352 pg/mL; p: 0.002). The differences remained statistically significant after correction for the effect of gestational age between both preterm groups.

CONCLUSIONS

The results obtained may be related to an immature cytokine response in premature infants, but the IL-12/IL-10 imbalance found in our patients also supports the hypothesis that inflammation plays a role in RDS.

Serum procalcitonin in children with suspected sepsis: a comparison with C-reactive protein and neutrophil count

OBJECTIVES

To investigate the specific characteristics of serum procalcitonin in children with severe infection, to identify relevant factors influencing procalcitonin increase, to assess its prognostic value, and to compare it with C-reactive protein and neutrophil count

DESIGN

A prospective observational study and 48 hrs of follow-up of a cohort of cases.

SETTING

A pediatric intensive care unit within a children's university hospital in collaboration with a laboratory mainly involved in research in pediatric clinical immunology.

PATIENTS

A total of 80 children (median age, 3.1 yrs; range, 1 month to 16 yrs) admitted to a pediatric intensive care unit by suspicion of sepsis.

INTERVENTIONS

All patients were treated according to a protocol using antibiotics, fluid resuscitation, inotropic drugs, and mechanical ventilation when they presented with shock or respiratory failure.

MEASUREMENTS AND MAIN RESULTS

Serum procalcitonin and C-reactive protein were measured at admission in all patients and, when possible, repeated 6,12, 24, and 48 hrs later. In most cases, serum procalcitonin was already very high at onset (range, 1.0-722 ng/mL), and it did not increase significantly afterward. Contrary to C-reactive protein, serum procalcitonin did not vary according to the age of patients. The increase of procalcitonin was higher in patients with shock or multiple organ dysfunction syndrome, having a high severity score (Pediatric Risk of Mortality) or in patients who later died.

CONCLUSIONS

Serum procalcitonin levels show a rapid increase in children with sepsis, even in infants < 12 month old, and they have a better prognostic value than C-reactive protein or neutrophil count.

Influence of leptin levels and body weight in survival of children with sepsis

High levels of serum leptin (LPT) were reported in adult patients with sepsis and a protective role was suggested. LPT was determined in sera from 55 children with severe sepsis at admission (0 h), 6, 24 and 48 h. LPT levels were higher at 0 h than at 24 h (2.80 vs 1.61 ng/ml; p = 0.009) and a negative correlation was found with IL-13 (p = 0.009), and granulocyte counts (p = 0.035), but not with other factors. Infants younger than 12 mo of age had higher LPT levels than older infants (5.88 vs 2.38 ng/ml; p = 0.0005). The increase in LPT levels was higher in non-survivor patients than in survivors, with a maximum difference at 24 h (5.30 vs 1.45 ng/ml; p = 0.0042). However, LPT levels were not associated with shock, multiorgan failure or the severity score. Children who died showed higher percentiles of weight than survivors (p = 0.025). A subgroup with higher LPT (> Pc75) included mainly patients with weight > Pc50 (p = 0.0065), low IL-13 levels (p = 0.007) and low granulocyte counts (p = 0.013), Neisseria meningitidis B being the most frequently isolated germ (p = 0.022).

CONCLUSION

Using a model of severe infection, mainly meningococcal, in young children (median 3 y 6 mo old), it was not possible to confirm previous results in adults. A general protective role for LPT in sepsis seems unlikely.

TNF alpha and LT alpha gene polymorphisms as additional markers of celiac disease susceptibility in a DQ2-positive population

TNFalpha and TNFbeta, or linfotoxin (LTalpha), are two molecules playing an important role in inflammation. Their genes map on Chromosome 6, between the HLA class II and class I loci. Polymorphisms in, or near, TNF genes have been associated with susceptibility to several autoimmune diseases. Studies of TNF genes in celiac disease (CD) have presented contradictory results. We have assessed the role of TNFalpha and linfotoxin alpha (TNFbeta) in CD and their relative value as CD markers in addition to the presence of DQ2. The TNFA -308 polymorphism and the polymorphism at the first intron of the LTA gene were typed in CD patients and healthy controls and the results were correlated with the presence of DQ2. Significant differences were found in genotype and allele frequencies for the TNFA and LTA genes between CD patients and controls, with an increase in the presence of the TNFA*2 and LTA*1 alleles in CD patients. These differences increase when DQ2-positive CD patients and DQ2-positive controls are compared. In DQ2-positive individuals, allele 2 (A) in position -308 of the promoter of TNFA and allele 1 (G) of the NcoI RFLP in the first intron of LTA are additional risk markers for CD.

