The effects of urban green space and road proximity to indoor traffic-related PM2.5, NO2, and BC exposure in inner-city schools

BACKGROUND

Since there are known adverse health impacts of traffic-related air pollution, while at the same time there are potential health benefits from greenness, it is important to examine more closely the impacts of these factors on indoor air quality in urban schools.

OBJECTIVE

This study investigates the association of road proximity and urban greenness to indoor traffic-related fine particulate matter (PM2.5), nitrogen dioxide (NO2), and black carbon (BC) in inner-city schools.

METHODS

PM2.5, NO2, and BC were measured indoors at 74 schools and outdoors at a central urban over a 10-year period. Seasonal urban greenness was estimated using the Normalized Difference Vegetation Index (NDVI) with 270 and 1230 m buffers. The associations between indoor traffic-related air pollution and road proximity and greenness were investigated with mixed-effects models.

RESULTS

The analysis showed linear decays of indoor traffic-related PM2.5, NO2, and BC by 60%, 35%, and 22%, respectively for schools located at a greater distance from major roads. The results further showed that surrounding school greenness at 270 m buffer was significantly associated (p < 0.05) with lower indoor traffic-related PM2.5: -0.068 (95% CI: -0.124, -0.013), NO2: -0.139 (95% CI: -0.185, -0.092), and BC: -0.060 (95% CI: -0.115, -0.005). These associations were stronger for surrounding greenness at a greater distance from the schools (buffer 1230 m) PM2.5: -0.101 (95% CI: -0.156, -0.046) NO2: -0.122 (95% CI: -0.169, -0.075) BC: -0.080 (95% CI: -0.136, -0.026). These inverse associations were stronger after fully adjusting for regional pollution and meteorological conditions.

IMPACT STATEMENT

More than 90% of children under the age of 15 worldwide are exposed to elevated air pollution levels exceeding the WHO's guidelines. The study investigates the impact that urban infrastructure and greenness, in particular green areas and road proximity, have on indoor exposures to traffic-related PM2.5, NO2, and BC in inner-city schools. By examining a 10-year period the study provides insights for air quality management, into how road proximity and greenness at different buffers from the school locations can affect indoor exposure.

Centripetal Nystagmus, Slow Saccades, Cerebellar Ataxia, and Parkinsonism in a Patient With Anti-GAD65-Associated Stiff Person Syndrome Spectrum Disorder

ABSTRACT

A 68-year-old woman with positional dizziness and progressive imbalance presented for vestibular evaluation. Examination was notable for spontaneous downbeat nystagmus (DBN), horizontal and vertical gaze-evoked nystagmus (GEN) with centripetal and rebound nystagmus, and positional apogeotropic nystagmus. There was also mild-moderate slowing of saccades horizontally and vertically and poor fast phases with an optokinetic stimulus. Further consultation by a movement disorder specialist uncovered asymmetric decrementing bradykinesia and rigidity, masked facies, and a wide-based stance without camptocormia. Screening serum laboratory results for metabolic, rheumatologic, infectious, heavy metal, endocrine, or vitamin abnormalities was normal. Surveillance imaging for neoplasms was unremarkable, and cerebrospinal fluid (CSF) analysis was negative for 14-3-3 and real-time quaking-induced conversion (RT-QuIC). However, her anti-glutamic acid decarboxylase-65 (GAD65) immunoglobulin G (IgG) level was markedly elevated in serum to 426,202 IU/mL (reference range 0-5 IU/mL) and in CSF to 18.1 nmol/L (reference range <0.03 nmol/L). No other autoantibodies were identified on the expanded paraneoplastic panel. The patient was referred to neuroimmunology, where torso rigidity, spasticity, and significant paravertebral muscle spasms were noted. Overall, the clinical presentation, examination findings, and extensive workup were consistent with a diagnosis of anti-GAD65-associated stiff person syndrome-plus (musculoskeletal plus cerebellar and/or brainstem involvement). She was subsequently treated with intravenous immunoglobulin (IVIg) and has been stable since commencing this therapy. In patients with centripetal nystagmus, especially in association with other cerebellar findings, an autoimmune cerebellar workup should be considered.

Updates in neuro-otology

PURPOSE OF REVIEW

Recent updates with clinical implications in the field of neuro-otology are reviewed.

RECENT FINDINGS

Important updates relating to several neuro-otologic disorders have been reported in recent years. For benign positional paroxysmal vertigo (BPPV), we provide updates on the characteristics and features of the short arm variant of posterior canal BPPV. For the acute vestibular syndrome, we report important updates on the use of video-oculography in clinical diagnosis. For autoimmune causes of neuro-otologic symptoms, we describe the clinical and paraclinical features of kelch-like protein 11 encephalitis, a newly-identified antibody associated disorder. For cerebellar ataxia, neuropathy, vestibular areflexia syndrome, we report recent genetic insights into this condition.

SUMMARY

This review summarizes important recent updates relating to four hot topics in neuro-otology.

