[Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for Critical Care and Emergency Medicine (DIVI), the Medical Directors of Emergency Medical Services in Bavaria (ÄLRD), the Scientific Working Group for Pediatric Anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI), the Scientific Working Group for Emergency Medicine of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the Society of Neonatology and Pediatric Critical Care Medicine (GNPI)]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present a literature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors.

RESULTS

The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have a gastric drainage possibility.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

Arteriell ischämischer Schlaganfall im Kindes- und Jugendalter

Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten pädiatrischen Notfällen, wird aber häufig erst mit prognostisch relevanter Zeitverzögerung diagnostiziert. Gründe sind geringe „Awareness“, die zuweilen unspezifische klinische Präsentation mit einer Breite an kritischen Differenzialdiagnosen und in der Fläche noch wenig verzahnte Akutversorgungsstrukturen. Die beim Erwachsenen etablierten Revaskularisationsstrategien zeigen auch beim Kind mögliche, z. T. spektakuläre Erfolge. Diese sind daher nach Möglichkeit auch betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit keine annähernd vergleichbare Evidenz vorliegt. Postakut ist die ätiologische Aufarbeitung aufgrund zu bedenkender Risikofaktoren komplex, muss aber das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die bio-psycho-sozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen.

Notfall-Neuropädiatrie – Der arteriell ischämische Schlaganfall als einer der zeitkritischsten Notfälle bei Kindern und Jugendlichen

Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten Notfällen in der Pädiatrie. Dennoch wird er häufig mit einer oft prognostisch relevanten Zeitverzögerung diagnostiziert. Gründe dafür liegen neben der geringen Awareness auch in der zuweilen unspezifischen klinischen Präsentation mit einer herausfordernden Breite kritischer Differenzialdiagnosen sowie in der Fläche noch wenig verzahnter Akutversorgungsstrukturen. Gleichwohl zeigen grundsätzlich die beim Erwachsenen etablierten Revaskularisationsstrategien auch beim Kind ihre möglichen, zum Teil spektakulären Erfolge. Es gilt also, diese nach Möglichkeit auch den betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit ein nicht annähernd vergleichbarer Grad an Evidenz erreicht ist. Postakut ist die ätiologische Aufarbeitung durch die größere Bandbreite zu bedenkender Risikofaktoren besonders komplex, muss aber in der Lage sein, das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise zu identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die biopsychosozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen und damit eine bestmögliche Integration des Kindes in sein soziales und schulisches, später berufliches Umfeld realisieren.

Respiratory diseases and allergy in farmers working with livestock: a EAACI position paper

Farmers constitute a large professional group worldwide. In developed countries farms tend to become larger, with a concentration of farm operations. Animal farming has been associated with negative respiratory effects such as work-related asthma and rhinitis. However, being born and raised or working on a farm reduces the risk of atopic asthma and rhinitis later in life. A risk of chronic bronchitis and bronchial obstruction/COPD has been reported in confinement buildings and livestock farmers. This position paper reviews the literature linking exposure information to intensive animal farming and the risk of work-related respiratory diseases and focuses on prevention. Animal farming is associated with exposure to organic dust containing allergens and microbial matter including alive microorganisms and viruses, endotoxins and other factors like irritant gases such as ammonia and disinfectants. These exposures have been identified as specific agents/risk factors of asthma, rhinitis, chronic bronchitis, COPD and reduced FEV₁. Published studies on dust and endotoxin exposure in livestock farmers do not show a downward trend in exposure over the last 30 years, suggesting that the workforce in these industries is still overexposed and at risk of developing respiratory disease. In cases of occupational asthma and rhinitis, avoidance of further exposure to causal agents is recommended, but it may not be obtainable in agriculture, mainly due to socio-economic considerations. Hence, there is an urgent need for focus on farming exposure in order to protect farmers and others at work in these and related industries from developing respiratory diseases and allergy.

Relevance of TH2 Markers in the Assessment and Therapeutic Management of Severe Allergic Asthma: A Real-Life Perspective

BACKGROUND

Although blood eosinophils are currently recognized as the main clinical marker of TH2-type inflammation, their relevance in identifying asthma severity remains a matter of debate.

METHODS

Our retrospective real-life study on severe asthmatics included in the NEONet Italian database aimed to investigate the relevance of blood eosinophil count and fractional exhaled nitric oxide (FeNO) in the clinical assessment of severe asthma and their role as potential predictors of responsiveness to anti-IgE therapy. The cut-off values chosen were 300 eosinophils/mm3 and FeNO of 30 ppm.

RESULTS

We evaluated 132 adult patients. No significant differences were observed between the groups (high and low baseline eosinophil counts) in terms of demographic data, total IgE, lung function, patient-reported outcomes, or nasal comorbidities. The Asthma Control Test score and Asthma Quality of Life Questionnaire scores were poorer in patients with FeNO ≥30 ppb than in patients with FeNO <30 ppb. In the high FeNO subgroup, more frequent hospital admissions and a higher number of working days lost in the previous year were registered. A combined score including both eosinophils and FeNO did not improve the accuracy of the individual parameters. In the high-eosinophil subgroup, the proportion of responders to omalizumab was greater and increased at each follow-up time point.

