Smartphone use and well-being of adolescent girls: a population-based study

BACKGROUND AND OBJECTIVES

Recent studies have reported an increasing incidence of anxiety among adolescent girls, and associated this with self-reported social media use. This study aimed to measure smartphone and social media use objectively and to evaluate its associations with measures of mental health and well-being.

METHODS

In autumn 2022, we recruited a cohort of 1164 first-year female students from 21 socioeconomically diverse high schools. Students responded to an online survey comprising validated questionnaires (Bergen Social Media Addiction Scale (BSMAS), Generalised Anxiety Disorder-7, and Body Appreciation Scale 2) and visual analogue scales of current health, mood, tiredness, and loneliness. We also requested that they attach screenshots depicting their smartphone use.

RESULTS

Among participants (mean age 16.3 years), 16% (n=183) had possible social media addiction and 37% (n=371) exceeded the cut-off for possible anxiety disorders. The BSMAS scores were associated with higher anxiety (r=0.380) and poorer body image (r=-0.268), poorer health (r=-0.252), lower mood (r=-0.261), greater tiredness (r=0.347), and greater loneliness (r=0.226) (p<0.001 for all). Among the 564 adolescents (48%) who sent screenshots of their smartphone use, average daily use was 5.8 hours (SD 2.2), including 3.9 hours (SD 2.0) of social media. Participants who sent screenshots had a higher grade point average than participants without screenshot data, but similar BSMAS and well-being measures.

CONCLUSIONS

Consistent with other studies, we found social media addiction was common among adolescent girls and was associated with poorer mental health and well-being. Measures should be taken to protect adolescents from the potential harmful effects of social media use.

Progressive Impairment of Prepubertal Growth in Children With APECED

CONTEXT

Subjects with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) have subnormal adult height. There are several potential APECED-related risk factors for suboptimal height attainment during childhood.

OBJECTIVE

To determine the growth patterns in children with APECED.

DESIGN

Retrospective longitudinal study.

SETTING

The Finnish national APECED cohort.

PATIENTS

59 children with APECED.

MAIN OUTCOME MEASURES

Length/height and weight z-scores from birth to the end of prepuberty.

RESULTS

Collectively, 59 children [30 (51%) girls] were included. Their median birth weight z-score (-0.60) was below the population average; 12 (20%) patients were born small for gestational age. Height attainment progressively declined from birth until the end of prepuberty (z-score -1.95), whereas weight-for-height z-score did not (+0.26). Of the 59 patients, 38 (64%) had all height z-scores below 0 during prepuberty, and seven (12%) had z-scores below -2.0. Age at the end of prepuberty, number of APECED manifestations, duration of glucocorticoid treatment, and growth hormone deficiency correlated negatively with height z-score at the end of prepuberty (p < 0.0001; p = 0.041; p = 0.013; p = 0.034, respectively).

CONCLUSIONS

Children with APECED had a progressive growth impairment from birth through prepuberty. Multiple predisposing risk factors were recognized, including disease severity and growth hormone deficiency. Timely interventions are needed to ensure optimal height attainment and new treatment options need to be developed.

Increased type 1 inflammation in gynecological cervicovaginal samples in patients with APS-1

BACKGROUND

Inborn errors of immunity offer important insights to mucosal immunity. In autoimmune polyendocrine syndrome type-1 (APS-1) chronic mucocutaneous candidiasis has been ascribed to neutralizing IL-17 autoantibodies. Recent evidence implicates ecxessive T-cell IFN-γ secretion ensuing epithelial barrier disruption in predisposition to candidiasis, but these results remain to be replicated. It is debated whether IL-17 paucity, increased type I inflammation or their combination underlies susceptibility to chronic mucocutaneus candidiasis in APS-1.

OBJECTIVE

To characterize the immunological features in cervicovaginal mucosa of females with APS-1.

METHODS

Vaginal fluid was collected with flocked swab from 17 females with APS-1 and 18 controls and cytokine composition analysed using Luminex. Cervical cell sample was obtained with a cervix brush from six patients and six healthy controls and subjected to transcriptome analysis.

RESULTS

The vaginal fluid from patients with APS-1 had IFN-γ concentration comparable to controls (2.6 vs 2.4 pg/ml), but contained high concentrations of Th1 chemokines CXCL9 and CXCL10 (1094 vs 110 pg/ml; p<0.001 and 4033 vs 273 pg/ml; p=0.001, respectively) while IL-17 levels were comparable (28 vs 8.8 pg/ml). RNAseq of cervical cells revealed upregulation of pathways related to mucosal inflammation and cell death in the patients.

CONCLUSION

Excessive Th1 response appears to underlie disruption of the mucosal immune responses in genital tract of patients with APS-1 and may contribute to susceptibility to candidiasis also in genital tract.

Girls referred for amenorrhea: analysis of a patient series from a specialist center

Objective

Among adolescents, amenorrhea is a common reason for medical consultation. Despite the variety of underlying etiologies, the prevalence of the causes is incompletely understood. This study aimed to assess the demographic and etiological factors among patients with amenorrhea treated in a single specialist unit of adolescent gynecology.

Design

Retrospective register study.

Methods

Medical records of 438 girls evaluated for primary or secondary amenorrhea in a single tertiary care center between 2015 and 2019 were retrospectively reviewed. In all, 423 patients-171 with primary amenorrhea and 252 with secondary amenorrhea-were included in the study. Data on underlying conditions, anthropometric variables, and selected hormonal markers were analyzed.

Results

Functional hypogonadotropic hypogonadism was the most frequent reason for primary (56%) and secondary (78%) amenorrhea. It was mostly explained by lifestyle-related functional hypothalamic amenorrhea caused by disordered eating, intense exercise, energy deficiency, psychological stress, and their combinations.

Conclusion

Menstrual pattern is a significant indicator of overall health and well-being among adolescent girls and young women. Functional reasons behind primary and secondary amenorrhea are important to recognize. Treatment often requires long-term lifestyle modifications. The frequency of functional causes also implies that most amenorrhea cases are preventable.

Fertility counselling and fertility preservation among early onset female cancer patients-A Finnish register-based study

INTRODUCTION

Advances in multimodality cancer treatments have increased long-term survival rates for early onset cancer patients, with 5-year survival rates reaching 80% in Northern Europe. According to recent recommendations, clinicians should, as early as possible, inform cancer patients about the impact that cancer treatment may have on their fertility. Still, there is limited published data on fertility counselling (FC) and fertility preservation (FP) for cancer patients.