Susceptibility genes for asthma and allergy: hits and questions

Allergy and asthma are closely related conditions which result from a complex interaction between several genetic and environmental factors. On the basis of familial linkage analysis data from different populations, some chromosomal regions containing a series of susceptibility loci have been identified. To date, genome-wide search studies have reported a group of chromosomal regions which include most likely several candidate genes for asthma and allergy. Some of these genes are excellent candidates, as they are known to modulate the immune response and airways inflammation processes. So, by focusing efforts on the analysis of those chromosomal regions, the characterization of the potentially important genes can be achieved. This will undoubtedly provide a clue for a better understanding of those pathologic components involved in the onset and development of asthma and allergic disorders.

The HLA-DRB4 gene is present in half of the Spanish HLA-DQ2-negative celiac patients

We studied nine consecutive DQ2-negative celiacs [from a group of 186 consecutive celiac disease (CD) patients] for the presence of the HLA-DQB1, DRB1, and DRBx alleles. HLA-DR53 was present in only 5 out of 9 (55%) of DQ2-negative patients. DRB4 (DR53) positivity -39% of chromosomes--among Spanish DQ2-negative CD patients is due to both DR4- and DR7-positive cases. Spanish DQ2-positive patients show a high frequency of DR7/DR11 heterozygous carriers of DRB4 (DR53). One-third of our DQ2-negative celiac patients have DRB1*04 (DR4). Six patients are DR4 negative: at least one of the DQ2 alleles (DQA1*0501/DQB1*02) is present in four cases, but none of the alleles of risk, including DR53, were found in the remaining two cases, both of whom carry DQB1*06 alleles (*0602/3 and 0604). The fact that half of our DQ2-negative patients lack DRB4 (DR53) leads us to believe that this gene is not an essential factor to confer CD susceptibility.

Cord blood interleukin-10 levels are increased in preterm newborns

Cell-mediated immunosuppression due to interleukin (IL)-10 may contribute to normal pregnancy. By contrast, delivery is associated with a predominance of T-helper-1 (Th1) cytokines (IL-12, interferon-gamma) and might be regarded as a graft rejection process. The aim of the study was to assess IL-10 and IL-12 levels in cord blood samples from newborns and their normal mothers in relation to the gestational age and type of delivery. Cord blood and serum samples were obtained from 31 term newborns (gestational age 38-42 weeks) and 40 preterm newborns (mean gestational age 32 weeks). Serum samples were obtained from 26 mothers of term newborns at birth. There were 18 term and preterm infants born by caesarean section. Measurements of IL-10 and IL-12 levels by ELISA were repeated in mothers 15 days after delivery and in 11 preterm infants (median 14 days of age). Cord blood IL-10 levels were significantly higher in preterm than in term newborns (median 17.0 versus 3.2 pg/ml, P = 0.0001), but were similar to term newborns and paired mothers (2.2 versus 1.0 pg/ml). Term and preterm newborns also showed similar cord blood IL-12 levels (median 349 versus 320 pg/ml), and these levels were significantly higher when compared to their paired mothers (median 14.5 pg/ml, P = 0.0003). Cord blood IL-10 levels showed a significant inverse correlation with gestational age (P = 0.0001). When preterm infants, at several weeks post-delivery, were compared to gestational age matched newborns, their IL-10 levels were similar (median 8.3 pg/ml) whereas IL-12 levels were clearly lower (147 pg/ml; P = 0.0007). The type of delivery (vaginal versus caesarean) did not influence cord blood IL-10 and IL-12 results.

CONCLUSION

Cord blood IL-10 levels are increased in preterm newborns and may be due to the immunosuppression occurring during pregnancy and to fetal immaturity because these levels are inversely correlated with gestational age.