CONCLUSIONS

Our findings show that blood eosinophil count is not an unequivocal marker of asthma severity, whereas a higher FeNO level is associated with more frequent hospital admissions and more working days lost. Blood eosinophils seem to act as a predictor of response to omalizumab.

Porphyromonas gingivalis in the tongue biofilm is associated with clinical outcome in rheumatoid arthritis patients

Several studies have suggested a link between human microbiome and rheumatoid arthritis (RA) development. Porphyromonas gingivalis seems involved in RA initiation and progression, as supported by the high occurrence of periodontitis. In this case-control study, we analysed tongue P. gingivalis presence and quantification in a large healthy and RA cohort. We enrolled 143 RA patients [male/female (M/F) 32/111, mean ± standard deviation (s.d.), age 57·5 ± 19·8 years, mean ± s.d. disease duration 155·9 ± 114·7 months); 36 periodontitis patients (M/F 11/25, mean ± s.d., age 56 ± 9·9 years, mean ± s.d. disease duration 25·5 ± 20·9 months); and 57 patients (M/F 12/45, mean ± s.d., age 61·4 ± 10·9 years, mean ± s.d. disease duration 62·3 ± 66·9 months) with knee osteoarthritis or fibromyalgia. All subjects underwent a standard cytological swab to identify the rate of P. gingivalis/total bacteria by using quantitative real-time polymerase chain reaction. The prevalence of P. gingivalis resulted similarly in RA and periodontitis patients (48·9 versus 52·7%, P = not significant). Moreover, the prevalence of this pathogen was significantly higher in RA and periodontitis patients in comparison with control subjects (P = 0·01 and P = 0·003, respectively). We found a significant correlation between P. gingivalis rate in total bacteria genomes and disease activity score in 28 joints (DAS28) (erythrocyte sedimentation rate) (r = 0·4, P = 0·01). RA patients in remission showed a significantly lower prevalence of P. gingivalis in comparison with non-remission (P = 0·02). We demonstrated a significant association between the percentage of P. gingivalis on the total tongue biofilm and RA disease activity (DAS28), suggesting that the oral cavity microbiological status could play a role in the pathogenic mechanisms of inflammation, leading to more active disease.

Accessory caudal glenoid ossification centre as possible cause of lameness in nine dogs

An accessory centre of ossification was identified on the caudal aspect of the glenoid (ACGOC) in nine dogs. In three of the dogs, concomitant lesions were found in the same shoulder joint. When they appeared to be loose, the fragments were removed using arthroscopy in eight dogs. Upon histological examination in four dogs, the presence of articular cartilage on these ACGOC confirmed the fact that they represented a portion of the glenoid. The resolution of the clinical signs in six cases with isolated ACGOC after fragment excision and without concomitant lesions suggests that ACGOC was the cause of lameness in these affected dogs.

Haemostatic testing prior to elective surgery in children? Not always!

In Germany, preoperative coagulation tests are commonly used, based on the belief that these tests should identify patients with an increased bleeding risk. However, published evidence does not longer support this approach for both traditional screening tests and novel techniques of global assessment of haemostasis. Unselected screening yields many false positive results and detects irrelevant disorders. It leads to postponement of surgery, anxiety in parents and patients, and is not cost effective. Even worse, it does not reliably detect relevant bleeding disorders such as the most common coagulopathy, von Willebrand disease. The bleeding history of patients and their relatives is a more effective tool to detect patients at risk. According to international guidelines and a joint statement of different German medical societies, a standardized questionnaire should be mandatory in preoperative screening. A diagnostic pathway should be employed to identify patients in whom specific tests are helpful. Because neither laboratory tests nor questionnaires can infallibly predict or exclude perioperative bleeding, guidelines for the management of these unexpected situations have to be established.

Coagulation testing in the evaluation of suspected child abuse

Every year in Germany nearly 3000 cases of child abuse were reported. When children are presented at emergency units with suspicious injuries and bruises a detailed documentation an evaluation is necessary after emergency treatment. As differential diagnosis inherited or acquired bleeding disorders should be excluded. In addition to a detailed evaluation of personal and family history and a physical evaluation different coagulation test to exclude defects of primary and secondary hemostasis should be performed. Clinician must know the limitations of these tests and keep in mind that an abnormal coagulation test does not exclude child abuse. Coagulation defects may be the consequence of child abuse and neglect or the two conditions may coexist.

Repeated coagulation testing in children

Background Mild bleeding disorders (BD) such as von Willebrand disease (VWD) type I are often difficult to diagnose because of inconclusive laboratory results. Our study examines the diagnostic value of repeated testing.

Patients, methods Prospective study on 200 children. Extensive laboratory testing was done twice and a standardized history was taken.

Results 165 patients completed the study (median age 5.6 years). Main reason for referral was aPTT prolongation (n = 109). The initial diagnosis was upheld in 74/165 (44.8%) children. Of 18 patients rated normal, 8 had to be reclassified as possible VWD later. Ten patients were diagnosed VWD I. In 36 patients possible VWD was found, 13 of these had normal results at the second visit while in 6 VWD became more likely. The main diagnosis was lupus-anticoagulant (n=79), normalizing in 24. A total of 88 children underwent surgery during the study period.

Conclusion Our study shows frequent changes in the diagnosis and highlights the limitations of single laboratory tests in detecting mild BD. Clinical and laboratory abnormalities have to be followed and tests must be repeated in unclear cases. Normal values at one point do not exclude a BD.