METHODS

This register-based study used hospital records to identify female cancer patients in the hospital district (n = 192) who received FC at the age of 16-42 years between 2011 and 2019.

RESULTS

Altogether, 97 (50.5%) cancer patients were eligible for FP. Of these, 55 (56.7%) underwent FP, whereas 42 (43.3%) declined. Women undergoing FP were recommended cancer treatments with a higher risk of infertility (p = 0.01), and women with breast cancer were more prone to undergo FP than women with lymphoma (p = 0.043). In FP treatment cycles, the mean number of oocytes retrieved (13.9 ± 7.7 vs. 12.0 ± 6.5, p = 0.04) and transferrable embryos (4.7 ± 2.9 vs. 3.7 ± 2.8, p = 0.002) was higher among cancer patients compared to age-matched comparisons with male or tubal factor infertility. The total mean gonadotropin dose used was higher among cancer patients (2243 ± 963 IU vs. 1679 ± 765 IU, p < 0.001).

CONCLUSION

We conclude that a good ovarian response during FP can be achieved in female cancer patients.

Pubertal development and hypogonadism in males with APECED - a retrospective study

The aim of this study was to describe the course of puberty and hypogonadism in males with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in the Finnish APECED cohort followed 1970-2020. Anthropometry, testicular volumes, and FSH, LH, and testosterone concentrations were analysed retrospectively. Forty-three males were followed until the median age of 42.5 years (range, 16.2-74.8). All subjects fulfilled the clinical criteria of APECED. The median age at the onset of spontaneous puberty was 13.3 years (10.8-14.8). Testosterone medication was used to promote pubertal development from the median age of 14.9 years (13.5-15.7), for 0.7-3.3 years in eight patients. The median adult height was 173.0 cm and differed from the mid-parental target height on average -1.3 SDS (P < 0.001). Hypogonadism was treated in six patients (14%). Azoospermia was found in three patients. Further studies are required to explore the role of AIRE in sperm production and testicular insufficiency.

Eating behaviours, menstrual history and the athletic career: a retrospective survey from adolescence to adulthood in female endurance athletes

Aim

To evaluate differences in menstrual and pubertal history and trends in eating behaviours among women with and without a competitive sports background. Additionally, we investigated if menstrual history and eating behaviours are associated with sports career-related factors.

Methods

This retrospective study was conducted on 100 women with a competitive endurance sports background and their age-matched, gender-matched and municipality-matched controls (n=98). Data were collected using a questionnaire using previously validated instruments. Generalised estimating equations were used to calculate associations of menstrual history and eating behaviours with outcome variables (career length, participation level, injury-related harms and career termination due to injury).

Results

Athletes reported higher rates of delayed puberty and menstrual dysfunction than controls. No differences between the groups were observed in the Eating Disorder Examination Questionnaire short form (EDE-QS) scores at any age. Previous disordered eating (DE) was associated with current DE in both groups. Among athletes, higher EDE-QS scores during the sports career were associated with a shorter career (B=-0.15, 95% CI -0.26 to -0.05). Secondary amenorrhoea was associated with lower participation level (OR 0.51, 95% CI 0.27 to 0.95), injury-related harms during the career (OR 4.00, 95% CI 1.88 to 8.48) and career termination due to injury (OR 1.89, 95% CI 1.02 to 3.51).

Conclusion

The findings indicate that DE behaviours and menstrual dysfunction, specifically secondary amenorrhoea, have a disadvantageous relationship with a sports career in women competing in endurance sports. DE during the sports career is associated with DE after the career.

Somatic Health and Psychosocial Background Among Finnish Adolescents with Gender Dysphoria Seeking Hormonal Interventions

Purpose

Although the number of young adults suffering from gender dysphoria (GD) is increasing, reports focusing on their somatic health remain scarce. We studied the somatic health, pubertal development, psychosocial background, and interest regarding gender-affirming surgical treatment of Finnish adolescents seeking gender-affirming hormonal treatment (GAHT).

Methods

In this retrospective register study at an adolescent gynecology clinic in Helsinki University Hospital, Finland we included 124 adolescents diagnosed with GD and referred to GAHT between January 1, 2011 and December 31, 2018. This cohort covered two thirds of all Finnish adolescents referred to GAHT during the follow-up. Data on the general adolescent population were obtained from the Finnish School Health Promotion (SHP) study of year 2017.

Results

Most adolescents were assigned female at birth. Sex ratio increased from 1.2 in 2012 to 5.2 in 2017. One-third of the patients were overweight or obese (body mass index [BMI] >25 kg/m2). Other somatic comorbidities were rare. Interest toward reconstructive genital surgery was more common among male-to-female than female-to-male patients (80% vs. 22%, respectively, p<0.001). Depression (29%) and anxiety (19%) were common psychiatric comorbidities. Parental divorce rate (57%) was higher than in the general adolescent population in Finland (23%, p<0.001).

Conclusion

Finnish adolescents diagnosed with GD-seeking GAHT have good somatic health, but a higher proportion of overweight, depression, and anxiety than the general adolescent population. Prospective follow-up of this cohort will provide an opportunity to evaluate the somatic and psychosocial outcomes and quality of life during GAHT.

Insect Herbivory Caused Plant Stress Emissions Increases the Negative Radiative Forcing of Aerosols

Plant stress in a changing climate is predicted to increase plant volatile organic compound (VOC) emissions and thus can affect the formed secondary organic aerosol (SOA) concentrations, which in turn affect the radiative properties of clouds and aerosol. However, global aerosol-climate models do not usually consider plant stress induced VOCs in their emission schemes. In this study, we modified the monoterpene emission factors in biogenic emission model to simulate biotic stress caused by insect herbivory on needleleaf evergreen boreal and broadleaf deciduous boreal trees and studied the consequent effects on SOA formation, aerosol-cloud interactions as well as direct radiative effects of formed SOA. Simulations were done altering the fraction of stressed and healthy trees in the latest version of ECHAM-HAMMOZ (ECHAM6.3-HAM2.3-MOZ1.0) global aerosol-climate model. Our simulations showed that increasing the extent of stress to the aforementioned tree types, substantially increased the SOA burden especially over the areas where these trees are located. This indicates that increased VOC emissions due to increasing stress enhance the SOA formation via oxidation of VOCs to low VOCs. In addition, cloud droplet number concentration at the cloud top increased with increasing extent of biotic stress. This indicates that as SOA formation increases, it further enhances the number of particles acting as cloud condensation nuclei. The increase in SOA formation also decreased both all-sky and clear-sky radiative forcing. This was due to a shift in particle size distributions that enhanced aerosol reflecting and scattering of incoming solar radiation.