Diagnosing and localizing the acute vestibular syndrome - Beyond the HINTS exam

When assessing the acutely dizzy patient, the HINTS 'Plus' (Head Impulse, Nystagmus, Test of Skew, 'Plus' a bedside assessment of auditory function) exam is a crucial component of the bedside exam. However, there are additional ocular motor findings that can help the clinician distinguish peripheral from central etiologies and enable accurate localization, especially when the patient has acute dizziness, vertigo and/or imbalance but without spontaneous nystagmus. We will review the literature on these findings which are 'beyond HINTS' and include saccades/ocular lateropulsion, smooth pursuit, and provocative maneuvers including head-shaking and positional testing (not part of the HINTS exam). Additionally, we will expound on the localizing value of nystagmus, ocular alignment and the ocular tilt reaction (parts of the HINTS exam). The paper has been organized neuroanatomically, based on brainstem and cerebellar structures that have been reported to cause the acute vestibular syndrome.

Neuro-Visual and Vestibular Manifestations of Concussion and Mild TBI

PURPOSE OF REVIEW

Mild traumatic brain injury, or concussion, is a major cause of disability. Vestibular and visual dysfunction following concussion is common and can negatively affect patients' well-being and prolong recovery. Etiologies of visual and vestibular symptoms are numerous, including ocular, neuro-ophthalmic, otologic, and neuro-vestibular conditions. Some etiologies are benign and may be treatable, while others are potentially vision or life-threatening, making a focused history and examination essential. This review offers an approach to the evaluation and treatment of the most common neuro-visual and vestibular impairments that may result from concussion.

RECENT FINDINGS

Treatment of concussion including exercise, computerized programs, transcranial magnetic stimulation, gene therapy, stem cell therapy, and nanoparticles has shown promise. Many novel therapies are in the pipework for visual and vestibular recovery after concussion; however, the treatment mainstay remains therapy and evaluation for co-existing diseases.

Current concepts in acute vestibular syndrome and video-oculography

PURPOSE OF REVIEW

We present here neuro-otological tests using portable video-oculography (VOG) and strategies assisting physicians in the process of decision making beyond the classical 'HINTS' testing battery at the bedside.

RECENT FINDINGS

Patients with acute vestibular syndrome (AVS) experience dizziness, gait unsteadiness and nausea/vomiting. A variety of causes can lead to this condition, including strokes. These patients cannot be adequately identified with the conventional approach by stratifying based on risk factors and symptom type. In addition to bedside methods such as HINTS and HINTS plus, quantitative methods for recording eye movements using VOG can augment the ability to diagnose and localize the lesion. In particular, the ability to identify and quantify the head impulse test (VOR gain, saccade metrics), nystagmus characteristics (waveform, beating direction and intensity), skew deviation, audiometry and lateropulsion expands our diagnostic capabilities. In addition to telemedicine, algorithms and artificial intelligence can be used to support emergency physicians and nonexperts in the future.

SUMMARY

VOG, telemedicine and artificial intelligence may assist physicians in the diagnostic process of AVS patients.

The fixation suppression test can uncover vertical nystagmus of central origin in some patients with dizziness

BACKGROUND

Identifying dangerous causes of dizziness is a challenging task for neurologists, as it requires interpretation of subtle bedside exam findings, which become even more subtle with time. Nystagmus can be instrumental in differentiating peripheral from central vestibular disorders. Conventional teaching is that peripheral vestibular nystagmus is accentuated by removal of visual fixation. We sought to systematically test the hypothesis that, in some cases, vertical nystagmus due to central vestibular disorders may also be easier to identify when fixation is removed.

METHODS

To identify patients with vertical nystagmus, we retrospectively reviewed clinical, MRI, and VNG data of consecutive patients undergoing VNG in our vestibular clinic over a 9-month period. We analyzed clinical features, bedside neuro-otological examination, MRI results, and VNG findings in fixation as well as those with fixation removed.

RESULTS

Two hundred and fourteen charts were reviewed. Twenty-six patients had vertical nystagmus with fixation removed on VNG. Only three (11.5%) of these patients had vertical nystagmus apparent with fixation (and only two had nystagmus observed clearly at the bedside with the unaided eye). Thirteen (50%) of the patients had posterior fossa lesions on MRI and eight of the rest (30.8%) were diagnosed with central vestibular disorders. Of the 13 patients with MRI-confirmed lesions, 3 patients (23.1%) had no neurological signs or conventional bedside oculomotor signs; in these cases, vertical nystagmus without fixation was the only sign of a central lesion.

CONCLUSIONS

Our findings go against conventional teaching and show that removing fixation can uncover subtle vertical nystagmus due to central vestibular disease, particularly from focal or chronic lesions.

Nonvestibular Dizziness

Dizziness is a common chief complaint with an extensive differential diagnosis that ranges from peripheral, central, to nonvestibular conditions. An understanding of nonvestibular conditions will aid accurate diagnosis and initiation of appropriate management. Thus, the objective of this article is to present an overview of nonvestibular etiologies that may plague a dizzy patient and the recommended treatment options.

Opinion and Special Articles: Remote Evaluation of Acute Vertigo: Strategies and Technological Considerations

Patients with acute vestibular disorders are often a diagnostic challenge for neurologists, especially when the evaluation must be conducted remotely. The clinical dilemma remains: Does the patient have a benign peripheral inner ear problem or a worrisome central vestibular disorder, such as a stroke? The use of a focused history and the virtual HINTS (head impulse test, nystagmus evaluation, and test of skew) examination are key steps towards correctly diagnosing and triaging the acute vertiginous patient. When looking for signs of vestibulo-ocular dysfunction, there are important technological and practical considerations for an effective clinical interpretation.