Arterial thrombosis in homozygous antithrombin deficiency

Antithrombin (AT), a serin protease inhibitor (serpin) produced in the liver, inhibits mainly thrombin and factor Xa. Antithrombin deficiency (AD) is associated with a higher incidence of thrombosis. Case report: We report a newborn with uncomplicated birth in the 40+5 week of gestation and postnatal appearance of a reticular, livide haematoma on the right upper arm and a tonic clonic epileptic seizure. Clinical examination revealed weak pulses in the A. radialis and ulnaris. MRI scan showed a large thrombus in the A. carotis interna and externa with large cerebral infarction and a thrombus in the A. subclavia. Laboratory work up showed elevated D-dimers and antithrombin levels < 20% (lowest 15%), age-related values for protein C, protein S, plasminogen, and no other inherited thrombophilia. Therapy: We started anticoagulation with unfractionated heparin intravenously (aPTT: 50–60 s) and under suspicion of an AD the substitution of AT (70 U/kg body weight). In course of time we changed anticoagulation to low molecular weight heparin (Anti Xa 0.6–0.8 U/ml) and substitution of 250 E/kg AT every second day. In the molecular work up we found a homozygous missense mutation in exon 2 of SERPINC1 gene (type „Budapest 3”). Molecular analysis showed also heterozygous mutations in both parents and a homozygous mutation in the asymptomatic brother aged three years. At age of six months we changed the anticoagulation to coumadin (INR 2.5–3.5). Anticoagulation with coumadin was also started in the brother. Discussion: Hereditary AD is associated with an increased risk of thrombosis. The homozygous status mainly leads to intrauterine fetal loss or the occurrence of peri- and postnatal thrombosis. Therapy consists in the substitution of AT and a lifelong anticoagulation with vitamin K antagonists also in asymptomatic patients.

Erste Ergebnisse der THROMKID-Studie

Im Rahmen der THROMKID-Studie als Qualitätsprojekt der Ständigen Kommission Pädiatrie der Gesellschaft für Thrombose- und Hämostaseforschung (GTH) wurden Daten pädiatrischer Patienten mit hereditären Thrombozytopathien zwischen Mai 2005 und August 2006 erfasst. Die Ergebnisse der Thrombozytenfunktionsdiagnostik wurden bei jedem Patienten bewertet und die Diagnosen als sehr wahrscheinlich, wahrscheinlich oder unwahrscheinlich eingestuft. Von insgesamt 215 Patienten aus 31 Zentren war bei 95 (44%) die Diagnose sehr wahrscheinlich und bei 28 (13%) wahrscheinlich. Folgende Erkrankungen wurden erfasst: Thrombasthenie Glanzmann (n = 39, 32%), Aspirin- like Defekt (n = 26, 21%), thrombozytäre Rezeptordefekte (n = 21, 17%), Storage-pool-Defekte (n = 18, 15%), Bernard-Soulier Syndrom (n=10, 8%), Hermansky-Pudlak-Syndrom (n = 6, 5%) und MYH9-assoziierte Makrothrombozytopenie (n = 3, 2%). Bei 92 (43%) Patienten war die Diagnose unwahrscheinlich.

Die geringe Prävalenz dieser Erkrankungen und der hohe Prozentsatz nicht klassifizierbarer Krankheitsentitäten zeigt die Notwendigkeit, ein Kompetenznetzwerk zur Betreuung dieser Kinder in deutschsprachigen Ländern zu etablieren.

Postoperative bleeding in paediatric ENT surgery

Bleeding after ear-nose-and throat surgery in children is a serious complication. With the help of the German Surveillance Unit for Rare Paediatric Disorders (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland; ESPED) a two year survey was performed to record the incidence, severity, reasons and treatment of haemorrhages. During the study period, 1069 bleeds were reported from 720 paediatric hospitals and departments of otorhinolaryngology after adenoidectomy and tonsillectomy. 713 reports could be analyzed. Two deaths occurred after adenoidectomy. Although laboratory screening was performed in more than 70% of all cases, bleeding complications were neither foreseeable nor preventable. Inherited coagulopathies were rare and in most cases not detected, neither by laboratory screening nor by taking a history. Since preoperative measures cannot help much to improve the situation, all efforts have to be taken to improve the postoperative period, especially since more than 20% of the hemorrhages occurred during weekends. Guidelines on postoperative care and behaviour should therefore be implemented and parents and patients must be informed on bleeding risks and on what to do in case of emergency. If bleeding occurs, extensive coagulation testing is mandatory.

Arthroscopic treatment of osteochondritis dissecans of the shoulder in 126 dogs

Osteochondritis dissecans of the shoulder joint was treated by arthroscopy in 126 dogs. Twenty-four dogs had bilateral surgery, making a total of 150 joints treated. The OCD flaps were removed in small pieces through the cannula or in a single piece through a stab incision. The lameness resolved completely within seven-60 days following arthroscopy in 137 out of 150 affected limbs. Within a subset of 47 dogs with unilateral OCD, it was found that lesions located on the caudo-medial region of the humeral head had a better functional outcome than those lesions located in the caudo-central region of the humeral head.

