Interdisciplinary management of orofacial lesions in early childhood: paediatric alert system at University of Verona

BACKGROUND

Orofacial trauma (OFT) occurs frequently in children and requires thorough evaluation not only by paediatric dentists but also by all specialists involved in emergency services, particularly in cases involving children under 3 years of age, given their inability to directly participate in clinical-anamnestic evaluations. Addressing early childhood orofacial trauma resulting from maltreatment, this study explores the key role played by various healthcare professionals, including paediatric dentists, general dentists, maxillofacial surgeons, dental hygienists, and paediatricians, in the optimal management of these cases. In the event of trauma due to suspected or confirmed mistreatment, it is essential that all healthcare workers involved have precise knowledge of the appropriate course of action from both a clinical and legal point of view, guaranteeing maximum protection for the young patient. This is particularly significant as cases of mistreatment with apparently minor consequences can degenerate into situations of irreparable severity. The latest guidelines from the International Association of Dental Traumatology (IADT) in 2020 continue to emphasise the potential correlation between OFT and cases of abuse or violence. Recent recommendations in the literature highlight the importance of facilitating mandatory reporting of incidents to relevant authorities and improving information sharing between dental healthcare professionals and child welfare services. A new flow diagram, called Paediatric Orofacial Trauma Alert (P.O.T.A.), has been proposed at the University of Verona. This tool is specifically designed to assist specialists dealing with early childhood orofacial trauma cases by assisting them in identifying potential cases of maltreatment. In this innovative approach, the collaborative efforts of general dentists, paediatric dentists, maxillofacial surgeons, dental hygienists and paediatricians play a vital role in cases of abuse. In addition to restoring the oral health of young patients, these professionals can activate a vast network of contacts, ensuring not only optimal oral health care but also providing comprehensive support to victims. The objective is to safeguard not only the physical but also the psychological well-being of these vulnerable subjects.

Role of genetic investigation in the diagnosis of short stature in a cohort of Italian children

BACKGROUND

Short stature (SS) is defined as height more than 2 standard deviations below the mean for age and sex. Hypothyroidism, celiac disease, growth hormone deficiency, hormonal abnormalities, and genetic conditions are among its causes. A wide range of conditions often due to largely unknown genetic variants can elude conventional diagnostic workup.

AIM

We used next-generation sequencing (NGS) to better understand the etiology of SS in a cohort of Italian children.

PATIENTS AND METHODS

The study sample was 125 children with SS of unknown origin referred to our Institute between 2015 and 2021. All had undergone complete auxological and hormonal investigations to exclude common causes of SS. Genetic analysis was performed using a NGS panel of 104 genes. Clinical data were reviewed to clarify the pathogenicity of the variants detected.

RESULTS

In this cohort, 43 potentially causing variants were identified in 38 children. A syndromic genetic condition was diagnosed in 7: Noonan syndrome in 3, Leri-Weill syndrome in 3, and hypochondroplasia in 1. Moreover, 8 benign variants and other 37 like benign variants were found. In 88 children, 179 variants of uncertain significance (VUS) were identified. No variant was found in 16 children.

CONCLUSION

Genetic analysis is a useful tool in the diagnostic workup of patients with SS, in adapting management and treatment, and in identifying syndromes with mild atypical clinical features. The role of VUS should not be underestimated, particularly when multiple VUS with possible mutual worsening effects are present in the same child.

Enforcing surveillance of antimicrobial resistance and antibiotic use to drive stewardship: experience in a paediatric setting

BACKGROUND

Antibiotic stewardship (AS) interventions in paediatrics are still not standardized regarding methodology, metrics, and outcomes. We report the results of an AS intervention in the paediatric area based on education and guideline provision via an electronic App.

MATERIALS AND METHODS

The AS intervention was conducted in 2021 through observation, education, audit and feedback and provision of an electronic App (Firstline.org) to support antibiotic prescription based on local susceptibility data. The primary outcome was the antibiotic consumption in the 12 months following the intervention (year 2022) compared with a historical 12-month control (year 2019) via an interrupted time series analysis. Secondary outcomes were appropriateness of therapy, length of stay, 30-day readmission, transfers to the paediatric intensive care unit, in-hospital mortality, and prevalence of antimicrobial resistance (AMR).

RESULTS

During the post-intervention phase, 29 cross-sectional audits and feedback were conducted including 467 patients. Prescriptions were appropriate according to the guidelines in 85.7% of cases, with a stable trend over time. A significant decrease in antibiotic consumption was measured in terms of defined daily doses per 1000 patient days (-222.13; P<0.001) and days of therapy per 1000 patient days (-452.49; P<0.001) in the post-intervention period with a clear inversion of the Access to Watch ratio (from 0.7 to 1.7). Length of stay, in-hospital mortality, intensive care unit transfers, and incidence of AMR infections remained stable, while 30-day readmission decreased from 4.9 per 100 admissions to 2.8 per 100 admissions (P<0.001).

CONCLUSIONS

The intervention was associated with a significant reduction in antimicrobial consumption and an increase in the appropriateness of prescriptions. Electronic tools can be of value in promoting adherence to guidelines and ensuring the sustainability of results.

THU0510 CHOREA AND CARDITIS: AN UNEXPECTED COMBINATION. THE NEW FACE OF ACUTE RHEUMATIC FEVER

Background:

Acute Rheumatic Fever (ARF) is an immunomediated multisystem disease that occurs about 2-5 weeks after Group A Streptococcus Pyogenes beta-hemolytic (GAS) pharyngitis. After a negative peak in the 1980s, following the introduction of antibiotic prophylaxis, the disease is currently recovering. Rheumatic carditis is one of the most worrying aspects as it is still one of the major causes of cardiovascular death in the young-adult population. However, if diagnosed early and treated, sequelae with aortic and mitral valve involvement can be prevented.

Objectives:

The aim of our study is a description of Acute Rheumatic Fever in all its manifestations in a cohort of pediatric patients belonging to the Azienda Ospedaliera Universitaria Integrata of Verona.