Pendular Oscillation and Ocular Bobbing After Pontine Hemorrhage

The pathophysiology of acute, vertical spontaneous eye movements following pontine hemorrhage is not well understood. Here, we present and discuss the video-oculography findings of a patient with acute pontine hemorrhage who developed vertical pendular oscillation and ocular bobbing while comatose. The amplitudes, peak velocities, frequency distribution, and phase planes (velocity versus position) of the eye movements were analyzed. The vertical pendular oscillation was rhythmic with a peak frequency of 1.7 Hz, but amplitudes (mean 1.9°, range 0.2-8.2°) and peak velocities (mean 20.6°/s; range 5.9-60.6°/sec) fluctuated. Overall, their peak velocities were asymmetric, faster with downward than upward. Higher peak velocities were seen with larger amplitudes (downward phase r = 0.95, p < 0.001; upward phase r = 0.91, p < 0.001) and with movements beginning at eye positions lower in the orbit (downward phase r = - 0.64, p < 0.001; upward phase r = - 0.86, p < 0.001). Interspersed were typical ocular bobbing waveforms with a fast (peak velocity 128.8°/s), large-amplitude (17.5°) downward movement, sometimes followed by a flat interphase interval (0.5 s) when the eye was nearly stationary, and then a slow return to mid-position with a decaying velocity waveform. To account for the presence and co-existence of pendular oscillations and bobbing, we present and discuss three hypothetical models, not necessarily mutually exclusive: (1) oscillations originating in the inferior olives due to disruption of the central tegmental tract(s); (2) unstable neural integrator function due to pontine cell group damage involving neurons involved in gaze-holding; (3) low-frequency saccadic intrusions following omnipause neuron damage.

Vestibular Disorders: Pearls and Pitfalls

Dizziness and vertigo are symptoms that commonly lead patients to seek neurologic or emergency care. Because symptoms are often vague and imprecise, a systematic approach is essential. By categorizing vestibular disorders based on the timing, triggers, and duration of symptoms, as well as emphasizing focused ocular motor and vestibular examinations, the majority of vestibular diagnoses can be made at the bedside. This paper will discuss the pearls and pitfalls in the history and examination of the most common acute, episodic, and chronic vestibular disorders.

It is not your eyes

A 55-year-old woman reported blurred vision while walking, numbness and tingling, contact allodynia, and gait imbalance. Visual acuity was 20/20 in both eyes, but there was a loss of 4 lines with horizontal dynamic visual acuity testing. Ocular motility examination demonstrated spontaneous downbeat nystagmus that increased in lateral gaze with a torsional component and impaired smooth pursuits. Head impulse test was positive, and electromyography demonstrated a sensory neuropathy/neuronopathy. Vestibular testing confirmed both central ocular motor pathway and bilateral peripheral vestibular system involvement. The constellation of clinical findings and paraclinical testing was consistent with a recently recognized neurodegenerative disorder termed cerebellar ataxia with neuropathy and vestibular areflexia syndrome.

Acute Visual Disorders-What Should the Neurologist Know?

Normal vision requires coordination of precisely controlled and coordinated eye movements and normal function of a large cortical and subcortical sensory network. Given the required precision of the system and wide anatomic distribution of the motor and sensory visual systems, vision can be disrupted by a variety of central and peripheral nervous system disorders. While many of these may be relatively benign or have no proven therapy, several may be isolated presentations or harbingers of more serious neurologic conditions. Both monocular and binocular vision losses may be isolated presentations of stroke or its equivalent. Other etiologies of monocular vision loss may represent the initial presentation of potentially disabling conditions. Binocular diplopia, caused by impaired movement of one or both eyes, may represent a condition with no acute therapy and a benign natural history, or a progressive potentially life-threatening syndrome. Most people are heavily reliant upon vision, so that even a subtle change in vision due to disturbed afferent or efferent pathways is invariably noticed, and presentation to the emergency department for eye symptoms is common. The accurate evaluation of these patients in the acute setting is essential to identify the patients requiring immediate testing or treatment.

Plasma metabolite profiles in children with current asthma

BACKGROUND

Identifying metabolomic profiles of children with asthma has the potential to increase understanding of asthma pathophysiology.

OBJECTIVE

To identify differences in plasma metabolites between children with and without current asthma at mid-childhood.

METHODS

We used untargeted mass spectrometry to measure plasma metabolites in 237 children (46 current asthma cases and 191 controls) in Project Viva, a birth cohort from eastern Massachusetts, USA. Current asthma was assessed at mid-childhood (mean age 8.0 years). The ability of a broad spectrum metabolic profile to distinguish between cases and controls was assessed using partial least squares discriminant analysis. We used logistic regression models to identify individual metabolites that were differentially abundant by case-control status. We tested significant metabolites for replication in 411 children from the VDAART clinical trial.