Proteome Analysis of Urticating Setae From Thaumetopoea pityocampa (Lepidoptera: Notodontidae)

Thaumetopoea pityocampa (Denis & Schiffermüller) (Lepidoptera: Notodontidae) is harmful to conifer trees because of defoliation and to public health because of the release of urticating setae from the caterpillars. Contact with setae by humans and domestic animals induces dermatitis, usually localized to the exposed areas. Recent studies demonstrated the presence of a complex urticating mechanism where proteins present in the setae may play a role as activators of immune responses. Yet, limited information is available at present about the proteins occurring in the setae of T. pityocampa. Using a refined method for protein extraction from the setae, and a combination of liquid chromatography tandem-mass spectrometry (LC-MS/MS), de novo assembly of transcriptomic data, and sequence similarity searches, an extensive data set of 353 proteins was obtained. These were further categorized by molecular function, biological process, and cellular location. All the 353 proteins identified were found to match through BLAST search with at least one Lepidoptera sequence available in databases. We found the previously known allergens Tha p 1 and Tha p 2 described from T. pityocampa, as well as enzymes involved in chitin biosynthesis, one of the principal components of the setae, and serine proteases that were responsible for inflammatory and allergic reactions in other urticating Lepidoptera. This new proteomic database may allow for a better understanding of the complexity of allergenic reactions due to T. pityocampa and to other Lepidoptera sharing similar defense systems.

Blood-Brain Barrier in a Haemophilus influenzae Type a In Vitro Infection: Role of Adenosine Receptors A2A and A2B

The blood-brain barrier (BBB) is mainly made up of tightly connected microvascular endothelial cells (BMECs), surrounded by pericytes (BMPCs) which regulate BBB tightness by providing soluble factors that control endothelial proliferation. Haemophilus influenzae type a (Hia) is able to reach the BBB, crossing it, thus causing meningitis. In this study, by using an in vitro model of BBB, performed with human BMECs and human BMPCs in co-culture, we demonstrated that, after Hia infection, the number of hBMPCs decreased whereas the number of hBMECs increased in comparison with non-infected cells. SEM and TEM images showed that Hia was able to enter hBMECs and reduce TEER and VE-cadherin expression. When the cells were infected in presence of SCH58261 and PSB603 but not DPCPX, an increase in TEER values was observed thus demonstrating that A_2A and A_2B adenosine receptors play a key role in BBB dysfunction. These results were confirmed by the use of adenosine receptor agonists CGS21680, CCPA, and NECA. In infected co-cultures cAMP and VEGF increased and TEER reduction was counter-balanced by VEGF-R1 or VEGF-R2 antibodies. Moreover, the phosphorylated CREB and Rho-A significantly increased in infected hBMECs and hBMPCs and the presence of SCH58261 and PSB603 significantly abrogated the phosphorylation. In conclusion, this study demonstrated that the infection stimulated A_2A and A_2B adenosine receptors in hBMECs and hBMPCs thus inducing the pericytes to release large amounts of VEGF. The latter could be responsible for both, pericyte detachment and endothelial cell proliferation, thus provoking BBB impairment.

Building dampness and mold in European homes in relation to climate, building characteristics and socio-economic status: The European Community Respiratory Health Survey ECRHS II

We studied dampness and mold in homes in relation to climate, building characteristics and socio-economic status (SES) across Europe, for 7127 homes in 22 centers. A subsample of 3118 homes was inspected. Multilevel analysis was applied, including age, gender, center, SES, climate, and building factors. Self-reported water damage (10%), damp spots (21%), and mold (16%) in past year were similar as observed data (19% dampness and 14% mold). Ambient temperature was associated with self-reported water damage (OR=1.63 per 10°C; 95% CI 1.02-2.63), damp spots (OR=2.95; 95% CI 1.98-4.39), and mold (OR=2.28; 95% CI 1.04-4.67). Precipitation was associated with water damage (OR=1.12 per 100 mm; 95% CI 1.02-1.23) and damp spots (OR=1.11; 95% CI 1.02-1.20). Ambient relative air humidity was not associated with indoor dampness and mold. Older buildings had more dampness and mold (P<.001). Manual workers reported less water damage (OR=0.69; 95% CI 0.53-0.89) but more mold (OR=1.27; 95% CI 1.03-1.55) as compared to managerial/professional workers. There were correlations between reported and observed data at center level (Spearman rho 0.61 for dampness and 0.73 for mold). In conclusion, high ambient temperature and precipitation and high building age can be risk factors for dampness and mold in homes in Europe.

Drop-out rate among patients treated with omalizumab for severe asthma: Literature review and real-life experience

Background

In patients with asthma, particularly severe asthma, poor adherence to inhaled drugs negatively affects the achievement of disease control. A better adherence rate is expected in the case of injected drugs, such as omalizumab, as they are administered only in a hospital setting. However, adherence to omalizumab has never been systematically investigated. The aim of this study was to review the omalizumab drop-out rate in randomized controlled trials (RCTs) and real-life studies. A comparative analysis was performed between published data and the Italian North East Omalizumab Network (NEONet) database.

Results

In RCTs the drop-out rate ranged from 7.1 to 19.4 %. Although the reasons for withdrawal were only occasionally reported, patient decision and adverse events were the most frequently reported causes. In real-life studies the drop-out rate ranged from 0 to 45.5 %. In most cases lack of efficacy was responsible for treatment discontinuation. According to NEONet data, 32 % of treated patients dropped out, with an increasing number of drop outs observed over time. Patient decision and lack of efficacy accounted for most treatment withdrawals.