Methods:

A retrospective analysis was conducted collecting all the cases of ARF, diagnosed by Jones’s criteria, related to Pediatric Rheumatology and Pediatric Cardiology of Verona from January 2005 to December 2019. Demographic and clinical data were collected for all patients such as clinical presentation, disease evolution and cardiac involvement.

Results:

73 patients were analyzed, of whom 53 had an acute onset of ARF and 20 received a diagnosis of previous ARF due to indolent carditis. The prevalent age at the time of diagnosis in both groups was between 5 and 14 years of age. Among patients with acute onset, carditis was the most frequent major manifestation (94.3%), followed by polyarthritis (41.5%), chorea (24.5%) and erythema marginatum (7.5%). Only in one patient we could observe subcutaneous nodules (1.8%). Regarding the minor manifestations, the increase in inflammation markers was present in 83% of cases and fever was present in 75.5%, followed by arthralgia (58.4%) and prolonged of PR interval to ECG (9.4%). Carditis was also present in all 13 patients who presented chorea. Clinically, previously unknown heart murmur occurred in 28 patients. Therefore, the mismatch between cardiac objectivity and carditis finding is clear: infact, compared to an important finding of carditis (50 patients) only slightly more than half of the patients (28 patients) showed an evident clinic finding. Finally, no correlation was found between the levels of the antistreptolysin O titer and the severity of heart damage. Patients with early diagnosis of carditis were treated at onset with corticosteroid therapy according to the American Heart Association scheme and did not show valvular cardiac outcomes. A patient who received a late diagnosis of carditis currently presents a significant and permanent cardiac damage despite adequate steroid treatment undertaken at the time of diagnosis.

Conclusion:

The description of this cohort of pediatric patients shows that the ARF has not disappeared in industrialized countries. Treatment of streptococcal infection (primary prophylaxis) plays a key role in preventing ARF. Of great impact is the prevalence of carditis which is present in 94.3% of patients. Early diagnosis is therefore of primary importance and the subsequent follow-up path, consisting of periodic therapy with penicillin (secondary prophylaxis) and periodic cardiological checks, greatly affects children’s quality of life. Chorea, unlike what has been described in the literature, occurred simultaneously with the cardiac process, while the cutaneous manifestations (subcutaneous nodules and erythema marginatum), once pathognomonic of the rheumatic disease, are today of rare observation.

References:

[1]Carapetis, Beaton, Cunningham et al. Acute rheumatic fever and rheumatic heart disease. Nature Reviews Disease Primers. 2016;2:15084.

Disclosure of Interests:

None declared

Relationship between Erythrocyte Hexokinase in Cancer Patients and Red Cell Age

A study of hexokinase isozymic pattern and age dependence of the enzyme was carried out on erythrocytes of 4 patients with adenocarcinoma of the gastrointestinal tract. On the basis of our results, we think that the increase in hexokinase activity previously reported and the increase in both subtypes (Ia and Ib) of the enzyme herein described are not due to a mean younger red cell population caused by secondary anemia, which is frequently present in cancer patients.

Serum and exhaled breath condensate leptin levels in asthmatic and obesity children: a pilot study

BACKGROUND

Recent studies have highlighted the possible involvement of leptin in inflammation. The leptin receptor is also expressed by alveolar macrophages, T lymphocytes and bronchial epitelial cells, suggesting a possible role in the cascade of airway inflammation.

OBJECTIVES

The aim of the study was to evaluate the levels of leptin in exhaled breath condensate (EBC) from asthmatic, normal- and overweight children, in relationship with airway inflammation.

METHODS

15 asthmatic non-obese children, 15 healthy non-asthmatic non-obese children, 11 obese children with asthma (OA) and 20 obese children without asthma (ONA) were enrolled. Body impedance of body weight, EBC collection, FeNO, spirometry and a blood sampling for serum leptin were assessed.

RESULTS

Leptin EBC levels were significantly higher (3.9 ng ml^-1 ± 1.3) in overweight children than those obese with asthma (3.6 ng ml^-1 ± 1.6; p = 0.97), non-owerweight asthmatics (2.2 ng ml^-1 ± 1.2; p < 0.0001) and in healthy children (0.9 ng ml^-1 ± 0.6; p < 0.001). Leptin EBC levels in asthmatic children were significantly higher than in healthy children (p = 0.05). Leptin serum levels were significantly higher in the overweight children compared with the asthmatics (12.7 ng ml^-1 ± 13.2; p < 0.001) and the healthy group (11.1 ng ml^-1 ± 11.2; p < 0.001). We observed a significant correlation between EBC-leptin levels and the serum-leptin levels (p = 0.001). No correlations were found between EBC-leptin levels, FeNO and lung function.

CONCLUSIONS

This study shows that leptin is measurable in EBC in children and that EBC-leptin levels are significantly higher in the obese subjects and in asthmatic ones compared with healthy subjects. Leptin may therefore represent a non-invasive marker of non-specific airway inflammation in children.

Tidal-breathing measurement of exhaled breath temperature (EBT) in schoolchildren

BACKGROUND

Non-invasive assessment of airway inflammation is particularly useful in children. The exhaled breath temperature (EBT) may reflect inflammatory vasodilation and serve to assess respiratory symptoms and therapy with inhaled corticosteroids (ICs).

AIMS

To compare EBT with other non-invasive measurements in unselected schoolchildren in relation to respiratory symptoms and IC-therapy, as well as to assess reproducibility, and potentially influencing factors.

METHODS

In 298 Italian schoolchildren, we assessed tidal-EBT, FE(NO), spirometry, skin-prick tests, questionnaires on chronic respiratory symptoms, and medication. Subjects were divided as follows: reported wheeze, respiratory symptoms other than wheeze, and without symptoms.

RESULTS

Subjects with reported wheeze (n = 30) more frequently presented atopy, respiratory symptoms, higher FE(NO), lower lung function than subjects with symptoms other than wheeze (n = 141) and those without symptoms (n = 127), but had a similar EBT. IC-treated children (5 wheeze, 9 respiratory symptoms other than wheeze, 4 without chronic symptoms) had lower median (interquartile range) EBT levels than IC-untreated children (n = 280) [EBT: 31.7 (30.1-32.5) vs. 32.6 (31.4-33.4), P = 0.027]. Duplicate EBT measurements were highly reproducible (ICC = 0.94). In a multiple linear-regression model, EBT was explained by age, weight, duration of EBT measurement, FE(NO), and ambient temperature (r = 0.63, P < 0.001).