RESULTS

There was no evidence of a systematic difference in the metabolome of children reporting current asthma vs. healthy controls according to partial least squares discriminant analysis. However, several metabolites were associated with odds of current asthma at a nominally significant threshold (P < .05), including a metabolite of nicotinamide (N1-Methyl-2-pyridone-5-carboxamide (Odds Ratio (OR) = 2.8 (95% CI 1.1-8.0)), a pyrimidine metabolite (5,6-dihydrothymine (OR = 0.4 (95% CI 0.2-0.9)), bile constituents (biliverdin (OR = 0.4 (95%CI 0.1-0.9), taurocholate (OR = 2.0 (95% CI 1.2-3.4)), two peptides likely derived from fibrinopeptide A (ORs from 1.6 to 1.7), and a gut microbiome metabolite (p-cresol sulphate OR = 0.5 (95% CI 0.2-0.9)). The associations for N1-Methyl-2-pyridone-5-carboxamide and p-cresol sulphate replicated in the independent VDAART population (one-sided P values = .03-.04).

CONCLUSIONS AND CLINICAL RELEVANCE

Current asthma is nominally associated with altered levels of several metabolites, including metabolites in the nicotinamide pathway, and a bacterial metabolite derived from the gut microbiome.

Eyelid Dysfunction in Neurodegenerative, Neurogenetic, and Neurometabolic Disease

Eye movement abnormalities are among the earliest clinical manifestations of inherited and acquired neurodegenerative diseases and play an integral role in their diagnosis. Eyelid movement is neuroanatomically linked to eye movement, and thus eyelid dysfunction can also be a distinguishing feature of neurodegenerative disease and complements eye movement abnormalities in helping us to understand their pathophysiology. In this review, we summarize the various eyelid abnormalities that can occur in neurodegenerative, neurogenetic, and neurometabolic diseases. We discuss eyelid disorders, such as ptosis, eyelid retraction, abnormal spontaneous and reflexive blinking, blepharospasm, and eyelid apraxia in the context of the neuroanatomic pathways that are affected. We also review the literature regarding the prevalence of eyelid abnormalities in different neurologic diseases as well as treatment strategies (Table 1).

Dizziness

Dizziness and vertigo are among the most common symptoms to bring a patient to a neurologist. Because symptoms are often vague and imprecise, a systematic approach is essential. By categorizing vestibular disorders based on timing, triggers, and duration, as well as through focused oculomotor and vestibular examinations, the vast majority of neuro-otologic diagnoses can be made at the bedside. Here the authors discuss historical and examination pearls for the most common neuro-otologic disorders.

Tinnitus, Oscillopsia, and Hyperventilation-Induced Nystagmus: Vestibular Paroxysmia

Vestibular paroxysmia is the name given to vascular compression of the vestibulocochlear nerve. Substantial evidence has been discovered in support of vascular compression of the trigeminal nerve as the etiology for trigeminal neuralgia, and effective therapies have been targeted to address this pathophysiology. Perhaps due to the common and often vaguely-described symptoms of dizziness and tinnitus, vascular compression of the vestibulocochlear nerve as a cause of symptoms has remained controversial. Recent clinical studies, however, have better defined diagnostic criteria for vestibular paroxysmia. In this report we discuss a case of vestibular paroxysmia, highlighting some findings of the condition that also uniquely separate it from other more common vestibular disorders. Finally, we discuss current clinical management of vestibular paroxysmia.

Asthma and allergy development: contrasting influences of yeasts and other fungal exposures

BACKGROUND

Infancy is a developmental stage with heightened susceptibility to environmental influences on the risk of chronic childhood disease. Few birth cohort studies have detailed measures of fungal diversity data in infants' bedrooms, limiting the potential to measure long-term associations of these complex exposures with development of asthma or allergy.

OBJECTIVE

We evaluated the relation of home fungal levels in infancy to repeated measures of wheeze and development of asthma and rhinitis by age 13, and sensitization by age 12 years.

METHODS

In the Epidemiology of Home Allergens and Asthma prospective birth cohort study, we recruited 408 children with family history of allergic disease or asthma. When children were aged 2-3 months, we measured culturable fungi in bedroom air and dust, and in outdoor air. Main outcomes included ascertainment of symptoms/disease onset by questionnaire from birth through age 13. We estimated hazard ratios and, for wheeze and sensitization, odds ratios for an interquartile increase in log-transformed fungal concentrations, adjusting for other outcome predictors and potential confounders.

RESULTS

Elevated levels of yeasts in bedroom floor dust were associated with reduced: i) wheeze at any age; ii) fungal sensitization; and iii) asthma development by age 13 (hazard ratio (HR) = 0.86; 95% confidence interval (CI), [0.75 to 0.98]). Outdoor airborne Cladosporium and dustborne Aspergillus predicted increased rhinitis. Risk of fungal sensitization by age 12, in response to environmental Alternaria and Aspergillus, was elevated in children with a maternal history of fungal sensitization.

CONCLUSIONS AND CLINICAL RELEVANCE

Despite the irritant and allergenic properties of fungi, early-life elevated dust yeast exposures or their components may be protective against allergy and asthma in children at risk for these outcomes. Ascertainment of fungal components associated with immunoprotective effects may have therapeutic relevance for asthma.

Developmental determinants in non-communicable chronic diseases and ageing

Prenatal and peri-natal events play a fundamental role in health, development of diseases and ageing (Developmental Origins of Health and Disease (DOHaD)). Research on the determinants of active and healthy ageing is a priority to: (i) inform strategies for reducing societal and individual costs of an ageing population and (ii) develop effective novel prevention strategies. It is important to compare the trajectories of respiratory diseases with those of other chronic diseases.