Conclusions

Treatment adherence is particularly crucial in patients with severe asthma considering the clinical impact of the disease and the cost of non-adherence. The risk of treatment discontinuation has to be carefully considered both in the experimental and real-life settings. Increased knowledge regarding the main reasons for patient withdrawal is important to improve adherence in clinical practice.

Real-time sonoelastography as novel follow-up method in Achilles tendon surgery

PURPOSE

To evaluate the sonoelastographic features of Achilles tendon healing after percutaneous treatment using real-time sonoelastography, a new tool able to quantify deformation in biological tissues.

METHODS

Patients with atraumatic Achilles tendon ruptures, treated with a percutaneous technique, were assessed. Sonoelastographic evaluations were performed at the myotendinous junction, tendon body/lesion site and osteotendinous junction, both for the operated and contralateral side, at 40 days, 6 months and 1 year after surgery. Using standard regions of interest, the "strain index" (SI) was calculated as an indicator of tendon elasticity. Clinical outcomes were assessed by the ATRS questionnaire at 6 months and 1 year post-operatively and correlated with sonoelastographic findings. Sixty healthy tendons from 30 volunteers were used to provide a healthy control range.

RESULTS

Twenty-five patients were recruited for this study. The SI in treated tendons showed progressive stiffening over time, especially at myotendinous junction and at the site of the sutured lesion, resulting in significantly higher stiffness than both the contralateral tendon and healthy volunteers. Peak thickness of treated tendons occurred at 6 months, with a tendency to reduce at 1 year, while never achieving a normal physiological state. Greatest remodelling was seen at the lesion site. The contralateral tendon showed significant thickening at the myotendinous and osteotendinous junctions. The SI of the contralateral tendon was found to be stiffer than physiological values found in the control group. ATRS score improved significantly between 6 months and 1 year, being negatively correlated with the SI (p < 0.001).

CONCLUSION

RTSE showed that operatively treated Achilles tendons become progressively stiffer during follow-up, while the ATRS score improved. From a biomechanical point of view, at 1 year after surgery Achilles tendons did not show a "restitutio ad integrum". Real-time sonoelastography provides more qualitative and quantitative details in the diagnostics and follow-up of Achilles tendon conditions as the post-operative evolution of the repairing tissue.

LEVEL OF EVIDENCE

Diagnostic and therapeutic study, Level III.

The risk of respiratory symptoms on allergen exposure increases with increasing specific IgE levels

BACKGROUND

The relation between IgE sensitization and allergic respiratory symptoms has usually been evaluated by dichotomizing specific IgE levels. The aim of this study was to evaluate the association between specific IgE levels and risk of symptoms on allergen-related exposure, with special reference to allergen-related asthma-rhinitis comorbidity.

METHODS

We considered 6391 subjects enrolled within the European Community Respiratory Health Survey 2, having information on cat/grass/D. pteronyssinus IgE levels and symptoms on exposure to animals/pollen/dust. The risk of oculonasal/asthmalike/both symptoms was evaluated by a multinomial logistic model.

RESULTS

A clear positive association was observed between specific IgE levels to cat/grass/mite and the risk of symptoms on each allergen-related exposure (test for trend with P < 0.001). This trend was particularly pronounced when considering the coexistence of asthmalike and oculonasal symptoms. Compared to non-sensitized subjects, subjects with specific IgE to cat >= 3.5 kU/l presented relative risk ratios of 11.4 (95% CI 6.7-19.2), 18.8 (8.2-42.8), and 55.3 (30.5-100.2) when considering, respectively, only oculonasal symptoms, only asthmalike symptoms, or both. A similar pattern was observed when considering specific IgE to grass/mite and symptoms on exposure to pollen/dust. Also the proportion of people using inhaled medicines or visiting a general practitioner for breathing problems in the previous year increased with increasing sum of specific IgE to cat/grass/mite.

CONCLUSION

Specific IgE level is the most important predictor of allergen-related symptoms. The risk of both oculonasal/asthmalike symptoms increases with specific IgE levels, suggesting that specific IgE contributes to the 'united airways disease'.

Role of cytosolic and calcium independent phospholipases A(2) in insulin secretion impairment of INS-1E cells infected by S. aureus

Cytosolic PLA2 (cPLA2) and Ca(2+)-independent PLA2 (iPLA2) play a significant role in insulin β-cells secretion. Bacterial infections may be responsible of the onset of diabetes. The mechanism by which Staphylococcus aureus infection of INS-1 cells alters glucose-induced insulin secretion has been examined. After acute infection, insulin secretion and PLA2 activities significantly increased. Moreover, increased expressions of phospho-cPLA2, phospho-PKCα and phospho-ERK 1/2 were observed. Chronic infection causes a decrease in insulin release and a significant increase of iPLA2 and COX-2 protein expression. Moreover, insulin secretion in infected cells could be restored using specific siRNAs against iPLA2 isoform and specific COX-2 inhibitor.

