Reduction in emergency department visits for children's asthma, ear infections, and respiratory infections after the introduction of state smoke-free legislation.

Despite the benefits of smoke-free legislation on adult health, little is known about its impact on children's health. We examined the effects of tobacco control policies on the rate of emergency department (ED) visits for childhood asthma (N=128,807), ear infections (N=288,697), and respiratory infections (N=410,686) using outpatient ED visit data in Massachusetts (2001-2010), New Hampshire (2001-2009), and Vermont (2002-2010). We used negative binomial regression models to analyze the effect of state and local smoke-free legislation on ED visits for each health condition, controlling for cigarette taxes and health care reform legislation. We found no changes in the overall rate of ED visits for asthma, ear infections, and upper respiratory infections after the implementation of state or local smoke-free legislation or cigarette tax increases. However, an interaction with children's age revealed that among 10-17-year-olds state smoke-free legislation was associated with a 12% reduction in ED visits for asthma (adjusted incidence rate ratios (aIRR) 0.88; 95% CI 0.83, 0.95), an 8% reduction for ear infections (0.92; 0.88, 0.97), and a 9% reduction for upper respiratory infections (0.91; 0.87, 0.95). We found an overall 8% reduction in ED visits for lower respiratory infections after the implementation of state smoke-free legislation (0.92; 0.87, 0.96). The implementation of health care reform in Massachusetts was also associated with a 6-9% reduction in all children's ED visits for ear and upper respiratory infections. Our results suggest that state smoke-free legislation and health care reform may be effective interventions to improve children's health by reducing ED visits for asthma, ear infections, and respiratory infections.

Clinical and Genotypic Spectrum of Chronic Granulomatous Disease in 71 Latin American Patients: First Report from the LASID Registry.

AIM: We analyzed data from 71 patients with chronic granulomatous disease (CGD) with a confirmed genetic diagnosis, registered in the online Latin American Society of Primary Immunodeficiencies (LASID) database. RESULTS: Latin American CGD patients presented with recurrent and severe infections caused by several organisms. The mean age at disease onset was 23.9 months, and the mean age at CGD diagnosis was 52.7 months. Recurrent pneumonia was the most frequent clinical condition (76.8%), followed by lymphadenopathy (59.4%), granulomata (49.3%), skin infections (42%), chronic diarrhea (41.9%), otitis (29%), sepsis (23.2%), abscesses (21.7%), recurrent urinary tract infection (20.3%), and osteomyelitis (15.9%). Adverse reactions to bacillus Calmette-Guérin (BCG) vaccination were identified in 30% of the studied Latin American CGD cases. The genetic diagnoses of the 71 patients revealed 53 patients from 47 families with heterogeneous mutations in the CYBB gene (five novel mutations: p.W361G, p.C282X, p.W483R, p.R226X, and p.Q93X), 16 patients with the common deletion c.75_76 del.GT in exon 2 of NCF1 gene, and two patients with mutations in the CYBA gene. CONCLUSION: The majority of Latin American CGD patients carry a hemizygous mutation in the CYBB gene. They also presented a wide range of clinical manifestations most frequently bacterial and fungal infections of the respiratory tract, skin, and lymph nodes. Thirty percent of the Latin American CGD patients presented adverse reactions to BCG, indicating that this vaccine should be avoided in these patients.

Domestic use of bleach and infections in children: a multicentre cross-sectional study.

OBJECTIVE: To report the effects of bleach use at home on the frequency of infections in 9102 school-age children participating in the HITEA project. METHODS: Parents of pupils aged 6-12 years from schools in Barcelona province (Spain), Utrecht province (the Netherlands) and Eastern and Central Finland were administered a questionnaire including questions on the frequency of infections (influenza, tonsillitis, sinusitis, otitis, bronchitis and pneumonia) in the past 12 months and bleach use at home. We developed multivariable mixed-effects multilogistic regression models to obtain relative risk ratios (RRR) and their 95% CI per country, and combined the RRR using random-effects meta-analyses. RESULTS: Bleach use was common in Spain (72%, n=1945) and uncommon in Finland (7%, n=279). Overall, the prevalence of infections (recurrent or once) was higher among children of bleach users. Significant combined associations were shown for influenza only once (RRR=1.20, 95% CI 1.04 to 1.38), recurrent tonsillitis (RRR=1.35, 95% CI 1.07 to 1.71) and any infection (RRR=1.18, 95% CI 1.01 to 1.38). CONCLUSIONS: Passive exposure to cleaning bleach in the home may have adverse effects on school-age children's health by increasing the risk of respiratory and other infections. The high frequency of use of disinfecting irritant cleaning products may be of public health concern, also when exposure occurs during childhood.