Maternal intestinal flora and wheeze in early childhood

BACKGROUND

Increasing evidence links altered intestinal flora in infancy to eczema and asthma. No studies have investigated the influence of maternal intestinal flora on wheezing and eczema in early childhood.

OBJECTIVE

To investigate the link between maternal intestinal flora during pregnancy and development of wheeze and eczema in infancy.

METHODS

A total of 60 pregnant women from the Boston area gave stool samples during the third trimester of their pregnancy and answered questions during pregnancy about their own health, and about their children's health when the child was 2 and 6 months of age. Quantitative culture was performed on stool samples and measured in log(10)colony-forming units (CFU)/gram stool. Primary outcomes included infant wheeze and eczema in the first 6 months of life. Atopic wheeze, defined as wheeze and eczema, was analysed as a secondary outcome.

RESULTS

In multivariate models adjusted for breastfeeding, day care attendance and maternal atopy, higher counts of maternal total aerobes (TA) and enterococci (E) were associated with increased risk of infant wheeze (TA: OR 2.32 for 1 log increase in CFU/g stool [95% CI 1.22, 4.42]; E: OR 1.57 [95% CI 1.06, 2.31]). No organisms were associated with either eczema or atopic wheeze.

CONCLUSIONS AND CLINICAL RELEVANCE

In our cohort, higher maternal total aerobes and enterococci were related to increased risk of infant wheeze. Maternal intestinal flora may be an important environmental exposure in early immune system development.

Longitudinal relationship of early life immunomodulatory T cell phenotype and function to development of allergic sensitization in an urban cohort

BACKGROUND

Immunomodulatory T cells are thought to influence development of allergy and asthma, but early life longitudinal data on their phenotype and function are lacking.

OBJECTIVES

As part of the Urban Environment and Childhood Asthma (URECA) study, we investigated the development of immunomodulatory T cell phenotype and function, and characterized their relation to allergic disease progression from birth through to 2 years of age.

METHODS

Immunomodulatory T cell phenotype and function in cord blood mononuclear cells (CBMC) and peripheral blood mononuclear cells (PBMC) at 1 and 2 years of age were characterized by analysing CD25(bright) and FoxP3(+) expression, proliferative responses and cytokine production. The relation of immunomodulatory T cell characteristics to allergic sensitization and disease at 1- and 2-years of age was investigated.

RESULTS

The proportion of CD4(+)CD25(bright) and CD4(+)CD25(+)FoxP3(+)T cells (n = 114, 83, 82 at birth, 1- and 2-years respectively) increased significantly, whereas there were no significant changes in the suppressive function of CD25(+)T cells (n = 78, 71, 81 at birth, 1- and 2-years respectively). Birth immunomodulatory T cell characteristics were not related to subsequent allergic sensitization or disease. However, increases in the numbers of CD4(+)CD25(bright) cells and their ability to suppress lymphoproliferative responses at 1 year of age were associated with reduced allergic sensitization at 1 (P = 0.03) and 2 (P = 0.02) years of age. Production of the anti-inflammatory cytokine IL-10 by CD25(+)T cells appeared to mediate this protective suppressive function. In contrast, by 2 years of age, we observed the emergence of a positive association of CD4(+)CD25(+) FoxP3(+) T cell numbers with allergic sensitization (P = 0.05) and eczema (P = 0.02).

CONCLUSIONS AND CLINICAL RELEVANCE

These findings suggest that the relationship between immunomodulatory T cell subsets, allergic sensitization and eczema is developmentally regulated. In the first year of life, CD4(+)CD25(+) IL-10 producing T cells are associated with a reduced incidence of allergic sensitization. Once allergic sensitization or eczema is established, CD4(+)CD25(+)FoxP3(+)T-reg cells expand to potentially counteract the allergic inflammatory response. Understanding the relationship between development of immunoregulatory T cells and early onset atopy could lead to new preventive strategies for allergic diseases.

Screening for Lesions with an Oral Mucosal Brush Biopsy

Objective: Evaluate the use and impact of providing a noninvasive oral brush biopsy to patients presenting on an initial visit with a mildly or nonsuspicious oral lesion. The cytopathologic findings can be used as confirmatory evidence in support of the clinical impression.

Method: The brush biopsy test provided an option to patients presenting nonsuspicious lesions at our office over a 24-month period. Impressions regarding obtaining a specimen and time required were monitored. When brush biopsy tests were ordered, cytologic evaluation was performed. Doctors were surveyed on their impressions of the test.

Results: The brush biopsy test was performed on patients with mildly to nonsuspicious lesions. Cytology evaluation was performed, and abnormal or dysplastic cells were reported. Results showed how the brush biopsy cytology confirmed the clinical impressions. Survey of clinicians indicated that tests were relatively easy to perform and could be completed in a reasonable timeframe of less than 10 minutes during the initial visit. Doctors reported benefits of ease of performance, absence of identifiable risks, and complications from the tests.

Conclusion: Oral brush biopsy can be provided to patients as a screening option for oral mucosal lesions that are not highly suspicious. Surveys indicated the test was perceived as an instrument to provide confidence to patients and gather information early with no complications and risk factors during the visit.