Increased TNFA*2, but not TNFB*1, allele frequency in Spanish atopic patients

Tumor necrosis factor (TNF) is a potent proinflammatory cytokine involved in asthma and atopy. Increased TNF-alpha levels have been found in airway biopsies and bronchoalveolar lavage fluids from asthmatic patients. Constitutional variations in the TNF-alpha secretion levels in vitro are associated with molecular polymorphisms located within and around the TNF loci. Our study objective was to investigate the association between atopy and two described di-allelic polymorphisms in the TNF locus: a G to A transition at position -308 in the 5'-promoter region of the TNFA gene (TNFA*1 and TNFA*2 alleles) and an Ncol restriction fragment length polymorphism (RFLP) in the first intron of the TNFB gene (TNFB*1 and TNFB*2 alleles). The genetic study was performed in 65 unrelated atopic patients and 60 healthy controls. The regions of interest were amplified from genomic DNA using specific primers and polymerase chain reaction. SSP-PCR analysis for TNFA -308 polymorphism genotyping and endonuclease digestion analysis for the TNFB Ncol RFLP were used. The frequency of the TNFA*2 allele was significantly higher in atopic subjects compared to the control group (38.5% vs. 10.5%; chi2 = 32.06; p <0.0001). The TNFA*2 allele is associated with a higher risk for the development of atopy (risk ratio = 9.44; EF = 0.65; chi2 = 30.06 p <0.0005). On the other hand, no significant association between the TNFB alleles and atopy was found. In conclusion, the TNFA*2 allele could be also a genetic risk marker for the predisposition to atopy in our population, as has been reported in other studies. Either the TNFA gene itself or a linked gene on chromosome region 6p21, which has yet to be identified, is a candidate gene for susceptibility to atopy.

Decreased interleukin-12 levels in umbilical cord blood in children who developed acute bronchiolitis

Respiratory syncytial virus (RSV) infection is common in young children, but only a few develop severe bronchiolitis. The relationship between bronchiolitis, asthma, and atopy has been debated for a long time, but the pathogenesis of wheezing remains unclear. A Th1 and Th2-type lymphocyte imbalance seems to be involved in asthma and atopic disease. Serum interleukin-12 (IL-12), IL-10, and soluble CD30 (sCD30) levels were measured by enzyme-linked immunosorbent assay (ELISA) in 23 cord blood samples kept frozen since birth: 11 from normal term newborns who several months later were admitted to the hospital with bronchiolitis, and 12 from newborns who did not develop the disease (controls). The study was also performed on 28 additional children (1-16 months old) suffering an episode of acute bronchiolitis. IL-12 was clearly increased in all cases at birth, but newborns who later developed bronchiolitis showed low IL-12 levels in cord blood compared to newborns who did not develop the disease (median 295 vs. 507 pg/mL; P = 0.001). sCD30 levels were also decreased in the first group (15 vs. 26 U/mL; P = 0.007). During episodes of bronchiolitis, a clear rise of IL-12, IL-10, and sCD30 was observed. None of the factors studied in the acute phase showed statistical differences in children who were later readmitted to the hospital due to repeated wheezing crises. Children who develop acute bronchiolitis with wheezing may have an immunological imbalance that is expressed at the time of delivery by a lower concentration of serum IL-12.

Lack of association between atopy and RsaI polymorphism within intron 2 of the Fc(epsilon)RI-beta gene in a Spanish population sample

BACKGROUND

The B genotype of RasI polymorphism located within intron 2 of the Fc-IgE receptor I (Fc(epsilon)RI) gene was previously found to be increased in atopic patients from a Japanese population sample.

METHODS

We studied these A/B genotypes in 70 Spanish atopic patients, and the results were compared to those of 51 nonatopic controls. RasI polymorphisms were studied by specific digestion of polymerase chain reaction fragments followed by polyacrylamide gel electrophoresis.

RESULTS

The polymorphism frequency (A/A: 25/70, A/B: 28/70, B/B: 17/70) found in patients did not differ from the frequency in nonatopic control subjects.

CONCLUSIONS

We did not find RasI polymorphisms associated with atopic disease. The genetic findings in atopy and asthma may be very different according to ethnic and local characteristics, and they must be carefully verified in different population samples.

HLA-DQA1*0501 and DQB1*02 homozygosity and disease susceptibility in Spanish coeliac patients

Coeliac disease (CD) susceptibility is strongly associated with HLA-DQA1*0501 and DQB1*02 alleles. There are discordant reports on whether homozygosity increases the risk. We genotyped HLA-DQA1*0501 and DQB1*02 in 50 CD patients, 100 parents, and 50 controls. Most patients (96%) were positive for DQA1*0501 (RR = 18.07, p < 0.001), 94% for DQB1*02 (RR = 17.55, p < 0.001), and 92% for both alleles together (RR = 31.82, p < 0.001). DQA1*0501 was found in 52% of controls, DQB1*02 in 44%, and only 24% had both alleles. Patients homozygosity or heterozygosity was estimated by assessing-in each case-whether one or both parents were carriers of the allele of risk. The frequencies of parents both positive for DQA1*0501 (58%) and for DQB1*02 (53.1%) were higher than expected by the fact that the proband is a carrier. These findings suggest that the frequency of homozygosity is increased among CD patients, and therefore, homozygosity for either DQA1*0501 or DQB1*02 represents a risk factor added to the fact of being a carrier.