Pregnancy Outcome in Women With APECED (APS-1): A Multicenter Study on 43 Females With 83 Pregnancies

CONTEXT

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED; also known as autoimmune polyendocrine syndrome type 1) has a severe, unpredictable course. Autoimmunity and disease components may affect fertility and predispose to maternal and fetal complications, but pregnancy outcomes remain unknown.

OBJECTIVE

To assess fetal and maternal outcomes and course of clinical APECED manifestations during pregnancy in women with APECED.

DESIGN AND SETTING

A multicenter registry-based study including 5 national patient cohorts.

PATIENTS

321 females with APECED.

MAIN OUTCOME MEASURE

Number of pregnancies, miscarriages, and deliveries.

RESULTS

Forty-three patients had altogether 83 pregnancies at median age of 27 years (range, 17-39). Sixty (72%) pregnancies led to a delivery, including 2 stillbirths (2.4%) and 5 (6.0%) preterm livebirths. Miscarriages, induced abortions, and ectopic pregnancies were observed in 14 (17%), 8 (10%), and 1 (1.2%) pregnancies, respectively. Ovum donation resulted in 5 (6.0%) pregnancies. High maternal age, premature ovarian insufficiency, primary adrenal insufficiency, or hypoparathyroidism did not associate with miscarriages. Women with livebirth had, on average, 4 APECED manifestations (range 0-10); 78% had hypoparathyroidism, and 36% had primary adrenal insufficiency. APECED manifestations remained mostly stable during pregnancy, but in 1 case, development of primary adrenal insufficiency led to adrenal crisis and stillbirth. Birth weights were normal in >80% and apart from 1 neonatal death of a preterm baby, no serious perinatal complications occurred.

CONCLUSIONS

Outcome of pregnancy in women with APECED was generally favorable. However, APECED warrants careful maternal multidisciplinary follow-up from preconceptual care until puerperium.

Quantification of urinary total luteinizing hormone immunoreactivity may improve the prediction of ovulation time

OBJECTIVES

Most of the currently available ovulation prediction kits provide a relatively rough estimation of ovulation time with a short fertility window. This is due to their focus on the maximum probability of conception occurring one day before ovulation, with no follow-up after LH surge until ovulation nor during the subsequent days thereafter. Earlier studies have shown that urine of reproductive age women contains at least 3 different molecular forms of luteinizing hormone (LH); 1) intact LH, 2) LH beta-subunit (LHβ) and a 3) small molecular weight fragment of LHβ, LHβ core fragment (LHβcf). The proportion of these LH forms in urine varies remarkably during the menstrual cycle, particularly in relation to the mid-cycle LH surge. In this exploratory study, we studied the potential implications of determining the periovulatory course of total LH immunoreactivity in urine (U-LH-ir) and intact LH immunoreactivity in serum (S-LH-ir) in the evaluation of the fertility window from a broader aspect with emphasis on the post-surge segment.

METHODS

We determined total U-LH-ir in addition to intact S-LH-ir, follicle-stimulating hormone (FSH), progesterone, and estradiol in 32 consecutive samples collected daily from 10 women at reproductive age. Inference to the non-intact U-LH-ir levels was made by calculating the proportion of total U-LH-ir to intact S-LH-ir.

RESULTS

Total U-LH-ir increased along with LH surge and remained at statistically significantly higher levels than those in serum for 5 consecutive days after the surge in S-LH-ir. S-LH-ir returned to follicular phase levels immediately on the following day after the LH surge, whereas the same took 7 days for total U-LH-ir.

CONCLUSIONS

The current exploratory study provides preliminary evidence of the fact that U-LH-ir derived from degradation products of LH remains detectable at peak levels from the LH surge until ovulation and further during the early postovulatory period of fecundability. Thus, non-intact (or total) U-LH-ir appears to be a promising marker in the evaluation of the post-surge segment of the fertility window. Future studies are needed to unravel if this method can improve the prediction of ovulation time and higher rates of fecundability in both natural and assisted conception.

Endocrine Disorders and Genital Infections Impair Gynecological Health in APECED (APS-1)

Objective

In autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) defects in the autoimmune regulator gene lead to impaired immunotolerance. We explored the effects of immunodeficiency and endocrinopathies on gynecologic health in patients with APECED.

Design

Cross-sectional cohort study combined with longitudinal follow-up data.

Methods

We carried out a gynecologic evaluation, pelvic ultrasound, and laboratory and microbiologic assessment in 19 women with APECED. Retrospective data were collected from previous study visits and hospital records.

Results

The study subjects' median age was 42.6 years (range, 16.7-65.5). Sixteen patients (84%) had premature ovarian insufficiency, diagnosed at the median age of 16.5 years; 75% of them used currently either combined contraception or hormonal replacement therapy. In 76% of women, the morphology and size of the uterus were determined normal for age, menopausal status, and current hormonal therapy. Fifteen patients (79%) had primary adrenal insufficiency; three of them used dehydroepiandrosterone substitution. All androgen concentrations were under the detection limit in 11 patients (58%). Genital infections were detected in nine patients (47%); most of them were asymptomatic. Gynecologic C. albicans infection was detected in four patients (21%); one of the strains was resistant to azoles. Five patients (26%) had human papillomavirus infection, three of which were high-risk subtypes. Cervical cell atypia was detected in one patient. No correlation between genital infections and anti-cytokine autoantibodies was found.

Conclusions

Ovarian and adrenal insufficiencies manifested with very low androgen levels in over half of the patients. Asymptomatic genital infections, but not cervical cell atypia, were common in female patients with APECED.

Heavy Menstrual Bleeding in Adolescent: Normal or a Sign of an Underlying Disease?

Heavy, and often irregular, menstrual bleeding (HMB) is a common gynecologic complaint among adolescents. During the first few post-menarcheal years, anovulatory cycles related to immaturity of the hypothalamic-pituitary-ovarian axis are the most common etiology for abnormal uterine bleeding and should be considered as a part of normal pubertal development rather than a disease. If an already regular menstrual cycle becomes irregular, secondary causes of anovulation should be ruled out. Inherited and acquired bleeding disorders, such as von Willebrand disease, and quantitative and qualitative abnormalities of platelets are relatively common findings in adolescents with HMB from menarche. History of excessive bleeding or a diagnosed bleeding disorder in the family supports this etiology, warranting specialized laboratory testing. First-line treatment of HMB among adolescents is medical management with hormonal therapy or nonhormonal options. Levonorgestrel-releasing intrauterine device is an effective tool also for all adolescents with menstrual needs.