CONCLUSION

Tidal-EBT measurements are easy to perform, reproducible, though symptom misclassification may affect the results obtained regarding the effect of IC therapy. Factors influencing EBT should be addressed in further epidemiological studies.

Bronchial and alveolar nitric oxide in exercise-induced bronchoconstriction in asthmatic children

BACKGROUND

Epidemiological studies have shown an association between the severity of exercise-induced bronchoconstriction (EIB) and fractional exhaled nitric oxide at the flow of 50 mL/s (FeNO(50)). However, no study has assessed the correlation between alveolar production (C(alv)) and bronchial flux (J(NO)) of nitric oxide (NO) and EIB in asthmatic children.

OBJECTIVE

To identify the relationship between severity of EIB and bronchial or alveolar nitric oxide.

METHODS

Our group included 36 allergic children with intermittent asthma. The EIB was determined by a standard exercise challenge and the severity was expressed as the maximum change in percentage from the baseline value of lung function (ΔFEV(1)%, ΔFEF(25-75)%) after exercising. A chemiluminescence analyser at multiple flows was used to calculate FeNO(50), J(NO) and C(alv,) which reflect large airways, J(NO) and alveolar concentration of NO respectively.

RESULTS

Sixteen (44.4%) children presented a ∆FEV(1) ≥ 10%, eight (22.2%) had ∆FEV(1) ≥ 15% and nine (25%) children had a ∆FEF(25-75) ≥ 26%. A significant correlation was observed between severity of EIB and FeNO(50) , J(NO) and C(alv.) EIB was significantly more severe in children sensitive to indoor allergens compared with outdoor allergens only (P = 0.014); those children showed also higher levels of C(alv) (P = 0.003) and of J(NO) (P = 0.044).

CONCLUSIONS AND CLINICAL RELEVANCE

Our results suggest that inflammation is present in the central and peripheral airways and that it is associated with the severity of EIB. Clinicaltrials.gov NCT00952835.

Adolescent health care in Italy: a mini-review

The purpose of this mini-review is to present the National Health System and services available for adolescents in Italy, and to review the most relevant data on morbidity and mortality in Italian teens. Adolescent medicine in Italy is not a separate speciality, but there are some distinct services for adolescents in paediatric departments or gynaecologic wards, mostly in large cities where university hospitals or hospital of national relevance are located. Primary health care in Italy is provided mainly by general practitioners (GPs) and pediatricians, and on-call physicians (Guardia Medica) for after-hours medical care and services. The number of centres providing care for adolescents in Italy is 4097 (50% of these are in the North of Italy, 20% in the Central regions and 20% in the South and Islands). The population of Italy on January 1st 2011 was approximately 60,477,881 and the number of adolescents, aged 10 to 19 years, was 6,214,000. The most frequent causes of death in adolescents are motor vehicle accidents - more than half of which are related to drug or alcohol use - followed by cancer and suicide. In primary care, adolescents present with a large number of issues, particularly upper respiratory infections, musculoskeletal problems, pain syndromes, obesity, eating disorders, dermatological issues, mood and somatoform disorders, school and mental health problems, and chronic fatigue, many of which require a coordinated, multidisciplinary management approach. The estimated population with a chronic illness is 8%. There are no specific protocols for the transition to adult medicine physicians for patients with chronic diseases or special health needs. In order to improve the quality and quantity of education in adolescent health for paediatricians and GPs, the Study Group of Emilia and Romagna Region for Adolescent Health Care (SGA-ER) is going to organize, beginning in 2012, a two year educational intervention course in adolescent health.

The SGA-ER educational intervention in adolescent health care for Italian physicians: goals, content and instructional design

Adolescent medicine is a field dedicated to helping young people grow and thrive, in relation to their particular stage of development. In Italy, adolescent medicine is not a distinct speciality, but it is practised in some services for adolescents in paediatric departments. Increasing educational opportunities in adolescent health may help to accelerate the development and dissemination of new and improved therapeutic approaches for serving youth and also attract a larger cadre of physicians. Other pediatric subspecialties, e.g. oncology, rheumatology and adolescent psychiatry, have developed successfully and may represent excellent models for adolescent medicine specialists to emulate. The Adolescent Health Study Group of the Emilia and Romagna Region (SGA-ER) was established in 2010 in an effort to generate strategies and possible solutions to improve the quality and quantity of knowledge in adolescent health care for pediatricians and GPs. Several methods and approaches have been implemented to improve physicians' skills in adolescent health care. The authors report the goals, content and instructional design of an educational course in adolescent medicine. Alliances with other adolescent health groups may provide an additional opportunity for networking, interaction and exchange of ideas amongst professionals.

Pharmacological treatment of severe, therapy-resistant asthma in children: what can we learn from where?

There is a lack of high-quality evidence on what treatment should be used in children with properly characterised severe, therapy-resistant asthma. Data have to be largely extrapolated from trials in children with mild asthma, and adults with severe asthma. Therapeutic options can be divided into medications used in lower doses for children with less severe asthma, and those used in other paediatric diseases but not for asthma (for example, methotrexate). In the first category are high-dose inhaled corticosteroids (ICS) (≤ 2,000 μg · day(-1) fluticasone equivalent), oral prednisolone, the anti-immunoglobulin (Ig)E antibody omalizumab, high-dose long-acting β(2)-agonists, low-dose oral theophylline and intramuscular triamcinolone. If peripheral airway inflammation is thought to be a problem, the use of fine-particle ICS or low-dose oral corticosteroids may be considered. More experimental therapies include oral macrolides, cyclosporin, cytotoxic drugs such as methotrexate and azathioprine, gold salts, intravenous infusions of Ig, subcutaneous β(2)-agonist treatment and, in those sensitised to fungi, oral antifungal therapy with itraconazole or voriconazole. Those with recurrent severe exacerbations, particularly in the context of good baseline asthma control, are particularly difficult to treat; baseline control and lung function must be optimised with the lowest possible dose of ICS, and allergen triggers and exposures minimised. The use of high-dose ICS, leukotriene receptor antagonists or both at the time of exacerbations can be considered. There is no evidence regarding which therapeutic option to recommend. Better evidence is required for all these treatment options, underscoring the need for the international and co-ordinated approach which we have previously advocated.