Asthenozoospermia and membrane remodeling enzymes: a new role for phospholipase A2

Phosholipase A2 (PLA2 ) activity in the seminal plasma and in sperm heads is closely related to sperm motility and male fertility. Therefore, the purpose of this study was to investigate the possible involvement of different isoforms of phospholipase in asthenozoospermia. To accomplish this, cPLA2 , phospho-cPLA2 , iPLA2 , and sPLA2 were evaluated by immunofluorescence and immunoblot analyses in spermatozoa obtained from 22 normozoospermic men and 28 asthenozoospermic patients. We found significant differences in cPLA2 and its phosphorylated/activated form, iPLA2 , and sPLA2 content and distribution in normal and asthenozoospermic patients. cPLA2 was localized in heads, midpieces, and tails of all spermatozoa as constitutive enzyme, less expressed in the tail of spermatozoa with low progressive motility. While active phospho-cPLA2 distribution was homogeneous throughout the cell body of control-donor spermatozoa, lower levels were detected in the tails of asthenozoospermic patients, as opposed to its strong presence in heads. Low immunofluorescence signal for iPLA2 was found in astenozoospermic patients, whereas sPLA2 was significantly lower in the heads of asthenozoospermic patients. Spermatozoa with low progressive motility showed differences both in terms of total specific activity and of intracellular distribution. cPLA2 , iPLA2 , and sPLA2 specific activities correlated positively and in a significantly manner with sperm progressive motility both in normozoospermic men and asthenozoospermic patients. In conclusion, PLA2 s are expressed in different areas of human spermatozoa. Spermatozoa with low motility showed differences in total specific activity and enzyme distributions. We speculated that PLA2 expression and/or different distribution could be potential biomarkers of asthenozoospermia, one of the major causes of male factor infertility.

[Therapy of inherited diseases of platelet function. Interdisciplinary S2K guideline of the Permanent Paediatric Committee of the Society of Thrombosis and Haemostasis Research (GTH e. V.)]

Inherited disorders of platelet function are a heterogeneous group. For optimal prevention and management of bleeding, classification and diagnosis of the underlying defect are highly recommended. An interdisciplinary guideline for a diagnostic approach has been published (AWMF # 086-003 S2K; Hämostaseologie 2014; 34: 201-212). Underlying platelet disorder, platelet count, age and clinical situation modify treatment. Exclusive transfusion of platelet concentrates may be inappropriate as potentially adverse effects can outweigh its benefit. A stepwise and individually adjusted approach for restitution and maintenance of haemostasis is recommended. Administration of antifibrinolytics is generally endorsed, but is of particular use in Quebec disease. Restricted to older children, desmopressin is favourable in storage pool disease and unclassified platelet disorders. Although licensed only for patients with Glanzmann thrombasthenia and alloantibodies, in clinical practice rFVIIa is widely used in inherited platelet disorders with severe bleeding tendency. This guideline aims at presenting the best available advice for the management of patients with inherited platelet function disorders.

House dust-mite allergen exposure is associated with serum specific IgE but not with respiratory outcomes

Exposure to house dust has been associated with asthma in adults, and this is commonly interpreted as a direct immunologic response to dust-mite allergens in those who are IgE sensitized to house dust-mite. Mattress house dust-mite concentrations were measured in a population-based sample of 2890 adults aged between 27 and 56 years living in 22 centers in 10 countries. Generalized linear mixed models were employed to explore the association of respiratory symptoms with house dust-mite concentrations, adjusting for individual and household confounders. There was no overall association of respiratory outcomes with measured house dust-mite concentrations, even in those who reported they had symptoms on exposure to dust and those who had physician-diagnosed asthma. However, there was a positive association of high serum specific IgE levels to HDM (>3.5 kUA /l) with mattress house dust-mite concentrations and a negative association of sensitization to cat with increasing house dust-mite concentrations. In conclusion, there was no evidence that respiratory symptoms in adults were associated with exposure to house dust-mite allergen in the mattress, but an association of house mite with strong sensitization was observed.

Adult eczema in Italy: prevalence and associations with environmental factors

BACKGROUND

Studies on the prevalence of eczema and atopic dermatitis (AD), and on the factors associated with these diseases, have been mostly performed in children, whereas studies on adult populations are lacking.

OBJECTIVES

To determine the prevalence of eczema and AD in the Italian adult population, and to investigate risk factors associated with the disease.

METHODS

A postal screening questionnaire was administered to 18 357 randomly selected subjects aged 20-44 years in the Gene-Environment Interaction in Respiratory Diseases study, which involved seven centres distributed across northern, central and southern Italy. The questionnaire included items on the occurrence of doctor-diagnosed eczema, asthma and hay fever, socio-demographic characteristics and environmental exposures.

RESULTS

In all, 10 464 (57.0%) subjects responded to the questionnaire. The prevalence of current eczema was 8.1% (95% CI: 7.6-8.7%), while the prevalence of eczema with asthma and/or hay fever (EAH), which was adopted as proxy of AD, was 3.4% (95% CI: 3.1-3.8%). About 60% of the subjects with current eczema reported the onset of the disease in adulthood. In multi-variable models, the prevalence of eczema was significantly associated with female sex, older age, living close to industrial plants, high levels of heavy traffic near home and living in central-southern Italy.

CONCLUSIONS

Eczema and EAH are highly prevalent in Italian young adults, especially in women. Our results suggest that adult onset is not unusual, and that environmental factors may influence the occurrence of eczema and EAH.

Short femoral stem and porous titanium: winning combination?