Cytology as an Oral Lesion Surgical Biopsy Timing Instrument

Objective: For patients with certain risk factors and suspicious oral cavity lesions not meeting criteria for immediate surgical biopsy, we evaluated the use of a brush biopsy cytology as a screening tool to assist in choosing between treatment options of immediate surgical biopsy and patient observation.

Method: Oral mucosal brush biopsy cytology was performed on patients with risk factors and mildly suspicious lesions in the oral cavity. Specimens obtained were reviewed for presence of abnormal or dysplastic cells. Data were collected from 2008 to 2011. We correlated the results with the follow-up treatment decisions.

Results: During the study period, 52 patients had brush biopsies. Pathology results in 21% ( P < 0.01) of cases showed presence of abnormal or dysplastic cells and an immediate follow-up surgical biopsy was performed. In 71% of cases, results did not reveal abnormal cells, and patients were put under observation. In 7% of cases results indicated a fungal infection, and patients were treated.

Conclusion: Where brush biopsy cytology revealed presence of abnormal or dysplastic cells, an immediate follow-up scalpel biopsy was recommended. Brush biopsy cytology from suspicious lesions provides information to aid in determining the treatment pathway for suspicious oral mucosal lesions not meeting criteria for an immediate surgical biopsy.

Umbilical cord plasma 25-hydroxyvitamin D concentration and immune function at birth: the Urban Environment and Childhood Asthma study

BACKGROUND

Recent studies have reported conflicting data on the association between maternal intake of vitamin D during pregnancy and asthma.

OBJECTIVE

To assess the influence of prenatal vitamin D status on immune function at birth.

METHODS

In an inner-city birth cohort of 568 newborns, 520 of whom had at least one atopic parent, we measured the umbilical cord (UC) plasma concentration of 25-hydroxyvitamin D (25(OH)D) and the cytokine responses of UC blood mononuclear cells (UCMCs) to stimuli including phytohaemagglutinin (PHA), lipopolysaccharide (LPS), and peptidoglycan. In a subset, the UCMC expression of regulatory T cell markers and the suppressive activity of CD4(+) CD25(+) UCMCs were measured. Results The 25th, 50th, and 75th percentiles of UC plasma 25(OH)D level were 15.0, 20.2, and 25.6 ng/mL, respectively. Most cytokine responses of UCMC were not correlated with UC 25(OH)D concentration; however, IFN-γ release after LPS stimulation was weakly positively correlated with UC 25(OH)D concentration (r=0.11, P=0.01). PHA responses were not significantly correlated with 25(OH)D concentration. The UC plasma 25(OH)D concentration was inversely related to the number of CD25(+) (r=-0.20, P=0.06), CD25(Bright) (r=-0.21, P=0.05), and CD25(+) FoxP3 (r=-0.29, P=0.06) cells as a proportion of CD4(+) T cells in UC blood (r=-0.26, P=0.04) but not to the suppressive activity of CD4(+) CD25(+) cells (r=0.17, P=0.22).

CONCLUSION AND CLINICAL RELEVANCE

UC 25(OH)D concentration was not correlated with most UCMC cytokine responses to multiple stimuli. There was a suggestion of a weakly positive correlation with IFN-γ release after LPS stimulation. The proportions of CD25(+) , CD25(Bright) , and CD25(+) FoxP3 cells to total CD4(+) T cells were inversely correlated with UC 25(OH)D concentration. Our findings suggest that higher vitamin D levels at birth may be associated with a lower number of T-regulatory cells. Vitamin D status in utero may influence immune regulation in early life.

Multiple microbial exposures in the home may protect against asthma or allergy in childhood

BACKGROUND

Experimental animal data on the gram-negative bacterial (GNB) biomarker endotoxin suggest that persistence, dose, and timing of exposure are likely to influence its effects on allergy and wheeze. In epidemiologic studies, endotoxin may be a sentinel marker for a microbial milieu, including gram-positive bacteria (GPB) as well as GNB, that may influence allergy and asthma through components (pathogen-associated molecular patterns) that signal through innate Toll-like receptor pathways.

OBJECTIVE

To determine the influence of current GNB and GPB exposures on asthma and allergic sensitization in school-aged children.

METHODS

We examined the relationship between bacterial biomarkers and current asthma and allergic sensitization in 377 school-aged children in a birth cohort study. We then evaluated the effects of school-aged endotoxin, after controlling for exposure in early life.

RESULTS

Exposure to GNB was inversely associated with asthma and allergic sensitization at school age [for >median endotoxin: prevalence odds ratio (POR)=0.34, 95% CI=0.2-0.7, for current asthma and prevalence ratio=0.77, 95% CI=0.6-0.97, for allergic sensitization]. In contrast, elevated GPB in the bed was inversely associated with current asthma (POR=0.41, 95% CI=0.2-0.9) but not with allergic sensitization (POR=1.07, 95% CI=0.8-1.4). School-aged endotoxin exposure remained protective in models for allergic disease adjusted for early-life endotoxin.

CONCLUSION

Both GNB and GPB exposures are associated with decreased asthma symptoms, but may act through different mechanisms to confer protection. Endotoxin exposure in later childhood is not simply a surrogate of early-life exposure; it has independent protective effects on allergic disease.