The measurement of exhaled nitric oxide in routine practice

Exhaled nitric oxide (NO) is considered the most easily available clinical test to indirectly assess the level of eosinophilic airway inflammation in asthma, and to predict the efficacy of anti-inflammatory treatment with inhaled corticosteroids (ICS). It is possible to measure the level of exhaled NO using online or offline methods. The most widely used online method employs techniques that enable NO in exhaled air to be measured in a single exhalation, calculating the value at the end-expiratory plateau. Because of the correlation between the level of exhaled NO with the level of eosinophilic inflammation in the airway of asthmatic patients, it has been proposed as a clinical marker in the practice of respiratory and allergy physicians with differing targets. In particular it is considered to be highly effective in the diagnosis of allergic asthma, to be capable of identifying those patients with a higher response probability to inhaled corticosteroids, and to a lesser extent, to be of value in contributing to the management of the disease. The possibility of easily taking measurements of FeNO in an office setting even by relatively young children, and the availability of a portable device, opens a significant perspective for the routine use of FeNO evaluation in daily practice.

Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach

There is poor agreement on definitions of different phenotypes of preschool wheezing disorders. The present Task Force proposes to use the terms episodic (viral) wheeze to describe children who wheeze intermittently and are well between episodes, and multiple-trigger wheeze for children who wheeze both during and outside discrete episodes. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting beta(2)-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitisation has been established. Maintenance treatment with inhaled corticosteroids is recommended for multiple-trigger wheeze; benefits are often small. Montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Large well-designed randomised controlled trials with clear descriptions of patients are needed to improve the present recommendations on the treatment of these common syndromes.

Swimming pool, respiratory health, and childhood asthma: should we change our beliefs?

Swimming is often recommended as a sport because of its several benefits to health. It is also recommended in asthmatic children as a sport with a lower potential for prompting exercise-induced asthma. However, there is growing interest in the potentially harmful effects of repeated respiratory tract exposure to chlorinated products and the problem of possible swimming-related health hazards is gaining importance at international level. It is already known that acute exposure to chlorine gas as in swimming pool accidents causes lung damage and also that elite swimmers may have increased airway inflammation and bronchial hyperreactivity, probably as a result of repeated exposure to chlorine derivatives. Recently some studies have been conducted to investigate whether repeated exposure to chlorine by-products in recreational swimmers might also lead to lung damage. In addition, some studies have been lately published on the even more debated issue of the possible harmful effects of baby swimming on respiratory health. This article reviews and discusses data from the literature on the effects of chlorine derivatives in different categories of people routinely attending swimming pools. The need for longitudinal studies is emphasized to definitely clarify any role of chlorinated swimming pool attendance in the development of asthma in recreational swimmers.

Azithromycin may reduce cholestasis in primary sclerosing cholangitis: a case report and serendipitous observation

The newer macrolides have been shown to exert additional anti-inflammatory effects. We report the possible effect of azithromycin on primary sclerosing cholangitis in a patient treated with the drug for severe asthma. A 45-year-old woman with Crohn?s disease and primary sclerosing cholangitis, also suffering from severe asthma, was treated with azithromycin 500 mg OD for 3 consecutive days a week because of the clinical suspicion of bronchiectasis and the severity of her asthma. When the therapy was discontinued, her urine again became darker, pruritus reappeared with the usual severity and laboratory parameters, evaluated after 6 weeks without azithromycin, also worsened. For these reasons macrolide treatment was re-established. Cholestasis-related symptoms and the dark colour of the urine were again reduced 6 weeks later and laboratory parameters were again reversed. We are therefore tempted to speculate that azithromycin may have an effect on primary sclerosing cholangitis on the basis of its anti-inflammatory properties.

Effect of budesonide and montelukast in asthmatic children exposed to relevant allergens

BACKGROUND

Montelukast has been shown to be effective in controlling the increase in exhaled NO in asthmatic children re-exposed to house dust mite (HDM). This study compared the effect of low dose inhaled budesonide and oral montelukast in preventing the expected relapse of airway inflammation and reactivity in a group of 24 mild asthmatic children allergic to HDM after a brief period of exposure to relevant allergens.

METHODS

Lung function, bronchial hyperresponsiveness (BHR) to methacholine (PC(20)), fractional exhaled nitric oxide (FeNO) levels and sputum eosinophilia were evaluated.

RESULTS

Pulmonary function remained stable. The BHR was unchanged after exposure in the group treated with budesonide, whereas a significant increase (P = 0.028) was observed in the patients receiving montelukast. No significant difference was observed in FeNO levels after exposure to mite antigen in the two groups. In both the groups of asthmatic children we observed a significant increase in sputum eosinophil % after the exposure to mite antigen.

CONCLUSIONS

The significant increase in BHR level observed in the group of children receiving montelukast suggests a more comprehensive effect as disease controller by inhaled steroids than by leukotriene antagonist in allergic asthmatic children re-exposed to relevant allergens.

Alteration of hypothalamus-pituitary-adrenal gland axis in colorectal cancer patients. Preliminary report

AIM

In advanced cancer patients a cell-mediated immunological impairment, both at baseline and during postoperative period, is often found and is associated with poor prognosis. Cortisol is strictly involved in the response to major surgical stress, is an immunosuppressor and causes a redistribution of immunological population cells in different tissues. The aim of the study was to verify serum levels and circadian rhythm of cortisol in patients with colorectal cancer at baseline before surgery and in the postoperative period, and relate it to the immune status.

METHODS

In 21 patients with colorectal cancer undergoing surgery we evaluated the assessment of total lymphocytes, CD4+, cortisolemia, circadian rhythm of cortisol (11 p.m. and 8 a.m.) at baseline and in 3(rd) and 7(th) postoperative days.