A lot of different implants are available in hip replacement arthroplasty (THA), stems differ mainly by type of fixation, material, length, diameter, shape, surface coating, modularity, etc. The main quality of a non-cemented stem is to pursuit primary and secondary stability, to preserve bone stock, to be adaptable and modular. The literature shows that the most popular non cemented stems used in THA are metaphyseal femoral stem in which the distal portion has only the action to avoid varus stem placement but can also be a source of complications such as stress shielding. The stability of a short stem is closely dependent on material that must allow a high "scratch fit" and facilitate osteointegration with a generous surface of bone-implant contact. From September 2010 we have performed 287 THA using a modular titanium porous short stem. The article shows the preliminary results, which are very encouraging, showing excellent primary and secondary osteointegration, also slightly undersized implants or in elderly porotic patients.

OCCUPATION study (OCCUPationl asthma: a naTIONal based study): a survey on occupational asthma awareness among Italian allergists

Occupational asthma (OA) is the most common work-related respiratory disease. Case identification still remains underperformed. The present survey aimed at investigating the awareness about OA among Italian allergists. 538 Italian Allergists completed a web anonymous questionnaire concerning: patient profile, occupational history, disease features, diagnostic work-up, causal agents, management after diagnosis. 80 cases were registered by 14 members (2.4%). Patients were mostly between 30 and 62 years old; noteworthy, 19% were between 18 and 30. All the patients had a concomitant rhinitis, usually preceding asthma onset. Bakers, hairdressers and healthcare workers were more frequently involved. Diagnostic process included: skin prick test (85%), stop/resume test (57%), specific IgE dosage for occupational allergens (52.5%), peak expiratory flow monitoring (32.5%). Noteworthy, only 27,5% of patients underwent specific challenge. After the diagnosis 50% of patients did not change job. One third of the subjects were not referred to the national Workers Compensation Authority. Our data show that OA is quite neglected by Italian allergists, despite they have a pivotal role both in early identification and in primary prevention of OA. Thus, it is worth increasing awareness concerning OA and creating an easy-access network involving allergists and referral centers for Occupational respiratory diseases.

Asthma and exposure to cleaning products - a European Academy of Allergy and Clinical Immunology task force consensus statement

Professional and domestic cleaning is associated with work-related asthma (WRA). This position paper reviews the literature linking exposure to cleaning products and the risk of asthma and focuses on prevention. Increased risk of asthma has been shown in many epidemiological and surveillance studies, and several case reports describe the relationship between exposure to one or more cleaning agents and WRA. Cleaning sprays, bleach, ammonia, disinfectants, mixing products, and specific job tasks have been identified as specific causes and/or triggers of asthma. Because research conclusions and policy suggestions have remained unheeded by manufactures, vendors, and commercial cleaning companies, it is time for a multifaceted intervention. Possible preventive measures encompass the following: substitution of cleaning sprays, bleach, and ammonia; minimizing the use of disinfectants; avoidance of mixing products; use of respiratory protective devices; and worker education. Moreover, we suggest the education of unions, consumer, and public interest groups to encourage safer products. In addition, information activities for the general population with the purpose of improving the knowledge of professional and domestic cleaners regarding risks and available preventive measures and to promote strict collaboration between scientific communities and safety and health agencies are urgently needed.

Evaluation of commercial skin prick test solutions for selected occupational allergens

BACKGROUND

Skin prick testing (SPT) is an important step in the diagnosis of IgE-mediated occupational allergic diseases. The outcome of SPT is related to the quality of allergen extracts. Thus, the aim of the study was to assess different commercially available SPT solutions for selected occupational allergens.

METHODS

SPT was performed in 116 bakers, 47 farmers and 33 subjects exposed to natural rubber latex (NRL), all with work-related allergic symptoms. The SPT solutions from different manufacturers (n = 3-5) for wheat flour, rye flour, soy, cow hair/dander, storage mites (Tyrophagus putrescentiae, Lepidoglyphus destructor, Acarus siro) and NRL were analysed with respect to their protein and antigen contents. SPT was carried out in 16 allergy centres in six European countries using standardized procedures. Specific IgE values were used as the gold standard to calculate the sensitivity and specificity of SPT solutions. The optimal cut-point for each SPT solution was determined by Youden Index.

RESULTS

Protein and antigen contents and patterns of the SPT solutions varied remarkably depending on the manufacturer. While SPT solutions for wheat flour and soy reached overall low sensitivities, sensitivities of other tested SPT solutions depended on the manufacturer. As a rule, solutions with higher protein and antigen content showed higher sensitivities and test efficiencies.

CONCLUSIONS

There is a wide variability of SPT solutions for occupational allergens, and the sensitivity of several solutions is low. Thus, improvement and standardization of SPT solutions for occupational allergens is essential.

EAACI position paper: skin prick testing in the diagnosis of occupational type I allergies

Skin prick testing (SPT) in combination with the clinical history of the patient is one important step in the diagnosis of IgE-mediated occupational allergies. However, skin test performance is related to the quality of allergen extracts. The present consensus document was prepared by an EAACI Task Force consisting of an expert panel of allergologists and occupational physicians from Germany, Italy, Spain, France, Austria, and Poland. All members of the panel were also involved in the data collection within the European multicentre study STADOCA (Standard diagnosis for occupational allergy). The aim of this Task Force was the assessment of the quality of commercially available SPT solutions for selected occupational allergens under standardized procedure conditions in different European centres and institutes of Occupational Medicine. The data evaluation shows a wide variability among SPT solutions and also indicates that the sensitivity of several SPT solutions is low. Therefore, improvement and standardization of SPT solutions for occupational allergens is highly recommended. Clinical practitioners should also not presume that their SPT solutions are fully reliable. The main objective of the document is to issue consensus suggestions for the use of SPT with occupational allergens based on the European multicentre study STADOCA, on existing scientific evidence and the expertise of a panel of allergologists.