Exposure to air pollution and respiratory symptoms during the first 7 years of life in an Italian birth cohort.

BACKGROUND: Ambient air pollution has been consistently associated with exacerbation of respiratory diseases in schoolchildren, but the role of early exposure to traffic-related air pollution in the first occurrence of respiratory symptoms and asthma is not yet clear. METHODS: We assessed the association between indexes of exposure to traffic-related air pollution during different periods of life and respiratory outcomes in a birth cohort of 672 newborns (Rome, Italy). Direct interviews of the mother were conducted at birth and at 6, 15 months, 4 and 7 years. Exposure to traffic-related air pollution was assessed for each residential address during the follow-up period using a Land-Use Regression model (LUR) for nitrogen dioxide (NO2) and a Geographic Information System (GIS) variable of proximity to high-traffic roads (HTR) (>10 000vehicles/day). We used age-specific NO2 levels to develop indices of exposure at birth, current, and lifetime time-weighted average. The association of NO2 and traffic proximity with respiratory disorders were evaluated using logistic regression in a longitudinal approach (Generalised Estimating Equation). The exposure indexes were used as continuous and categorical variables (cut-off points based on the 75th percentile for NO2 and the 25th percentile for distance from HTRs). RESULTS: The average NO2 exposure level at birth was 37.2 µg/m(3) (SD 7.2, 10-90th range 29.2-46.1). There were no statistical significant associations between the exposure indices and the respiratory outcomes in the longitudinal model. The odds ratios for a 10-µg/m(3) increase in time-weighted average NO2 exposure were: asthma incidence OR=1.09; 95 CI% 0.78 to 1.52, wheezing OR=1.07; 95 CI% 0.90 to 1.28, shortness of breath with wheezing OR=1.16; 95 CI% 0.94 to 1.43, cough or phlegm apart from cold OR=1.11; 95 CI% 0.92 to 1.33, and otitis OR=1.08; 95 CI% 0.89 to 1.32. Stronger but not significant associations were found considering the 75th percentile of the NO2 distribution as a cut-off, especially for incidence of asthma and prevalence of wheeze (OR=1.41; 95 CI% 0.88 to 2.28 and OR=1.27; 95 CI% 0.95 to 1.70, respectively); the highest OR was found for wheezing (OR=2.29; 95 CI% 1.15 to 4.56) at the 7-year follow-up. No association was found with distance from HTRs. CONCLUSIONS: Exposure to traffic-related air pollution is only weakly associated with respiratory symptoms in young children in the first 7 years of life.

Effect of an injectable trace mineral supplement containing selenium, copper, zinc, and manganese on immunity, health, and growth of dairy calves.

The objective of this study was to evaluate the effect of 2 subcutaneous injections of a multimineral preparation, each containing 60 mg of zinc, 10mg of manganese, 5mg of selenium, and 15 mg of copper at 3 and 30 d after birth on immunity, health, and growth of dairy calves during the preweaning period. The study was conducted in upstate New York in 2 commercial dairy farms. A total of 790 Holstein heifer calves were randomly allocated at birth into 1 of 2 treatments: trace mineral supplement (TMS) treated or control. Blood samples were collected at 3, 14, and 35 d after birth to evaluate glutathione peroxidase (GPx) activity, superoxide dismutase (SOD) activity, haptoglobin, and neutrophil and monocyte function. Incidence of diseases and average daily gain was evaluated in the first 50 d of life. At 14 d of life, TMS-treated calves had increased neutrophil activity compared with control calves. Moreover, TMS-treated calves had greater GPx activity on d 14 after birth than control calves. The TMS treatment reduced the incidence of diarrhea (TMS=41.7% vs. control=49.7%) and combined incidence of pneumonia or otitis or both (TMS=41.7% vs. control=49.1%). Additionally, GPx was greater for calves diagnosed with otitis at d 35 after birth. However, calves diagnosed with pneumonia had decreased GPx activity at d 35 after birth. Serum SOD and haptoglobin concentrations were not affected by treatment or disease. Moreover, no effects were observed on average daily gain and survivability between TMS-treated and control calves during the preweaning period. Supplementation with trace minerals at 3 and 30 d of life increased neutrophil function and GPx activity and reduced the incidence of health disorders.