RESULTS

Increase of cortisolemia, as decrease of total and CD4+ lymphocytes in the postoperative period versus baseline was statistically significant. Patients with an altered circadian rhythm were 47% and 36% at 3rd and 7th postoperative days, respectively. At baseline 19% of patients had an altered cortisol circadian rhythm and it was more frequent in patients with nodal involvement (p<0.05) and with metastasis (p<0.01). No relations between lymphocytopenia and alteration of cortisolemia and cortisol circadian rhythm were found, either at baseline or postoperatively (p<0.05).

CONCLUSION

Lymphocytopenia in cancer patients seems not to be associated with cortisol level and circadian rhythm alteration, either at baseline or after surgical stress. An impairment of circadian rhythm of cortisol was found at baseline in 19% of patients. It was significantly associated with the presence of metastatic disease.

Cysteinyl leukotrienes and 8-isoprostane in exhaled breath condensate of children with asthma exacerbations

BACKGROUND

Cysteinyl leukotrienes (Cys-LTs) and isoprostanes are inflammatory metabolites derived from arachidonic acid whose levels are increased in the airways of asthmatic patients. Isoprostanes are relatively stable and specific for lipid peroxidation, which makes them potentially reliable biomarkers for oxidative stress. A study was undertaken to evaluate the effect of a course of oral steroids on Cys-LT and 8-isoprostane levels in exhaled breath condensate of children with an asthma exacerbation.

METHODS

Exhaled breath condensate was collected and fractional exhaled nitric oxide (FE(NO)) and spirometric parameters were measured before and after a 5 day course of oral prednisone (1 mg/kg/day) in 15 asthmatic children with an asthma exacerbation. Cys-LT and 8-isoprostane concentrations were measured using an enzyme immunoassay. FE(NO) was measured using a chemiluminescence analyser. Exhaled breath condensate was also collected from 10 healthy children.

RESULTS

Before prednisone treatment both Cys-LT and 8-isoprostane concentrations were higher in asthmatic subjects (Cys-LTs, 12.7 pg/ml (IQR 5.4-15.6); 8-isoprostane, 12.0 pg/ml (9.4-29.5)) than in healthy children (Cys-LTs, 4.3 pg/ml (2.0-5.7), p=0.002; 8-isoprostane, 2.6 pg/ml (2.1-3.0), p<0.001). After prednisone treatment there was a significant decrease in both Cys-LT (5.2 pg/ml (3.9-8.8), p=0.005) and 8-isoprostane (8.4 pg/ml (5.4-11.6), p=0.04) concentrations, but 8-isoprostane levels remained higher than in controls (p<0.001). FE(NO) levels, which fell significantly after prednisone treatment (p<0.001), did not correlate significantly with either Cys-LT or 8-isoprostane concentrations.

CONCLUSION

After a 5 day course of oral prednisone there is a reduction in Cys-LT and 8-isoprostane levels in EBC of children with an asthma exacerbation, although 8-isoprostane levels remain higher than in controls. This finding suggests that corticosteroids may not be fully effective in reducing oxidative stress in children with an exacerbation of asthma.

Radical surgery does not recover immunodeficiency associated with gastric cancer

Cell-mediated immunodeficiency is known to occur in advanced cancer patients, but it is less characterized in earlier stages. Pre-existing immunodeficiency may impair the recovery of postoperative lymphocytopenia, occurring generally within 8-14 days after surgical stress. This study was aimed to verify whether immunodeficiency exists in patients with operable gastric adenocarcinoma and whether radical surgery may restore a count of peripheral blood T helper cells (CD4) and CD4/CD8 ratio within physiological normal values in the late postoperative period. Thirty-five consecutive patients (M/F 18/17; mean age 67 years, range 42-82) with histologically proven gastric adenocarcinoma, undergoing surgery with radical intent, were studied. Assessment of total lymphocyte count and lymphocyte subsets was performed by FAC scan at baseline, then postoperatively 14 and 50 days after surgery. Normal reference values were according to CDC criteria for HIV immunodeficiency (total lymphocyte > 1500/mmc; CD4 cells > 500/mmc; CD4/CD8 > 1.2). Surgical interventions, including D2 locoregional lymphadenectomy, were as follows: 19 Roux Y total gastrectomies; 3 Roux Y subtotal gastrectomies and 13 Billroth II subtotal gastrectomies. Pathological nodal staging was pN0 in 18 and pN+ in 17 cases. Hystotype was intestinal in 14 patients, diffuse in 14 and unclassifiable in 7. Grading was G1 n = 7; G2 n = 7; G3 n = 21. Lymphocyte immunodeficiency was found at baseline in 41% of patients and at 14 days after surgery in 67% of patients. Recovery of postoperative surgery-induced lymphocytopenia occurred on the 50th day only in those patients with normal values at baseline (59%). CD4 deficiency was significantly more frequent in pN+ vs. pN0 patients, either at baseline (p < 0.001 ), on the 14th day (p < 0.02) and on the 50th day (p < 0.007) postoperatively. Cancer-related CD4 deficiency was a frequent finding in our consecutive series of gastric cancer patients; this systemic immune impairment was not restored after complete tumor removal, even in late postoperative period (50th day ). Further studies on a larger number of cases may confirm the prognostic value of lymphocyte count in early gastric cancer stages, and to verify whether early and late postoperative immunodeficiency may be prevented by IL-2 administration.

Meal-induced thermogenesis and obesity: is a fat meal a risk factor for fat gain in children?