Electrophysiologic study: its predictive value for ventricular arrhythmias

Studies have shown the predictive value of inducible ventricular tachycardia and clinical arrhythmia in patients who have structural heart disease. We examined the possible predictive value of electrophysiologic study before the placement of an implantable cardioverter-defibrillator. Our retrospective study group comprised 315 patients who had ventricular tachycardia that was inducible during electrophysiologic study and who had undergone at least 1 month of follow-up (247 men; mean age, 66.9 +/- 13.5 yr; mean follow-up, 24.9 +/- 14.8 mo). Recorded characteristics included induced ventricular tachycardia cycle length, atrio-His and His-ventricular electrograms, PR and QT intervals, QRS duration, and drug therapy. Of the 315 patients, 97 experienced ventricular arrhythmia during the follow-up period, as registered by 184 of more than 400 interrogations. There were 187 episodes of ventricular arrhythmia (tachycardia, 178; fibrillation, 9) during 652.5 person-years of follow-up. Subjects with a cycle length > or =240 msec were more likely to have an earlier 1st arrhythmia than those with a cycle length <240 msec (P=0.032). A quarter of the subjects with a cycle length > or =240 msec had their 1st arrhythmia by 19.14 months, compared with 23.8 months for a quarter of the subjects with a cycle length <240 msec (P <0.032). Among the electrophysiologic characteristics examined, inducible ventricular tachycardia with a cycle length > or =240 msec is predictive of appropriate implantable cardioverter-defibrillator therapy at an earlier time. This may have prognostic implications that warrant implantable cardioverter-defibrillator programming to enable appropriate antitachycardia pacing in this group of patients.

Mouse allergen exposure, wheeze and atopy in the first seven years of life

BACKGROUND

Little is known about mouse allergen exposure in home environments and the development of wheezing, asthma and atopy in childhood.

OBJECTIVE

To examine the relation between mouse allergen exposure and wheezing, atopy, and asthma in the first 7 years of life.

METHODS

Prospective study of 498 children with parental history of allergy or asthma followed from birth to age 7 years, with longitudinal questionnaire ascertainment of reported mouse exposure and dust sample mouse urinary protein allergen levels measured at age 2-3 months.

RESULTS

Parental report of mouse exposure in the first year of life was associated with increased risk of transient wheeze and wheezing in early life. Current report of mouse exposure was also significantly associated with current wheeze throughout the first 7 years of life in the longitudinal analysis (P = 0.03 for overall relation of current mouse to current wheeze). However, early life mouse exposure did not predict asthma, eczema or allergic rhinitis at age 7 years. Exposure to detectable levels of mouse urinary protein in house dust samples collected at age 2-3 months was associated with a twofold increase in the odds of atopy (sensitization to >=1 allergen) at school age (95% confidence interval for odds ratio = 1.1-3.7; P = 0.03 in a multivariate analysis.

CONCLUSIONS

Among children with parental history of asthma or allergies, current mouse exposure is associated with increased risk of wheeze during the first 7 years of life. Early mouse exposure was associated with early wheeze and atopy later in life.

Increased use of beta-agonists leading to non-ST-segment elevation myocardial infarction in a patient with hemodynamically significant myocardial bridging

Myocardial bridging is not uncommon. However, hemodynamic instability in the setting of myocardial bridging is rare. We describe an unusual case of a 47-year-old woman whose increased use of inhaled albuterol led to a non-ST-segment elevation myocardial infarction and unmasking of hemodynamically significant myocardial bridging. We detail its diagnosis through myocardial perfusion imaging and coronary angiography. To our knowledge, this is the first time previously undiagnosed myocardial bridging has led to a myocardial infarction in the setting of inhaled albuterol use.

Fetal cord blood: aspects of heightened immune responses

Neonatal immune responses have been associated with the development of atopy in childhood. We assessed in cord blood mononuclear cells (CBMC) whether increased allergen/mitogen-induced lymphoproliferation (LP) is associated with pro-allergic Th2 cytokine IL-13 or Th1 cytokine IFN-gamma secretion. We determined whether LP to one allergen is related to heightened lymphocyte function to other allergens/mitogen. CBMC from 135 neonates were stimulated with house dust mite (Derf1), cockroach, ovalbumin, or mitogen. LP to one allergen was associated with significantly increased LP to other allergens/mitogen. Increased Derf1-LP was associated with increased Derf1-induced IL-13 secretion (r = 0.21, p = 0.01). After adjusting for neonatal gender, race, and maternal smoking, Derf1-LP remained associated with Derf1-IL-13 (OR 3.08, 95% CI 1.56-6.10). Increased mitogen-induced proliferation was associated with increased mitogen-induced IL-13 secretion (r = 0.37, p < 0.001). For some individuals, a predisposition to a heightened immune response is already evident at birth. Whether this phenotype results in atopy in childhood warrants further investigation.