MANAGEMENT OF ENDOCRINE DISEASE: Diagnosis and management of primary amenorrhea and female delayed puberty

Puberty is the period of transition from childhood to adulthood characterized by the attainment of adult height and body composition, accrual of bone strength and the acquisition of secondary sexual characteristics, psychosocial maturation and reproductive capacity. In girls, menarche is a late marker of puberty. Primary amenorrhea is defined as the absence of menarche in ≥ 15-year-old females with developed secondary sexual characteristics and normal growth or in ≥13-year-old females without signs of pubertal development. Furthermore, evaluation for primary amenorrhea should be considered in the absence of menarche 3 years after thelarche (start of breast development) or 5 years after thelarche, if that occurred before the age of 10 years. A variety of disorders in the hypothalamus-pituitary-ovarian axis can lead to primary amenorrhea with delayed, arrested or normal pubertal development. Etiologies can be categorized as hypothalamic or pituitary disorders causing hypogonadotropic hypogonadism, gonadal disorders causing hypergonadotropic hypogonadism, disorders of other endocrine glands, and congenital utero-vaginal anomalies. This article gives a comprehensive review of the etiologies, diagnostics and management of primary amenorrhea from the perspective of pediatric endocrinologists and gynecologists. The goals of treatment vary depending on both the etiology and the patient; with timely etiological diagnostics fertility may be attained even in those situations where no curable treatment exists.

Norethisterone and its acetate - what's so special about them?

INTRODUCTION

Progestogens (progestins) are widely used for contraception, in postmenopausal hormone therapy, and in treatment of abnormal uterine bleeding and endometriosis. Norethisterone (NET) and its acetate (NETA) differ from other progestogens by their partial conversion to ethinylestradiol (EE). We review their special characteristics and focus on the clinically relevant risk factors associated with estrogen action, such as migraine with aura and risk of thrombosis.

METHODS

Narrative review based on a medical literature (OvidMedline and PubMed) search.

RESULTS

NET converts to significant amounts of EE; 10-20 mg NET corresponds to 20-30 µg EE. The effects of NET on the endometrium are pronounced, making it a good choice for treating abnormal uterine bleeding, endometriosis, and endometrial hyperplasia. NET also has beneficial effects on bone mineral density and positive or neutral effects on cardiovascular health. Conversely, long-term use of NET is associated with a slightly increased breast cancer risk, and the risk of venous thromboembolism is moderately increased. This risk seems to be dose-dependent; contraceptive use carries no risk, but therapeutic doses might be associated with an increased risk. Studies suggest an association between combinations of EE and progestogens and ischaemic stroke, which in particular concerns women with migraine. No studies have, however, assessed this risk related to the therapeutic use of NET.

CONCLUSIONS

NET is a potent progestogen, especially when considering the endometrium. Its partial conversion to EE, however, is important to remember. Clinical consideration is required with women at high risk for either breast cancer or thromboembolism, or experiencing migraine with aura.

Outcomes of 42 pregnancies in 14 women with cartilage-hair hypoplasia: a retrospective cohort study

BACKGROUND

Cartilage-hair hypoplasia (CHH) is a rare skeletal dysplasia characterized by disproportionate short stature, immunodeficiency, anemia and risk of malignancies. All these features can affect pregnancy and predispose to maternal and fetal complications. This study aimed to evaluate obstetric history and maternal and fetal outcomes in women with CHH.

METHODS

Among 47 Finnish women with CHH, we identified 14 women with ICD codes related to pregnancies, childbirth and puerperium in the National Hospital Discharge Registry and obtained detailed data on gynecologic and obstetric history with a questionnaire. Offspring birth length and weight were collected and compared with population-based normal values.

RESULTS

There were altogether 42 pregnancies in 14 women (median height 124 cm, range 105-139 cm; 4'1'', range 3'5''-4'7''). Twenty-six pregnancies (62%), including one twin pregnancy, led to a delivery. Miscarriages, induced abortions and ectopic pregnancies complicated 9, 5, and 2 pregnancies, respectively. Severe pregnancy-related complications were rare. All women with CHH delivered by cesarean section, mostly due to evident cephalo-pelvic disproportion, and in 25/26 cases at full-term. In the majority, the birth length (median 48 cm, range 45.5-50 cm; 1'7'', range 1'6''-1'8'') and weight (3010 g, range 2100-3320 g; 6.6 lb, range 4.6-7.3 lb) of the offspring in full-term singleton pregnancies was normal.

CONCLUSIONS

Despite CHH mothers' significant short stature and other potential CHH-related effects on pregnancy outcome, most pregnancies lead to a term cesarean section delivery. Since fetal growth was generally unaffected, cephalo-pelvic disproportion was evident and planned cesarean section should be contemplated in term pregnancies.

Pubertal development and premature ovarian insufficiency in patients with APECED

OBJECTIVE

To determine the natural course of pubertal development, growth during puberty, and development of POI in females with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), also called autoimmune polyendocrine syndrome type I.

DESIGN

Longitudinal follow-up study.

METHODS

A national cohort of females with APECED aged ≥12 years were followed during 1965-2018. Attainment of adult height was defined when patients' height increased less than 1 cm per year. Diagnosis of POI was based on delayed puberty or POI symptoms with amenorrhea, and/or FSH ≥40 IU/L.

RESULTS

Altogether 40 women with APECED were followed up to the average age of 37.3 (range: 14.6-61.9) years; 16 females (40%) were ≥ 40 years. Pubertal development started spontaneously in 34 patients and 29 had spontaneous menarche. POI developed in 28 patients (70%) at the median age of 16.0 years (range: 11.3-36.5), and in 20 of them (71%) before attaining adult height. In 11 cases puberty was induced or completed by hormonal therapy. Patients with POI were significantly shorter at menarche, but adult heights did not differ from non-POI females. Patients with POI had more often primary adrenocortical insufficiency (93% vs 58%, P = 0.017) and ovarian antibodies (81% vs 30%, P=0.003) compared to those with normal ovarian function (n = 12).

CONCLUSIONS

POI developed in the majority of patients with APECED, often before or shortly after menarche. Timely commencement of hormonal replacement therapy is important to ensure optimal pubertal development and growth. The possibility of fertility preservation before development of POI in APECED patients should be further studied.