Diet composition, in particular fat intake, has been suggested to be a risk factor for obesity in humans. Several mechanisms may contribute to explain the impact of fat intake on fat gain. One factor may be the low thermogenesis induced by a mixed meal rich in fat. In a group of 11 girls (10.1 +/- 0.3 yr), 6 obese (body mass index, 25.6 +/- 0.6 kg/m(2)), and 5 nonobese (body mass index, 19 +/- 1.6 kg/m(2)), we tested the hypothesis that a mixed meal rich in fat can elicit energy saving compared with an isocaloric and isoproteic meal rich in carbohydrate. The postabsorptive resting energy expenditure and the thermic effect of a meal (TEM) after a low fat (LF; 20% fat, 68% carbohydrate, and 12% protein) or an isocaloric (2500 kJ or 600 Cal) and isoproteic high fat (HF; 48% fat, 40% carbohydrate, and 12% protein) meal were measured by indirect calorimetry. Each girl repeated the test with a different, randomly assigned menu (HF or LF) 1 week after the first test. TEM, expressed as a percentage of energy intake was significantly higher after a LF meal than after a HF meal (6.5 +/- 0.7% vs. 4.3 +/- 0.4%; P < 0.01). The postprandial respiratory quotient (RQ) was significantly higher after a LF meal than after a HF meal (0.86 +/- 0.013 vs. 0.83 +/- 0.014; P < 0.001). The HF low carbohydrate meal induced a significantly lower increase in carbohydrate oxidation than the LF meal (20.3 +/- 6.2 vs. 61.3 +/- 7.8 mg/min; P < 0.001). On the contrary, fat oxidation was significantly higher after a HF meal than after a LF meal (-1.3 +/- 2.4 vs. -15.1 +/- 3.6 mg/min; P < 0.01). However, the postprandial fat storage was 8-fold higher after a HF meal than after a LF meal (17.2 +/- 1.7 vs. 1.9 +/- 1.8 g; P < 0.001). These results suggest that a high fat meal is able to induce lower thermogenesis and a higher positive fat balance than an isocaloric and isoproteic low fat meal. Therefore, diet composition per se must be taken into account among the various risk factors that induce obesity in children.

Sentinel Node and Radioguided Surgery in Breast Cancer of Limited Size. Preliminary Experience at ASL 1, Massa E Carrara

The aim of this study was to evaluate the effectiveness of sentinel node (SN) biopsy in breast cancer. Twenty-five female patients classified as T1N0 according to the TNM system of the UICC were evaluated with this procedure from April to October 1999. The day before surgery a subdermal injection of 99mTc-nanocoll within the tissue overlying the neoplastic lesion and subsequent lymphoscintigraphy were performed. In all patients the SN was detected with a radioguided probe during scintigraphy and surgery. Histological examination of the SN for detection of metastases was positive in four patients who subsequently underwent axillary dissection. In the remaining patients with normal SNs no axillary dissection was performed. The preliminary results confirm the validity of the sentinel node procedure.

Cell-specific differences in the regulation of IL-6 expression by PMA

We have studied the regulation of IL-6 expression in human blood monocytes and lymphocytes. LPS and IFN-gamma induced IL-6 gene expression with a similar qualitative profile in both cell types. Treatment of monocytes and lymphocytes with PMA resulted, instead, in different effects: monocytes accumulated IL-6 and its message, while lymphocytes were inhibited either in the absence or the presence of LPS and IFN-gamma. These results suggest that the signal transduction pathways triggered by LPS and IFN-gamma are similar in both cell types, while PMA may activate a tissue-specific pathway which leads to opposite responses.

Increased nasal eosinophils in children with otitis media with effusion

The pathogenesis of otitis media with effusion is still under debate, but allergic sensitization has been suggested in some cases. We investigated whether nasal cytology may indicate an allergic pathogenesis for otitis media with effusion. Atopic symptoms, results of skin prick tests to common aeroallergens, and nasal cytology by nasal scraping were evaluated in 40 children with current otitis media with effusion and compared with findings in a group of 40 healthy children. The presence of nasal eosinophils was significantly more frequent in children with otitis media with effusion than in the control group (p < 0.05). Nasal eosinophils were significantly associated with both allergic rhinitis (p < 0.001) and positive skin prick test results (p < 0.001). Allergic rhinitis with nasal eosinophilia was found in six children of the study group and in one child of the control group (p < 0.05). Our data suggest that nasal allergic inflammation may play a role in a subset of patients with otitis media with effusion. Therefore the possibility of allergic sensitization must always be considered in patients with serous otitis media.

Ligation of members of the beta 1 or the beta 2 subfamilies of integrins by antibodies triggers eosinophil respiratory burst and spreading

Eosinophils interact with extracellular matrix proteins and endothelial cells through adhesion proteins belonging to the beta 1 and beta 2 subfamilies of integrins. Extending previous observations, we found that tumour necrosis factor (TNF) and granulocyte-macrophage colony-stimulating factor stimulated generation of superoxide anion by eosinophils plated on fibronectin-coated surfaces. As studies with adherent neutrophils indicated that TNF might act as activating leucocyte integrins to deliver signals involved in activation of cell functions, we investigated the effects of monoclonal antibodies (mAb) directed against VLA-4 (CD49d/CD29), LFA-1 (CD11a/CD18), CR3 (CD11b/CD18) or the common beta 2 subunit (CD18) on generation of eosinophil toxic oxygen molecules and spreading. We show that cross-linking of members of both the beta 1 and the beta 2 integrin subfamilies triggers eosinophil respiratory burst and spreading. Evidence for the selectivity of anti-integrin mAb effects is derived from the findings that isotype-matched mAb of other specificities (anti-class I MHC Ag, anti-beta 2-microglobulin, anti-CD4) did not trigger eosinophil functions. The findings presented in this paper suggest that integrin-dependent, eosinophil adhesion in sites of allergic reaction may be accompanied by release of toxic oxygen molecules involved in tissue damage.