Elevated allergen-induced IL-13 secretion predicts IgE elevation in children ages 2-5 years

It is unclear if early immune responses to allergens, specifically Th1 and Th2 cytokine production, predict later immune responses, including increased IgE levels. In a group of children (n = 151) with a parental history of allergy or asthma followed from ages 2 through 5 years, we examined IL-13, IL-4, and IFN-gamma secretion by peripheral blood mononuclear cells in response to phytohemagglutinin (PHA), and to dust mite (Der f 1), cockroach (Bla g 2), and cat (Fel d 1) allergens in relation to elevated IgE. Elevated IgE was defined either as a positive IgE-specific response to at least one allergen (dust mite, cockroach, cat, and ovalbumin) or as an elevated total IgE level above a specified cut-off value. In multivariate logistic regression models including 181 observations made between the age of 2 through 5 years and accounting for repeated measures, we found an association between increased IL-13 secretion in response to Der f 1 and elevated IgE (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.09-1.34). Age did not modify this relationship. No association was found between allergen-induced IFN-gamma secretion and IgE production. Among the group of children with measurements made at age 4-5 (n = 70), IL-13 in response to Der f 1 (p = 0.046), and IL-4 in response to PHA (p = 0.04) were increased among children with elevated IgE. In a smaller subset of children with measurements made at both age 2-3 and age 4-5 (n = 36), IL-13 levels at age 2-3 were also significantly increased in response to Der f 1 (p = 0.01) and Fel d 1 (p = 0.002) among those with elevated IgE at age 4-5. In a group of children ages 2-5 years, there is an association between IL-13 and elevated IgE.

Air pollution and inflammation in type 2 diabetes: a mechanism for susceptibility

BACKGROUND

Particulate air pollution has been associated with several adverse cardiovascular health outcomes, and people with diabetes may be especially vulnerable. One potential pathway is inflammation and endothelial dysfunction-processes in which cell adhesion molecules and inflammatory markers play important roles.

AIM

To examine whether plasma levels of soluble intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1) and von Willebrand factor (vWF) were associated with particle exposure in 92 Boston area residents with type 2 diabetes.

METHODS

Daily average ambient levels of air pollution (fine particles (PM2.5), black carbon (BC) and sulphates) were measured approximately 500 m from the patient examination site and evaluated for associations with ICAM-1, VCAM-1 and vWF. Linear regressions were fit to plasma levels of ICAM-1, VCAM-1 and vWF, with the particulate pollutant index, apparent temperature, season, age, race, sex, glycosylated haemoglobin, cholesterol, smoking history and body mass index as predictors.

RESULTS

Air pollutant exposure measures showed consistently positive point estimates of association with the inflammatory markers. Among participants not taking statins and those with a history of smoking, associations between PM(2.5), BC and VCAM-1 were particularly strong.

CONCLUSIONS

These results corroborate evidence suggesting that inflammatory mechanisms may explain the increased risk of air pollution-associated cardiovascular events among those with diabetes.

Ambient particulate air pollution and cardiac arrhythmia in a panel of older adults in Steubenville, Ohio

OBJECTIVES

Ambient particulate air pollution has been associated with increased risk of cardiovascular morbidity and mortality. Pathways by which particles may act involve autonomic nervous system dysfunction or inflammation, which can affect cardiac rate and rhythm. The importance of these pathways may vary by particle component or source. In an eastern US location with significant regional pollution, the authors examined the association of air pollution and odds of cardiac arrhythmia in older adults.

METHODS

Thirty two non-smoking older adults were evaluated on a weekly basis for 24 weeks during the summer and autumn of 2000 with a standardised 30 minute protocol that included continuous electrocardiogram measurements. A central ambient monitoring station provided daily concentrations of fine particles (PM(2.5), sulfate, elemental carbon) and gases. Sulfate was used as a marker of regional pollution. The authors used logistic mixed effects regression to examine the odds of having any supraventricular ectopy (SVE) or ventricular ectopy (VE) in association with increases in air pollution for moving average pollutant concentrations up to 10 days before the health assessment.

RESULTS

Participant specific mean counts of arrhythmia over the protocol varied between 0.1-363 for SVE and 0-350 for VE. The authors observed odds ratios for having SVE over the length of the protocol of 1.42 (95% CI 0.99 to 2.04), 1.70 (95% CI 1.12 to 2.57), and 1.78 (95% CI 0.95 to 3.35) for 10.0 microg/m3, 4.2 microg/m3, and 14.9 ppb increases in five day moving average PM2.5, sulfate, and ozone concentrations respectively. The other pollutants, including elemental carbon, showed no effect on arrhythmia. Participants reporting cardiovascular conditions (for example, previous myocardial infarction or hypertension) were the most susceptible to pollution induced SVE. The authors found no association of pollution with VE.

CONCLUSION

Increased levels of ambient sulfate and ozone may increase the risk of supraventricular arrhythmia in the elderly.

Silent sinus syndrome: a case presentation and comprehensive review of all 84 reported cases

OBJECTIVES

The term silent sinus syndrome has been used to describe the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical chronic maxillary sinusitis. Currently, it is believed to occur as a result of the sequence of events following maxillary sinus hypoventilation due to the obstruction of the ostiomeatal complex.

METHODS

In this study, we present a case of true silent sinus syndrome. In addition, we highlight the previously published cases of silent sinus syndrome, as well as provide a review of the etiology, pathophysiology, radiologic diagnosis, surgical treatment, and pitfalls to avoid in the management of patients with silent sinus syndrome.

RESULTS

Eighty-three previously published cases of silent sinus syndrome were reported in the literature and are summarized in this review.

CONCLUSIONS

A well-defined set of criteria is needed to classify a patient under the diagnosis of silent sinus syndrome, which include enophthalmos and/or hypoglobus in the absence of clinically evident sinonasal inflammatory disease.