Production and characterisation of monoclonal antibodies for the quantification of potentially allergenic xylanase from Aspergillus niger

Xylanase from Aspergillus niger (ANX) is widely used in bakeries as a processing aid since it stabilises and improves dough quality. An association between allergic symptoms among bakery workers and sensitisation to ANX has been reported, indicating that this enzyme is an occupational allergen. The presence of ANX in dough improvers and semi-finished goods is often hidden due to incomplete and unclear labelling. The quantification of microbial enzymes in these products is necessary and the determination of the actual concentration of ANX in workplaces is therefore essential to assess the occupational risk. To this purpose we have developed and characterised monoclonal antibodies to ANX. The monoclonal antibodies do not show any cross-reaction with other commonly used microbial enzymes, and they allow the detection of ANX in complex mixtures by ELISA inhibition assays down to the concentration limit of approximately 10 µg kg(-1). These mAbs are a valuable tool to detect and quantify ANX and to investigate its allergenic potential in the workplace.

Prospective evaluation of a pediatric bleeding questionnaire and the ISTH bleeding assessment tool in children and parents in routine clinical practice

BACKGROUND

Diagnosing mild bleeding disorders (BDs) in children is difficult. Bleeding scores (BSs) have been proposed for obtaining standardized quantitative histories.

OBJECTIVES

To compare the Canadian pediatric bleeding questionnaire (PBQ) with the new ISTH bleeding assessment tool (ISTH BAT) for the determination of BS in a routine pediatric outpatient setting.

METHODS

One hundred children with a suspected BD were enrolled in this cross-sectional study. Bleeding scores were calculated for all children and their natural parents. For all children, extensive laboratory investigations were performed.

RESULTS

Based on laboratory tests, 56 children were diagnosed as having no BD, 11 were diagnosed with possible VWD, 12 with VWD 1, 11 with VWD 2, five with possible platelet defects, and five with mild factor deficiencies. Both questionnaires were able to discriminate between no BD and VWD (P = 0.0001), but the area under the receiver characteristics curve to detect any mild BD was only 0.76. Despite the inherited nature of the BD, a family score did not increase the ability to discriminate between no BD and VWD (P = 0.2052). There was no significant difference between the two tools used (P = 0.3253) or simple qualitative criteria, such as yes/no questions regarding bleeding (P = 0.3477).

CONCLUSIONS

The two tools translated into German did not differ substantially. Both were able to discriminate between no BD and a possible BD with acceptable accuracy. A BS of < 2 makes a BD unlikely. Simple qualitative criteria were similar; however, to allow comparison of studies and follow-up in patients over time, we recommend the ISTH BAT.

[Occupational risk by the pine processionary moth Thaumetopoea pityocampa in the forestry workers of Verona]

Pine processionary moth (Thaumetopoea pityocampa) is a lepidopteran living in the Mediterranean countries whose mature larvae have microscopic hairs that can be released and carried far from the source. The hairs are responsible of urticating symptoms on the exposed areas although systemic manifestation might be involved. The study involved 94 forestry workers (92 M, 2 F) of the Regional Forest Service of Verona and the objective was to determine the prevalence of skin and respiratory disorders due to exposure to this insect. 21 chainsaw operators and 2 labourers experienced symptoms on exposed skin areas; 3 of them reported also ocular and respiratory symptoms. The chainsaw operators resulted most at risk whereas individual already suffering from others allergies do not seem to be affected. The results highlight the importance of risk assessment to Thaumetopoea pityocampa in forestry workers and the need for instruments to assess the allergic sensitization in medical surveillance.

Respiratory health and endotoxin: associations and modification by CD14/-260 genotype

Exposure to endotoxin has been associated with increased respiratory symptoms and decrements in lung function in occupational settings but little is known about the health effects of domestic exposure in adults. Here, we describe the association of respiratory disease, immunoglobulin (Ig)E sensitisation, bronchial reactivity and lung function with mattress endotoxin levels in adults, and determine whether these associations are modified by polymorphisms in CD14. Endotoxin levels in mattress dust from a population-based sample of 972 adults were measured. Associations were examined using generalised linear mixed models, adjusting for individual and household confounders. Effect modification of these associations by CD14/-260 (rs2569190) was assessed. Mattress endotoxin levels varied from 0.1 to 402.6 EU · mg(-1). Although there was no overall association of lung function with endotoxin exposure, there was evidence that the association of forced expiratory volume in 1 s and forced vital capacity with endotoxin was modified by CD14/-260 genotype (p-value for interaction 0.005 and 0.013, respectively). There was no evidence that symptoms, IgE sensitisation or bronchial reactivity were associated with mattress endotoxin levels. In this large epidemiological study of adults, there was no evidence that mattress endotoxin level was associated with respiratory symptoms or IgE sensitisation but the association of lung function with endotoxin levels may be modified by CD14 genotype.