Glucose-6-phosphate dehydrogenase activity and protein turnover in erythroblasts separated by velocity sedimentation at unit gravity and Percoll gradient centrifugation

This work was undertaken to improve a separation method for preparation of large amounts of erythroid cells of different age with homogeneous and minimal contamination of myeloid cells. Our method was suitably employed in the study of the decay mechanism of glucose-6-phosphate dehydrogenase (G6PDH) during the erythroid cell maturation. Twenty fractions of erythroid cells at different advancing stages of maturation were prepared by fractionating, at unit gravity, bone marrow cells from anaemic rabbit. The specific activity of the G6PDH was assayed and plotted vs the fraction number and the typical sigmoid curve of the activity decay was drawn. The separated cells were then grouped in three sets of fractions following the three phases of the sigmoid curve and the fractions of each set were combined. From the cytochemical analysis of the three main fractions so obtained, we found a 25-30% myeloid cell contamination in the first fraction, while in the other two fractions the myeloid contamination was 10% or less. For this reason we performed a rapid separation of the first fraction on a discontinuous percoll gradient. By this method, the myeloid cell contamination of the first fraction was levelled down to the other two. The fractions, so obtained, (I, II and III in order of increasing cell maturation) showed a four fold decrease of glucose-6-phosphate dehydrogenase activity expressed both per cell number and on protein base. On the contrary the concentration of the total soluble proteins did not change significantly in the three fractions. The three purified cellular populations were used to provide information on the protein turnover of the erythroid cells during their development. We measured, in intact cells, the rate of synthesis and degradation of total proteins and then, in cell lysates, we determined the rate of degradation of G6PDH, purified from rabbit RBC and radiolabeled by reductive methylation with C14-formaldehyde. The rates of proteolysis obtained with total proteins and methyl-G6PDH clearly indicate that the proteolytic machinery of the erythroblasts reduces its activity during the cell maturation.

[Effect of ATP on glucose-6-phosphate dehydrogenase during erythroblast maturation in the rabbit]

The glucose-6-phosphate dehydrogenase (G6PD) activity of erythroblasts, separated at different advancing stages of development, shows a marked decline of activity. A proteolytic mechanism, strictly controlled, is likely responsible of this decay, since a sufficient level of enzyme activity still remains in the circulating erythrocyte. In this report we suggest a model that could explain what triggers the mechanism of proteolytic degradation. HPLC analysis of the nucleotide content of erythroblasts and reticulocytes, showed a marked decline of adenine and pyridine nucleotides and of their catabolic products during the cell development. From thermostability tests, at fixed temperature, we have seen that ATP and NADP only, significantly protected the enzyme activity. In this light, we incubated 10 min at increasing temperatures, with and without ATP or NADP lysates of erythroblasts, separated at different stage of development and of reticulocytes. In the absence of nucleotides, we determined for all fractions a T degree break at 42 degrees C. In the presence of NADP all fractions were stabilized with no break point in the range 37-50 degrees C. On the contrary, the presence of ATP caused a progressive shift of the T degrees C break from the most immature erythroblasts (T degree break at 46 degrees C) to the reticulocytes (T degree break at 42 degrees C). Since ATP did not show any protective effect on the reticulocyte enzyme, we hypothesize the presence in these cells of a structurally modified G6PD. Furthermore, these data support our belief that the marked decline of ATP during cellular development, may represent the element responsible for the enzyme modification.

[Progression of the peripheral blood profile in phenylhydrazine-induced hemolytic anemia]

Male rabbits were made anemic by subcutaneous injections of 3 mg/Kg body weight of phenylhydrazine (PHZ) for the duration of three days. Blood samples were collected prior to the experiment, on the 2nd and 5th day from the end of the treatment. Hematocrit, reticulocyte count, MCV, osmotic resistance, RBC volume distribution curve and morphological analysis were performed on each sample in order to obtain a picture of the progressive changes of the parameters following the PHZ administration. Hematocrit values changed from 49 to 27%, whereas the reticulocytosis increased from 0.6 to 73%. A significant elevation of MCV was detected and the cell volume distribution curve, which presented the typical bell-shape profile in the normal animals became bimodal on the 5th day. The osmotic resistance of RBC of anemic animals, showed a marked deviation from the normal pattern. In fact initial haemolysis started at 0.75-0.70% NaCl concentration in the 5th day samples, while it was between 0.55-0.50% before the PHZ treatment. Finally, morphological analysis revealed a progressive increase of RBC with Heinz bodies, of macro-megalocytes and of immature erythroblasts thus indicating that the cell population, produced during recovery from PHZ induced anemia, is widely heterogeneous.

[Hepatic hematopoiesis in phenylhydrazine-induced hemolytic anemia]

Ten adult rabbits were divided into two groups: the control rabbits, which received subcutaneous injections of 0.9% NaCl in three days; the experimental animals which received 3 mg/Kg body weight of phenylhydrazine (PHZ) subcutaneously also in three days. On the 8th day from the initial treatment the control and experimental animals were sacrificed, blood was collected to determine hematological parameters and livers were cut into small pieces. Sections were prepared by pressing the pieces onto slides which were stained with the Giemsa stain. The hematocrit and the reticulocytosis of experimental animals were 25 + 3%, and 70 + 5% respectively. In the liver sections of the PHZ treated animals we found a very rich population of immature erythroblasts. In fact proerythroblasts and basophilic erythroblasts were 19%, polychromatic and orthochromatic erythroblasts were 22% and 13% respectively. On the contrary, these cells were absent in the control livers. The lymphocyte and lymphoblast population, on the other hand, was very rich in control animals with a value of 38.8% compared to 1.62% in the anemic animals. The results clearly indicate the hematopoietic function of the liver in the anemic animals although the low percentage of orthochromatic erythroblasts with respect to their precursors suggests the ineffectiveness of the process.

[Splenic hematopoiesis in an experimental model of hemolytic anemia]

The splenic hemopoiesis of rabbits, made anemic with acetylphenylhydrazine, and of control animals was investigated. Pieces of spleen of both groups were fixed in formalin and embedded in paraffin. Paraffin sections, cut 5-7 microns in thickness, were stained with hematoxylin-eosin, Giemsa, Perls' method for tissue iron (hemosiderin), and Perls-Chayen's method for iron stored in the hemoglobin. The erythroid line in the anemic rabbits, showed a marked increase of proerythroblasts and basophilic erythroblasts, while the poli and orthochromatic erythroblasts were less than their precursors. In contrast these cells were more than their precursors in control animals. There was no notable quantitative difference in the mature elements of this line in the anemic animals and in the controls. Megaloblasts and macroblasts were frequently observed in anemic spleens but they were practically absent in the controls. Regarding to other cell lineages, we noted in the anemic spleens many macrophages containing Perls and Perls-Chayen positive material and some megakaryocytes. Our results indicate that the APH-induced anemia stimulate the erythropoietic activity of the spleen in the rabbit, but the reversion of the amplification phase of the differentiation steps reveals that the erythropoietic process is ineffective. The presence of megalo- and macroblasts provide morphological evidence of dyserythropoiesis and the megakaryocytes suggest that under the anemia condition also the platelet regenerating process is stimulated.