Gynecologic health in cartilage-hair hypoplasia: A survey of 26 adult females

Cartilage-hair hypoplasia (CHH) is a rare metaphyseal chondrodysplasia significantly affecting adult height and quality of life. Immunodeficiency and increased risk for malignancies contribute to significant morbidity. Little is known about gynecologic health in CHH. We performed a questionnaire study of 26 women (mean age 42.3 years) with genetically confirmed CHH, inquiring about pubertal development, menstrual cycle, use of contraception, pregnancies, gynecologic infections, and gynecologic cancers. Mean age at menarche and menopause was 12.7 and 46.1 years, respectively. Mean length of menstrual cycle was 27 days. Contraception was used by 76%, most commonly condom (60%), and combined contraception (60%). Despite significant short stature (mean height 121 cm) and potentially small pelvic diameters, 10 CHH women (38%) had been pregnant. Six of these women reported miscarriages and three had, induced pregnancy terminations. Eight women had in total, 19 deliveries. Abnormal Pap smear was reported in five patients and cervical cancer once. Our findings of normal timing of puberty and menopause suggest a fairly normal length of the fertility period in women with CHH. However, many patients expressed concerns regarding the safety of pregnancy and lack of prepregnancy counseling. Immunodeficiency may predispose CHH women to prolonged HPV infections. This study highlights the importance of careful gynecologic follow-up for these patients.

Diversity of Pubertal Development in Cartilage-Hair Hypoplasia; Two Illustrative Cases

BACKGROUND

Cartilage-hair hypoplasia (CHH) is a rare chondrodysplasia, including disproportionate short stature, hypoplastic hair, immunodeficiency, and increased risk of malignancies. Absent pubertal growth spurt and absent pubic hair complicate monitoring of pubertal development in these patients.

CASES

Two CHH patients with delayed puberty and excessive growth failure are described. One of the girls had hypogonadotropic hypogonadism whereas the other had hyponormogonadotropic hypogonadism with no spontaneous pubertal development and slow response to estrogen therapy, both requiring permanent replacement therapy.

SUMMARY AND CONCLUSION

Careful follow-up of pubertal development in individuals with CHH and other growth-restricting bone diseases is needed. In delayed pubertal development timely hormone therapy is essential to ensure maximal growth and well developed secondary sex characteristics.

GnRH receptor gene mutations in adolescents and young adults presenting with signs of partial gonadotropin deficiency

Biallelic, partial loss-of-function mutations in GNRHR cause a wide spectrum of reproductive phenotypes from constitutional delay of growth and puberty to complete congenital hypogonadotropic hypogonadism. We studied the frequency of GNRHR, FGFR1, TAC3, and TACR3 mutations in nine adolescent and young adult females with clinical cues consistent with partial gonadotropin deficiency (stalled puberty, unexplained secondary amenorrhea), and describe phenotypic features and molecular genetic findings of monozygotic twin brothers with stalled puberty.

Two girls out of nine (22%, 95%CI 6–55%) carried biallelic mutations in GNRHR. The girl with compound heterozygous c.317A>G p.(Gln106Arg) and c.924_926delCTT p.(Phe309del) GNRHR mutations displayed incomplete puberty and clinical signs of hypoestrogenism. The patient carrying a homozygous c.785G>A p.(Arg262Gln) mutation presented with signs of hypoestrogenism and unexplained secondary amenorrhea. None of the patients exhibited mutations in FGFR1, TAC3, or TACR3. The twin brothers, compound heterozygous for GNRHR mutations c.317A>G p.(Gln106Arg) and c.785G>A p.(Arg262Gln), presented with stalled puberty and were discordant for weight, and the heavier of them had lower testosterone levels.

These results suggest that genetic testing of the GNRHR gene should be offered to adolescent females with low-normal gonadotropins and unexplained stalled puberty or menstrual dysfunction. In male patients with partial gonadotropin deficiency, excess adipose tissue may suppress hypothalamic-pituitary-gonadal axis.

Detecting early kidney damage in horses with colic by measuring matrix metalloproteinase -9 and -2, other enzymes, urinary glucose and total proteins

Background

The aim of the study was to investigate urine matrix metalloproteinase (MMP-2 and -9) activity, alkaline phosphatase/creatinine (U-AP/Cr) and gamma-glutamyl-transpeptidase/creatinine (U-GGT/Cr) ratios, glucose concentration, and urine protein/creatinine (U-Prot/Cr) ratio and to compare data with plasma MMP-2 and -9 activity, cystatin-C and creatinine concentrations in colic horses and healthy controls. Horses with surgical colic (n = 5) were compared to healthy stallions (n = 7) that came for castration. Blood and urine samples were collected. MMP gelatinolytic activity was measured by zymography.

Results

We found out that horses with colic had significantly higher urinary MMP-9 complex and proMMP-9 activities than horses in the control group. Colic horses also had higher plasma MMP-2 activity than the control horses. Serum creatinine, although within reference range, was significantly higher in the colic horses than in the control group. There was no significant increase in urinary alkaline phosphatase, gamma-glutamyltranspeptidase or total proteins in the colic horses compared to the control group. A human cystatin-C test (Dako Cytomation latex immunoassay^® based on turbidimetry) did not cross react with equine cystatin-C.

Conclusion

The results indicate that plasma MMP-2 may play a role in the pathogenesis of equine colic and urinary MMP-9 in equine kidney damage.

Neuromuscular function and balance of prepubertal and pubertal blind and sighted boys

AIM

To compare the neuromuscular function and balance of blind prepuberty- and puberty-aged boys to those with normal sight.

METHODS

Thirty-three prepubertal (aged 9-13 y) and pubertal (aged 15-18 y) blind and sighted boys were tested for muscle mass thickness, electromyography and maximal isometric strength, dynamic explosive actions, and balance.

RESULTS

There was no difference in the muscle mass thickness, maximal strength or vertical jump between the blind and sighted boys. However, fitness-ball throwing and five-jump distances were significantly shorter in both blind groups compared to the sighted groups. One-leg stance of the prepuberty-aged sighted boys was 109 (67) s and in blind boys 32 (12) s, and in the puberty-aged boys 120 (57) s and 31 (8) s, respectively. When vision was blocked in the sighted boys, differences between the blind and sighted boys disappeared.

CONCLUSION

The results showed comparable performance between prepubertal and pubertal blind and sighted boys in the static physical fitness tests. However, balance and performance in dynamic multi-joint tests did not improve similarly in the blind groups compared to sighted groups, indicating that maturation, learning and experience by themselves cannot compensate for the loss of sight.