Hearing loss in patients with mucopolysaccharidosis II: data from HOS - the Hunter Outcome Survey.

BACKGROUND: Subjectively reported hearing loss is a common feature of mucopolysaccharidosis II (MPS II, Hunter syndrome). This study provides an epidemiological description of hearing loss and other otolaryngological manifestations reported by patients registered in the Hunter Outcome Survey (HOS), an international registry of patients with MPS II. METHODS: Data about ear signs and symptoms were available for 554 of the 605 patients alive at HOS entry. The degree of hearing loss for 162 pure-tone audiograms (PTAs) from 83 patients was classified by independent interpreters using both the age-specific International Institute of Standardization (ISO) 7029 standard and the age-independent World Health Organization (WHO) clinical guidelines. A linear regression analysis using cross-sectional data was conducted to investigate the relationship between hearing loss and age. RESULTS: The most prevalent otolaryngological manifestations and interventions reported were otitis (either acute otitis media or chronic otitis media [72%]), hearing loss (67%), insertion of ventilation tubes (50%), adenoidectomy (47%), and hearing aids (41%). According to the ISO standard, only one patient out of the 83 with audiogram data in HOS had normal hearing in both ears at all time points. According to the WHO classification, 16% had normal hearing; hearing loss was mild in 24%, moderate in 31%, severe in 22%, and profound in 7%. In the linear regression analysis, the hearing threshold in the cohort increased with age at an estimated rate of approximately 1 dB per year. CONCLUSIONS: Hearing impairment is common in MPS II. Early otolaryngological evaluation and intervention is recommended.

Use of intravenous immunoglobulin to treat chronic bilateral otomastoiditis in the setting of rituximab induced hypogammaglobulinemia.

The temporal bone may be affected by a variety of systemic pathology because the disease nature, location, and extent determine the symptoms. Middle ear and mastoid infections may be the initial clinical manifestation of autoimmune and acquired immunodeficiency disorders. Rituximab, an anti-CD20 chimeric antibody, has become increasingly popular as a therapeutic agent for patients with a wide range of autoimmune disorders refractory to standard treatments. Normal levels of immunoglobulin levels are usually maintained during and after rituximab therapy, and clinical trials to date have shown no statistically significant increase of serious infections among patients with autoimmune diseases being treated with rituximab (Cohen SB, Emery P, Greenwald MW, Dougados M, Furie RA, Genovese MC, et al, for the REFLEX Trial Group. Rituximab for rheumatoid arthritis refractory to anti-tumor necrosis factor therapy: results of a multicenter, randomized, double-blind, placebo-controlled, phase III trial evaluating primary efficacy and safety at 24 weeks. Arthritis Rheum. 2006;54:2793-2806. Edwards JC, Szczepanski L, Szechinski J, Filipowicz-Sosnowska A, Emery P, Close DR, et al. Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis. N Engl J Med. 2004;350:2572-2581). However, there have been several reports of opportunistic infections associated with rituximab (Kelesidis T, Daikos G, et al. Does rituximab increase the incidence of infectious complications? A narrative review. Int J Infect Dis 2011;15:e2-e16. Teichmann LL, Woenckhaus M, Vogel C, et al. Fatal Pneumocystis pneumonia following rituximab administration for rheumatoid arthritis. Rheumatology 2008;47:1256-1257), as well as cases of it accelerating the presentation of hypogammaglobulinemia (Diwakar L, Gorrie S, et al. Does rituximab aggravate pre-existing hypogammaglobulinaemia? J Clin Pathol 2010;63:275-277). Humoral immune defects can cause persistent acute and serous otitis media, with the development of chronic suppurative otitis media refractory to medical and surgical therapy (Sasaki CT, Askenase P, Dwyer J, et al. Chronic ear infection in the immunodeficient patient. Arch Otolaryngol 1981;107:82). Here, we describe the first presentation, diagnostic workup, and treatment with intravenous immunoglobulin of chronic bilateral otomastoiditis in the setting of rituximab-induced hypogammaglobulinemia.

Ear pain after breathing oxygen at altitude: prevalence and prevention of delayed barotrauma.