[Glucose-6-phosphate dehydrogenase activity as a marker of resolution in the separation of rabbit erythroblasts according to their stage of maturation]

The glucose 6 phosphate dehydrogenase (G6PD) activity of erythroblasts, separated at different advancing stages of development by the velocity sedimentation technique at unit gravity, shows a characteristic sigmoidal curve. The G6PD activity is high and constant in the dividing compartment, steeply declines between the polychromatic and the orthochromatic stage, and returns almost constant during the development from the orthochromatic to the reticulocyte stage. This report focuses on the possibility to use the G6PD activity curve to indicate a loss of resolution in the fractionation process. For this purpose two parameters of the graph were used: (h) which represents the distance between the two constant phases of the curve and (s) the slope of the decreasing part of the graph. In this view we have fractionated on a 400 ml linear gradient of sucrose (1%-2% in PBS), increasing amounts of bone marrow cells from anaemic rabbit. Suspensions of 100, 200, 350 and 700 millions of cells (25 ml in PBS) were separated in different experiments and the obtained G6PD activity curves were compared. We have seen that the two parameters h and s remained constant up to 200 millions of cells, while they declined markedly when the number of cells loaded on the gradient increased to 350 and 700 millions. The separated cells were grouped into three sets of fractions: fraction I with cells belonging to the high and constant phase of the graph, fraction II to the decreasing phase and fraction III to the low and constant activity phase.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and duration of action of oral procaterol in asthmatic children after single administration of different dosages

A double-blind crossover study was performed to evaluate the bronchodilating effect of different single doses of procaterol (less than 0.5 micrograms/kg, 1.5 micrograms/kg, and placebo) orally administered. Sixteen asthmatic children, age 6-12 years, participated in the trial. Pulmonary function, heart rate, blood pressure, and tremor were evaluated at 30, 60, 90, and 120 min and then hourly for 8 hours after administration. All three doses were therapeutically effective. The 1.5 micrograms/kg dose produced a more sustained bronchodilatation effect, but was also associated with an increase in the incidence of tremors. The 0.5 micrograms/kg dosage may, however, be a good starting dose because it assures a reasonable risk/benefit ratio.

[Leukemia in childhood]

The prognosis of leukemia in children has changed remarkably in the last 20 years. Today more than 50% of children with Acute Lymphoblastic Leukemia (ALL) and about 30% of children with Acute non Lymphoblastic Leukemia (ANLL) can be cured with chemotherapy. The German Group BFM has obtained a significant improvement of results, both in ALL and ANLL using multidrug intensive treatment schedules. In Italy, thanks to the Italian Pediatrics Association of Hematology and Oncology (AIEOP), results have been improved in the last 10 years; very recently, new protocols with the BFM strategy have been started. Allogenic matched bone marrow transplantation (BMT) is indicated in children with ALL in 2nd complete remission (CR) following a relapse during or shortly after discontinuing treatment and in patients with Chronic Myeloid Leukemia. Chemotherapy results remain very poor in these patients. Allogenic BMT in usually performed also in children with ANLL in 1st CR. Autologous BMT, and allogenic BMT mismatched or from unrelated donors are being used with promising results when matched donors are not available. Most children cured of leukemia can enjoy a normal quality of life. However long term studies are still needed to determine the incidence of late effects, and to evaluate the psychosocial impact of the disease. In this context is becoming more and more important the role of the family doctor.

Effect of age on some properties of mice erythrocytes

The hematological parameters of young (2-month-old) and old (2-year-old) mice were compared. No differences could be detected with the exception of an increased percentage of reticulocytes in the old animals suggesting that anemia in senescent mice does not occur. Red blood cell mean half-life in old mice was 8 +/- 0.8 days compared to 12 +/- 1 days in young mice. This reduced survival of red blood cell is not due to a different rate of cell phagocytosis in the reticulohistiocytic system of young and old animals since erythrocytes from young mice have the same mean half-life when injected both in young and old animals and vice versa. Thus, the old mice have a reduced red cell life-span but the same hematocrit of the young, suggesting that old animals possess a chronologically younger population of erythrocytes than do young animals. This has been confirmed by measuring the specific activities of some red blood cell age-dependent enzymes (hexokinase, glucose-6-phosphate dehydrogenase, pyruvate kinase) that were found to be higher in the older animals, and by the separation of erythrocytes into different density (age) groups by Percoll/albumin density gradient centrifugation. However, the erythrocytes osmotic fragility, and the cellular contents of adenine and pyridine nucleotides, as well as the content of 2,3-diphosphoglycerate and reduced glutathione, show that circulating erythrocytes in old animals constitute an heterogeneous cell population whose properties cannot be explained on the basis of a chronologically younger erythrocyte population. Furthermore, evaluation of cell components in hemopoietic tissues have shown an increased porportion of erythroid precursor cells in old animals confirming that old mice compensate for reduced red cell survival with an increased erythropoiesis.

Prospective randomized comparison of two prophylactic regimens with trimethoprim-sulfamethoxazole in leukemic children: a two year study

Between 1 July 1984 and 30 June 1986 all children treated for acute hematologic malignancy at our center were randomized to receive continuous (group A) or intermittent (3 days/week, group B) prophylaxis with trimethoprim-sulfamethoxazole (5-25 mg/kg/day/p.o.) against interstitial pneumonia with the aim of investigating if an intermittent regimen is as effective as and less toxic than a continuous regimen. The number of severe infections (group A, 17; group B, 21) and side-effects (group A, 30; group B, 34) was similar in the two groups, and compliance was also similar. We conclude therefore that neither regimen offers advantages over the other and the decision which to use should be based on cost (where regimen B has the advantage) and the children's and parents' preferences and compliance.