Astemizole in combination with pseudoephedrine in the treatment of seasonal allergic rhinitis

The efficacy and side effects of once-daily astemizole-D, a combination of 10 mg astemizole and 240 mg pseudoephedrine, were compared with those of twice-daily brompheniramine-D, a combination of 12 mg brompheniramine and 50 mg phenylpropanolamine (Lunerin), in 64 patients with seasonal allergic rhinitis caused by birch pollen. Efficacy was monitored by patient's diary scores, investigator assessments of nasal and eye symptoms and need of rescue medication during the 4-week study period. Both astemizole-D and brompheniramine-D reduced nasal and eye symptoms of allergy. There were no significant differences between the treatment groups regarding obstruction, but brompheniramine-D alleviated symptoms of rhinorrhoea and itchy eyes significantly more than astemizole-D. On the other hand, the patients in the brompheniramine-D group reported dry mouth, tiredness and drowsiness more often than those in the astemizole-D group. The results indicate that the two drugs are effective in the treatment of seasonal allergic rhinitis, but astemizole-D is better tolerated than brompheniramine-D.

Long-term clinical course of hypersensitive rhinitis

Information on the long-term clinical course of hypersensitive rhinitis was collected among 180 patients who had previously participated in an allergological study. The time period between the initial study and the follow-up questionnaire study was about 18.2 years. Of the patients, 72 were men and 108 women, aged 3.6-69.3 years (mean age 28.5 years) at the time of the initial study. Initially, atopic rhinitis had been verified by allergological investigations in 61.7% while 38.3% of the cases had been designated as intrinsic. During the 18-year period symptoms decreased in severity in 37.2% and ceased completely in 27.2%. Total disappearance of symptoms was more frequent in the intrinsic than in the atopic group.

A comparison between intranasal budesonide aerosol and budesonide dry powder in the treatment of hay fever symptoms

Sixty patients with seasonal allergic rhinitis due to birch pollen were enrolled in an open, randomized parallel group study. Efficacy and side effects were studied after intranasal administration of budesonide given as a freon propellant aerosol or as dry powder with a sniff actuated inhalation device. Medication started a few days before the actual peak pollen season and lasted for three weeks. The dose was 400 micrograms once daily. Efficacy was assessed daily by patient-rated symptoms scores and by nasal peak inspiratory flow measurements at the visits to the clinic. Safety was assessed by monitoring clinical adverse events. No clear changes in nasal symptom scores or nasal peak flow occurred during the pollen season in either treatment group as compared to the pretreatment period, although the pollen season was very difficult in Finland during the study, ad 12000 grains per m3. Substantial or total control of symptoms was achieved in 93% of the patients in the aerosol group and in 79% in the powder group. Side effects were minimal in both groups. We conclude that dry powder administration of budesonide is as effective and well tolerated as the aerosol in the treatment of seasonal allergic rhinitis.

Terfenadine with or without phenylpropanolamine in the treatment of seasonal allergic rhinitis

The efficacy of terfenadine in combination with phenylpropanolamine was assessed by comparison with terfenadine alone in a double-blind, parallel group study of 66 patients with nasal birch pollen allergy. The patients were allocated randomly into two groups; 34 patients received terfenadine (60 mg) twice daily and 32 patients a combination tablet containing terfenadine (60 mg) and phenylpropanolamine (50 mg) twice daily for 17 days during the birch pollen season. Nasal symptoms (sneezing, discharge, itching and blockage) were relieved significantly by both drugs, but control of symptoms was more rapid and better with the terfenadine-phenylpropanolamine combination. Rhinoscopic evaluation of nasal secretion and mucosal swelling showed no differences between the treatment groups. Compared with pre-season values, nasal peak expiratory flow (PEF)-values worsened significantly during the season in the terfenadine, but not in the terfenadine-phenylpropanolamine, group. The general condition of the patients was significantly better in the terfenadine-phenylpropanolamine group. There were no marked side-effects in either group. At the end of the trial some of the patients in both treatment groups still had symptoms; this is apparently due to the long-lasting and severe pollen season. It is concluded that terfenadine combined with phenylpropanolamine gives better control of seasonal allergic rhinitis than terfenadine alone.

Nasal reactions elicited by unilateral allergen challenge

Nasal reactions to unilateral allergen provocation were studied separately in both nasal cavities of 9 subjects with established seasonal allergic rhinitis. Three tests with the same allergen at the same concentration were performed in the same cavity at 48-h intervals. The parameters observed were clinical symptoms, changes in nasal airway resistance on rhinomanometry, and amount, weight and histamine content of the collected secretion. Nasal obstruction increased significantly on the provoked side but not contralaterally. Secretion increased symmetrically but the histamine content rose only on the provoked side. No priming effect was observed. The results are compatible with the view that the release of histamine has a 2-fold effect. Histamine directly caused vasodilatation of capacitance vessels and capillaries, which resulted in obstruction on the provoked side, and indirectly the histamine release led to stimulation of sensory nerve endings, which by triggering parasympathetic reflexes caused rhinorrhea in both nasal halves.

Ordinary and high-dose ipratropium in perennial nonallergic rhinitis

The aim of the present study was to test the efficacy of the topically active cholinoceptor antagonist, ipratropium, in the treatment of rhinorrhea in perennial nonallergic rhinitis, with special reference to identification of subgroups of responders and increased efficacy from high-dose therapy. Thirty-six adult patients with watery rhinorrhea as a dominant symptom completed the study, which consisted of a 2-week run-in period followed by two 3-week treatment periods with placebo and ipratropium in an ordinary dosage (80 micrograms four times a day) in a double-blind, crossover design, and, finally, an open 2-week period with high-dose therapy (400 micrograms four times a day). The number of nose blowings was 47% lower during treatment with ipratropium in the ordinary dosage than during the placebo period (p less than 0.001). There was an additional reduction during high-dose therapy that was slight but statistically significant (p less than 0.05). Ipratropium had no effect on the number of sneezes or on nasal blockage index. During ordinary-dose therapy, side effects were slight and confined to the nose, whereas the high-dose therapy caused unpleasant nasal dryness and, in a few cases, systemic side effects. It was not possible to separate responders from nonresponders by case history, physical examination, or nasal methacholine testing. It is concluded that intranasal ipratropium is effective in the treatment of watery rhinorrhea in perennial nonallergic rhinitis and that 320 micrograms a day is sufficient in most patients.