INTRODUCTION: Military pilots frequently report ear pain with onset several hours after altitude exposure while breathing pure oxygen, but the prevalence of this problem is unknown. A similar problem is described in divers after breathing hyperbaric oxygen and it is related to the oxygen contained in the middle ear. METHODS: In order to assess the prevalence of delayed ear pain after altitude exposure and investigate the effectiveness of preventive use of a nasal balloon (NB), we studied 88 healthy military jet pilots who were asymptomatic after altitude chamber exposure which included 100% oxygen breathing. A group of 44 subjects received the NB shortly after the chamber and they were advised to use it every hour before going to sleep. A control group of 44 subjects was requested to perform the Valsalva maneuver alone over the same period. All subjects underwent clinical examination by an otolaryngologist and tympanometry just before the chamber exposure and again the day after. RESULTS: The day after the altitude exposure, 53.4% of subjects reported ear pain. In the treated group, 61.4% of subjects were free of symptoms, compared to 31.8% in the control group (P < 0.01). Tympanogram was abnormal in eight symptomatic subjects and in six asymptomatic. CONCLUSION: Our data suggest that in our subjects there is high prevalence of delayed ear barotrauma after altitude chamber exposure while breathing pure oxygen and the tympanogram may improve the accuracy of the diagnosis in asymptomatic subjects. The nasal balloon appears to be effective for prevention.

[From barotrauma otitis to a fulminant meningitis]. / De l'otite barotraumatique à la méningite en direct.

OBJECTIVES: To report the case of a patient who in the follow-up of a barotrauma otitis presented a fulminant meningitis. CLINICAL CASE: 38 year old man sportsman who presented a barotrauma otitis during scuba diving. In spite of a treatment associating steroids and nasal vasoconstrictor this otitis persisted. Five weeks after the initial episode the patient went back to the clinics in emergency complaining of intense cephalgia for a few hours with impression of faintness without fever. The state of consciousness of the patient then degraded quickly during the conversation. Into the 15 minutes time, the patient slipped of a stuporous state to coma. Hospitalized in emergency in intensive care unit, the diagnosis of an otogenic meningitis with Streptococcus pneumoniae was made. The patient cured without sequelae. CONCLUSION: An inadequate treatment accompanied by a favorable anatomical factor facilitated the diffusion of the bacterial invasive process of the ear drum through the osseous barrier until the dura mater. A banal barotrauma otitis which persists can cause serious complications. An antibiotic must be prescripted starting from stage III, i.e. when there is retrotympanic effusion. In front of a behavioral problem during an otitis, it is necessary to always think of the intracranial complications and not to delay the anti-infectious treatment which must be started as soon as possible. To obtain a complete cure without sequelae, it seems that the adapted anti-infectious treatment must be instaured within a time below 10 hours.

Successful development of methodology for detection of hapten-specific contact hypersensitivity (CHS) memory in swine.

Hapten contact hypersensitivity (CHS) elicits a well-documented inflammation response that can be used to illustrate training of immune cells through hapten-specific CHS memory. The education of hapten-specific memory T cells has been well-established, recent research in mice has expanded the "adaptive" characteristic of a memory response from solely a function of the adaptive immune system, to innate cells as well. To test whether similar responses are seen in a non-rodent model, we used hapten-specific CHS to measure the ear inflammation response of outbred pigs to dinitrofluorobenzene (DNFB), oxazolone (OXA), or vehicle controls. We adapted mouse innate memory literature protocols to the domestic pig model. Animals were challenged up to 32 days post initial sensitization exposure to the hapten, and specific ear swelling responses to this challenge were significant for 7, 21, and 32 days post-sensitization. We established hapten-specific CHS memory exists in a non-rodent model. We also developed a successful protocol for demonstrating these CHS responses in a porcine system.

Idiopathic, Infectious and Reactive Lesions of the Ear and Temporal Bone.

A number of infectious, inflammatory and idiopathic lesions develop within otologic tissues that may share similar clinical and/or microscopic features. This review first provides a working classification for otitis externa, and then otitis media and includes two recently described entities, eosinophilic otitis media and otitis media with ANCA-associated vasculitis. Next, the microscopic findings of a spectrum of otopathologic conditions are described, including post-inflammatory conditions such as tympanosclerosis and aural polyps, an overview of animate aural foreign body as well as iatrogenic aural foreign body reactions. Finally, a review of fungal disease affecting the ear with a brief synopsis of Candida auris, a recently described and virulent organism, is presented.