Alpha-1 antichymotrypsin levels are actively increased in normal colostrum

BACKGROUND

It is well known that human colostrum has important antiinflammatory functions. The purpose of the current study was to determine antiprotease levels in colostrum and serum and to assess the importance of local synthesis and the electrophoretic differences in both locations.

METHODS

Five protease inhibitors were determined by radical immunodiffusion in colostrum and serum samples taken simultaneously from 50 healthy women, 36 to 72 hours after delivery.

RESULTS

Antithrombin II, inter-alpha trypsin inhibitor, and alpha-2 macroglobulin levels were undetectable in colostrum. Mean antitrypsin levels in colostrum were 6% of serum levels, but colostrum alpha-1 antichymotrypsin was higher than expected (0.39+/-0.34 g/l) in relation according to the albumin passive transport, and their mean value was 41% of serum levels. Colostrum antichymotrypsin levels did not correlate with serum antichymotrypsin levels or with colostrum albumin levels. The antichymotrypsin molecule in colostrum had a slower electrophoretic mobility when compared with that of serum antichymotrypsin, and it showed a different pattern in Western blot analysis, with a predominating 80-kDa molecule.

CONCLUSIONS

Although the origin of colostral antichymotrypsin is unclear, local production in breast epithelial cells is likely. Antichymotrypsin is increased in colostrum, and its molecule has some characteristic differences, suggesting that it has an important and specific role in infant nutrition during breast milk feeding.

Lack of correlation between soluble CD14 and IL-6 in meningococcal septic shock

Meningococcal sepsis is a good model to study the dynamic response of cytokines and other soluble factors in vivo in the early stages of the disease. Levels of soluble CD14, interleukin-6 (IL-6), IL-6 receptor (IL-6R), and C-reactive protein (CRP) have been measured in plasma from 26 children with septic shock (nine of whom had disseminated intravascular coagulation) and from ten control children. All samples were collected at the onset, before treatment, and, when possible, 24 and 48 hours later. At admission, patients had significantly higher levels of IL-6 (p < 0.001) and CRP (p < 0.001), and lower levels of IL-6R (p < 0.005) than normal controls. After 24 hours, there was a significant increase of sCD24 (p < 0.05) and CRP (p < 0.001). Although IL-6 showed a progressive decline since the onset, its levels were always higher than controls. There was an inverse correlation between IL-6 and both IL-6R (p < 0.001) and CRP (p < 0.001), probably due to the later increase of CRP. Nevertheless, sCD14 did not correlate with IL-6 levels. We have confirmed the finding of IL-6 as a sensitive and reliable inflammatory marker in septic shock. Moreover, the ratio IL-6/IL-6R may have a prognostic value, given a putative role of IL-6R in modulating the effects of IL-6 in meningococcal sepsis.

Monoclonal antibody-standardized cat extract immunotherapy: risk-benefit effects from a double-blind placebo study

Twenty-eight patients (14 in an active treatment group and 14 in a placebo group) with rhinoconjunctivitis and asthma caused by cat hypersensitivity took part in a placebo-controlled, randomized, double-blind study to evaluate the risk-benefit quotient of the maintenance dose corresponding to 13.2 micrograms Fel d I antigen. The cat extract was biologically standardized and quantified with monoclonal antibodies (100 biological units: 33 microgram of Fel d I antigen, 650 micrograms of albumin, and 99 micrograms of Fel d Bd/K30 antigen). After 1 year of treatment, the systemic reactions to cat extract immunotherapy were mild and infrequent. Improvement was observed in the active treatment group in comparison with the placebo group in the medication-symptoms score (p < 0.001); in skin prick test (p < 0.001), conjunctival provocation test (p < 0.001), and allergen bronchoprovocation test (p < 0.05) results, and in nonspecific bronchial hyperreactivity measured with methacholine, which was not statistically significant. This study demonstrates the favorable risk-benefit quotient of the dose of 13.2 micrograms of Fel d I antigen, which may serve as a future reference in defining the optimum dose and appropriate proportion of antigens that should be administered in cat extract immunotherapy.