Balanced physiological saline in the treatment of chronic rhinitis

The effects of a special balanced physiological saline on nasal symptoms of 93 patients with chronic rhinitis were studied. The main diagnoses of the patients were allergic rhinitis, atrophic rhinitis and ozaena, rhinitis sicca, chronic sinusitis, nasal polyposis and postoperative condition after nasal surgery. The tested solution was administered by a simple metered dose pump. 85 (91%) of the patients reported beneficial effects of the tested solution on nasal symptoms. In addition, 22 (71%) of those patients who used continuous anti-allergic medication, mainly intranasal steroids, reported that the tested solution improved the efficacy of their ordinary drug. So the tested solution proved to be beneficial in humidifying atrophic or otherwise dry mucosa, douching crusty nose and as adjuvant therapy in the treatment of allergic rhinitis.

Clinical findings in patients with allergic rhinitis

Clinical observations, X-ray findings and results of laboratory tests were evaluated in 770 patients with allergic rhinitis. Anamnestic data and results of the allergological examination of these patients have been presented elsewhere (Holopainen et al., 1979b; Binder et al., 1982). Allergic symptoms were seasonal in 54.5% and perennial in 45.5% of the patients. Mucosal changes as seen on rhinoscopy were significantly more common among patients with perennial than among patients with seasonal rhinitis. Watery discharge was the most common nasal finding, observed in 90% of all patients. Nasal smears showed increased numbers of eosinophilic leucocytes in 70% of the cases. Relationships between the cellular population of the nasal secretion, other laboratory test results and clinical findings are described. X-ray examination revealed pathological changes in the paranasal sinuses in 53.4% of the patients.

Aspiration cytology in acute otitis media

One hundred and ninety-three middle ear effusion samples from patients with acute otitis media were studied for cellular content and bacteria. Findings were compared with clinical and radiological data. In samples positive for pathogenic bacteria (Haemophilus, pneumococci) neutrophils predominated, whereas monocytes or phagocytes were more numerous in samples with nonpathogens. Inflammatory cells were more frequent in large than in small mastoid air cell systems. Destruction of cell walls was associated with increase of neutrophils and sclerosis with preponderance of lymphocytes, monocytes and phagocytes.

Ipratropium (Atrovent) in the treatment of vasomotor rhinitis of elderly patients

Ipratropium is a parasympatholytic agent with high topical activity. The effect of intranasal ipratropium was studied in 34 patients who were over 60 years of age and who suffered from chronic watery vasomotor rhinorrhoea. The study was a double-blind cross-over placebo controlled trial. Trial parameters were: daily nasal symptom and side effect scores, nasal methacholine testing before and after treatment, and clinical evaluation. The active drug clearly reduced nasal discharge. Nasal methacholine testing showed reduction of nasal secretion after the active treatment period. The majority of the patients preferred the active drug to the placebo. Excessive drying of the nasal mucosa was the most common side effect. Ipratropium seems to have a beneficial effect on vasomotor rhinitis, which often is an irritating condition in elderly patients.

Astemizole in the treatment of hay fever

A double-blind parallel trial of astemizole, pheniramine and placebo was carried out in 51 patients with hay fever. Astemizole is a new potent H1-antihistamine with long duration of action but devoid of central activity. Evaluation criteria were daily symptom- and side effect score cards, daily nasal peak flow measurements, clinical examination and blood tests. Control of nasal symptoms was significantly better with both antihistamines than with placebo. Tiredness and anticholinergic side effects were less common in the astemizole group than in the pheniramine group. No significant changes in the "safety evaluation" blood tests were observed.

Anamnestic data in allergic rhinitis

In a study of 770 patients with allergic rhinitis, anamnestic data were collected by means of a questionnaire. 484 (63%) of the patients were women and 286 (37%) men. 45.5% of the patients had perennial symptoms, 33.5% had seasonal symptoms only, and 21% had predominantly seasonal but also some perennial symptoms. More than 50% of the patients belonged to the age group 21-40 years. The seasonal group included significantly more young patients than the perennial group. More than 50% of the parents and about 45% of the siblings had some atopic disorder. About 20% of the rhinitis patients had a concomitant allergic disorder. Sneezing was the commonest complaint in both rhinitis groups, but it was significantly more frequent in patients with seasonal rhinitis. Nasal blockage, again, was significantly commoner in perennial rhinitis. More than half of the patients reported severest symptoms in the morning. 282 patients had some domestic animal or pet, and 34% of these developed symptoms when close to an animal. Hypersensitivity to animals was significantly more frequent in patients who had domestic animals or pets than in those who did not. There was a clear correlation in perennial allergic rhinitis between the duration of rhinitis and deterioration of the sense of smell.

Children's atopy and mastocytosis in the nasal smear

Nasal secretion samples from 473 children aged 0--15 years were studied in order to evaluate the role of mast cells in the nasal smear in different types of atopy and food allergy. The occurrence of eosinophils in the nasal secretion and in the blood, and susceptibility to upper respiratory infection were recorded. A mast cell count of more than 20 cells per slide was indicative of atopy and there was a clear correlation between eosinophilia and mastocytosis in the nasal smear. No type of allergy seemed to be significantly predominant in the total material, but in young children aged 0--3 years mastocytosis was clearly related to food allergy. The examination of nasal smears for mast cells is a valuable test in diagnosing atopy in children and especially food allergy among young children. However, the test is not reliable enough to be used as a single screening test.

Secretory otitis media and allergy. With special reference to the cytotoxic leucocyte test

This study is an investigation on whether allergy, and especially food allergy, is more common in patients with secretory otitis media (SOM) than in others. At the same time, the effectiveness of the cytotoxic leucocyte test (CLT) as an aid in the diagnosis of food allergy was also studied. The material comprised 90 patients: 69 suffering from secretory otitis media and 21 without the disease as controls. Patients were studied using allergy history, ear status, tests for nasal and blood eosinophilic cells, total IgE, skin tests for 20 allergens. RAST for milk and wheat, immunoglobulin A, G and M, precipitating antibodies for milk and gluten. Mantoux test, and the CLT for 23 allergens. Allergy was found in 20% of the SOM patients and 10% of the control patients; the difference was not statistically significant. The best methods for verifying allergy were history, skin tests, and tests for nasal eosinophils cells. Laboratory tests could not verify objectively that food allergy was more common among SOM patients than controls, although 16% of the SOM patients compared with none of the controls had a history of food allergy. Of the tests used, the CLT correlated best with a history of allergy, but the results of the different tests were not in accordance wtih each other.