[Epidemiological analysis of the incidence of invasive and non-invasive pneumococcal infections in different population groups].

Despite modern achievements in diagnostics and treatment, invasive and non-invasive pneumococcal infections remain a topical public health problem. To a large extent, it is connected with the absence or inconsistence of evidence-based information on this kind of infection. In this paper, retrospective analysis of the incidence of pneumococcal infections was performed on the basis of medical records available today in every health institution; the peculiarities of their nosologic structure were revealed. Among invasive forms, pneumococcal pneumonias prevailed (50.06%); apparent hypodiagnostics of pneumococcal meningitis was noted (only 4.02%). Among non-invasive forms, acute otitis with various complications prevailed (47.5%), acute sinusitis was registered in 37.5% of cases, and other ENT diseases (sphenoiditis, frontitis, ethmoiditis, etc.) were registered in 15% of cases. The study found that the main risk factors in these patients had been different ENT diseases which the patients had suffered from during the previous three months before the actual illness. Thus, the necessity for the development and perfection of techniques of microbiological diagnostics and the development of epidemiological control methods on their basis are obvious.

[The character and structure of infectious complications in patients with chronic renal failure, who received or did not receive replacement therapy (hemodialysis)].

The subjects of the study were 176 patients with chronic renal failure (CRF) (101 men; 75 women) aged 17 to 81. Stage I CRF was found in 46 patients, stage II CRF--in 69 patients, and stage III CRF--in 61 patients. Thirty-one patients with stage III CRF received program hemodialysis. Chronic glomerulonephritis was the main cause of CRF. With the progress of CRF, the frequency of infectious complications grew up to 2.2% in stage I, 7.2% in stage II, and 36.1% in stage III. The rate of infectious complications was higher in patients on program dialysis vs. patients without it: 51.6 and 20%, respectively. Pneumonia was the most frequent complication regardless CRF stage.

Cochlear implant electrode array exposure: A delayed complication.

Exposure of the cochlear implant electrode array as a late complication has been reported rarely in the literature. A retrospective analysis revealed 4 patients presenting with exposure of their cochlear implant electrode arrays from 2 to 17 years after implantation. Data collected from these 4 patients were surgical implantation approach, type of implant, age at implant, interval between implant and complication, surgical correction of the problem, pathology at the time of correction, and length of follow-up after intervention. All 4 patients presented with otitis or mastoiditis. Each had undergone a transmastoid approach with facial recess and cochleostomy and full implant insertion. In 3 cases, the tympanic membrane had retracted to expose the electrode array. In 1 patient, the electrode array had eroded through the external canal, lateral to the facial recess. The exposed arrays were addressed surgically, including explantation/reimplantation for 1 patient. Cochlear implant electrode arrays can become exposed by relative migration of the array and the tympanic membrane. Implant surgeons and audiologists need to be aware of the possibility of this complication. Closure of the ear canal appears to be the most effective surgical intervention.

[Ototoxicity in head and neck cancers after radiotherapy and chemoradiotherapy: From primary prevention to tertiary prevention]. / Ototoxicité radio-induite et chimio-induite dans les cancers ORL : de la prévention primaire à la prévention tertiaire.

Each year, 15,000 head and neck cancer are treated in France. Prognosis is steadily improving. Consequently, limitation of late toxicities becomes essential. Ototoxicity is common, disabling and undervalued. We aimed to inventory primary, secondary and tertiary prevention measures to reduce ototoxicity induced by radiotherapy and chemotherapy, as well as its impact on quality of life of patients treated for head and neck cancer. External radiation therapy induced 30 to 40% of ototoxicity, including irreversible sensorineural hearing loss. Primary prevention of this risk is based on limiting the dose to the cochlea: 40Gy in case of radiotherapy alone, 10Gy during concomitant chemoradiotherapy with cisplatin. Dose gradients allowed by intensity-modulated radiotherapy help respecting these limits. Concurrent chemotherapy with high dose cisplatin (100mg/m2) also causes hearing loss by cochlear damages. Prescription of carboplatin-5-fluorouracil combination or cetuximab should be preferred in case of high risk of ototoxicity. This risk must be precisely evaluated before treatment. Ototoxicity monitoring during treatment allows early management, and lower long-term impact. Radiosensitivity predictive tests and research of genetic factors predisposing to chemo-induced ototoxicity should enable optimization of therapeutic choices and monitoring.