Cytotoxic leukocyte reaction

Blood samples from 49 subjects were submitted to cytotoxic leukocyte tests, which were read double-blind by two laboratory technicians. The results were identical in 78% of the tests and the statistical error of the method was 0.46. In a group of 32 subjects, the cytotoxic test was repeated on 3 consecutive days. Deviations in the results occurred in 18--20% of the tests, the statistical errors varying between 0.38 and 0.43. In a series of serum samples (75 subjects) with positive leukocyte reactions to food antigens, various in vitro procedures were carried out in connection with the cytotoxic test. The following observations were made: In 42 of 58 tests, a positive leukocyte reaction was transferred with the reactive serum to cells from non-reactive subjects. After heating of the reactive serum (56 degrees C, 2 h) and washing of the cells, reactivity was no longer observable in 44 out of 52 tests. Treatment with EDTA consistently blocked expected cytotoxic reactions in 36 tests. DSCG inhibited expected reactions in 45%, antihistamine in 93%, and cortisone in 20% of the tests.

Nasal smear as a screening test for immediate-type nasal allergy

From a previous sample of 634 students and school children, 115 subjects were selected for a thorough rhinological examination and allergy work-up in order to assess the value of nasal secretion eosinophilia in screening for immediate-type nasal allergy. Part of the subjects had, in the previous study, been found to have secretion eosinophilia and a history of chronic/allergic rhinitis, part of the subjects had either a secretion eosinophilia or a rhinitis history, and part of them had neither a secretion eosinophilia nor a rhinitis history. A significant correlation was obtained between secretion eosinophilia and allergy. Nasal provocation tests correlated with skin tests in 87%, whereas the correlation between nasal provocation tests and Ige determinations in the serum was poorer. Thickening of the maxillary sinus was, when present, usually attributable to infection and not to allergy. Reasons for "false positive or false negative" smears for eosinophils are discussed.

Wegener's granulomatosis in childhood. A clinical report based on 3 cases

Wegener's granulomatosis is a very rare disease in children; only 10 cases have been reported in the literature. The present report describes 3 cases where Wegener's granulomatosis developed at an early stage, beginning with upper respiratory tract symptoms. All the 3 children have been successfully treated with a combination of azathioprine and corticosteroids.

Nasal polyposis. Relationships to allergy and acetylsalicyclic acid intolerance

Allergological, clinical and histological findings in 109 unselected patients, treated for nasal polyps during the period Feb. 1977 to Feb. 1978 are reported. The material was divided into three groups according to clinical findings: 1) Atopy Group; 18 patients with positive history and skin test; 2) ASA Intolerance Group; 25 patients with a definite history of acetylsalicylic acid intolerance; and 3) Intrinsic Disease Group; 66 patients in whom specific etiological factors were not found. On skin testing, positive reactions were obtained in 42 patients. In 23 of the patients, the skin test result agreed with the history. Secretion and tissue eosinophilia, noted in 97 and 102 patients, respectively, correlated in 88% of the patients, whereas correlation with blood eosinophilia was poor (30%). The mean IgE level was 140 in the serum and 731 in the polyp fluid, serum values above 150 occurring in 28 out of 105 patients and fluid values above 150 in 58 out of 84 patients. The predominant histological finding in the polyp biopsies was tissue eosinophilia, which was most abundant in the ASA intolerance group. Squamous metaplasia was seen in 30% but it was marked only in 5 cases. In 10 patients ASA intolerance was confirmed by oral provocation.

Vestibular neurectomy and saccus decompression surgery in Meniere's disease

Results of vestibular neurectomy, total eighth nerve section, and saccus decompression in 42 patients with Meniere's disease are reported. Vestibular nerve section was found in isolated cases to be a very effective method of abolishing the symptom of vertigo. Hearing is not affected but may be lost owing to opening of the vertical canal or disruption of blood supply. Saccus surgery might be the surgical treatment of choice in early cases with good hearing but in patients with fixed non-fluctuating hearing loss, rehabilitation can be effected only by vestibular neurectomy. In bilateral cases either sac surgery or the use of vestibulotoxic drugs is advised.

Diagnostic procedures in chronic rhinitis

Various methods of diagnosing allergic factors in chronic rhinitis are discussed. Among the procedures which aim at detecting specific allergens, i.e. skin testing, RAST, and nasal provocation tests, the last mentioned, as they are performed directly on the shock organ, have so far been found to give the most accurate picture of clinically dominant allergens and of the intensity and character of the rhinitis. However, information obtained by analysing the correlations between different procedures is not unanimous. As long as test techniques and allergen extracts have not been standardized, one particular test cannot be recommended as the method of choice.

The most important allergens in allergic rhinitis

The distribution of allergens, found on thorough allergy work-up in a series of 770 patients with seasonal and perennial nasal symptoms, is reported. The percentages of positive reactions to grass, tree, and herb pollens were equally high (30--40%) but, clinically, pollens from grasses (Timothy, Alopecurus, Kentucky Blue and Meadow fescue), birch and mugwort (Artemisia) were the most important. In the Nordic countries house dust is evidently the commonest causative agent in perennial rhinitis but the heterogenous composition of house dust makes it difficult to determine potent allergenic factors. Sensitivity to house dust was present in 44% of the patients; a positive reaction to mite extract in only 10%. Animal danders were not found to be great importance in allergic rhinitis (13--18%). Reactions to moulds were observed in 9% of the patients.

Experiences of treating allergic rhinitis with intra-nasal beclomethasone dipropionate. Short-term trials and long-term follow-up

The effect of locally acting intra-nasal beclomethasone dipropionate was observed in 42 patients suffering from seasonal allergic rhinitis and 50 patients suffering from perennial rhinitis. The study consists of three parts: 1) a simple double-blind trial in seasonal rhinitis, 2) a double-blind crossover trial in perennial rhinitis, 3) a 1-year follow-up of the perennial group. The active drug was significantly superior to placebo when comparing subjective symptoms, nasal resistance and secretion eosinophilia in the patients. In long-term use it was possible to reduce the initial dose considerably. On objective examination no significant changes were seen in the epithelium following long-term use. No suppression of the hypothalamic-pituitary-adrenal axis was observed after 1 year's regular use of beclomethasone dipropionate. The side effects were mild, the most common complaint being irritation of the nasal mucous membrane, apparently caused by the propellant gas.

Nasal challenge

Seven years' experience of nasal challenge is presented. On the basis of a material of 1492 controlled provocation tests performed on 715 patients, practical problems concerning the performance period of the provocation, application methods, allergen preparations, interpretation of the results as well as the relevance and correlation of different investigation methods of allergic rhinitis are discussed.