Eustachian tuboplasty and shrinkage of ostial mucosa with new devices : Including a proposal of a classification system.

OBJECTIVE: A new combined approach to Eustachian tube dysfunction (ETD) employing new minimally invasive devices is described. STUDY DESIGN: An anatomoclinical classification of ETD was conceived to allow correct categorization of patients and enable comparative studies to be performed. Herein, the authors report on their experience with a consecutive series of obstructive ETD patients treated by balloon dilation of the Eustachian tube using AERA (Acclarent, Menlo Park, CA, USA), combined with a quantic molecular resonance (QMR)-mediated rhinopharyngeal tubal ostial mucosa shrinkage technique with a dedicated "Mitto" hand piece (Telea, Sandrigo-Vicenza, Italy). METHODS: A prospective study was conducted in 102 patients with ETD. Medical history, complete clinical ENT evaluation and oto-functional examinations were performed in all patients. In all cases, balloon dilatation of the Eustachian tube was performed via the transnasal approach under video-endoscopic control. This was followed by decongestion of the torus tubarius and the inferior turbinate by QMR, with immediate shrinkage of the mucosa of the turbinate and a reduction of the prolapse of the mucosal plica on the tubal ostium. RESULTS: Comparison of pre- and postoperative oto-functional examinations revealed a significant improvement. The postoperative hearing symptoms were reduced in a statistically significant manner on the visual analog scale (VAS). It was possible to perform the postoperative "swallowing-opening-Toynbee-Valsalva" (SOTV) test in a significant percentage of cases compared to the preoperative test. CONCLUSION: The combined surgical procedure of balloon tubodilation with simultaneous QMR-mediated shrinkage of the tubal ostial mucosa and reduction of the posterior portion of the inferior turbinate was found to be an effective, safe, and complete treatment for tubal dysfunction in the majority of patients.

A major susceptibility locus for atopic dermatitis maps to chromosome 3q21.

Atopic dermatitis (eczema) is a chronic inflammatory skin disease with onset mainly in early childhood It is commonly the initial clinical manifestation of allergic disease, often preceding the onset of respiratory allergies. Along with asthma and allergic rhinitis, atopic dermatitis is an important manifestation of atopy that is characterized by the formation of allergy antibodies (IgE) to environmental allergens. In the developed countries, the prevalence of atopic dermatitis is approximately 15%, with a steady increase over the past decades. Genetic and environmental factors interact to determine disease susceptibility and expression, and twin studies indicate that the genetic contribution is substantial. To identify susceptibility loci for atopic dermatitis, we ascertained 199 families with at least two affected siblings based on established diagnostic criteria. A genome-wide linkage study revealed highly significant evidence for linkage on chromosome 3q21 (Zall=4.31, P= 8.42 10(-6)). Moreover, this locus provided significant evidence for linkage of allergic sensitization under the assumption of paternal imprinting (hlod=3.71,alpha=44%), further supporting the presence of an atopy gene in this region. Our findings indicate that distinct genetic factors contribute to susceptibility to atopic dermatitis and that the study of this disease opens new avenues to dissect the genetics of atopy.

Comparative study on the effectiveness of Coblation-assisted turbinoplasty in allergic rhinitis.

OBJECTIVES: To evaluate the efficacy of adding Coblation-assisted inferior turbinoplasty to a medical treatment regimen for symptoms associated with hypertrophic inferior turbinates. STUDY DESIGN/SETTING: Prospective, open-label, non-randomized trial with outpatient treatment. Patients were assigned to treatment groups in order of enrolment into the study. SUBJECTS AND METHODS: From June 2007 to June 2008, 220 patients with allergic rhinitis and hypertrophic inferior turbinates were enrolled and assigned into two groups: the surgical group who received radiofrequency thermal ablation inferior turbinoplasty and medical therapy, and the medical group who received medical therapy only. Groups were further divided into two allergen types based on antigen sensitivity: perennial and seasonal. Subjective complaints (nasal obstruction, itching, rhinorrhea, sneezing), clinical rhinoendoscopy and rhinomanometry tests results were recorded at the start of the study and 2 months post-treatment. Effect sizes for the mean improvements after treatment were tabulated for all groups. RESULTS: All study outcomes improved within all groups. Comparison between medical and surgical groups showed higher improvement in both perennial and seasonal, respectively, in nasal obstruction, sneezing, rhinomanometry, and rhinomanometry after NPT. Itching improved only in perennial allergen type. Rhinoendoscopy clinical score showed improvement in surgical group over medical group in both allergen types. CONCLUSION: Coblation-assisted turbinate reduction is a promising adjunct to medical therapy in patients with persistent symptoms associated with allergic rhinitis. Patients undergoing this surgery had greater reduction of symptoms than patients receiving medical therapy alone, where patients with perennial allergies appeared to benefit most.

Favism: association with erythrocyte acid phosphatase phenotype.

The frequency of carriers of the P(a)and P(c) alleles of the gene for acid phosphatase in the erythrocyte is significantly higher in male subjects deficient in glucose-6-phosphate dehydrogenase and having hemolytic clinical favism than it is in the general population. This observation seems to indicate that alleles (P(a) and P(c)) of a gene polymorphic in all human populations affect the fitness of the involved phenotypes in special genotypic and nongenotypic conditions.

Paediatric tonsillectomy: radiofrequency-based plasma dissection compared to cold dissection with sutures.

Aim of this study was to compare post-operative recovery over 14 days in children submitted to tonsillectomy using a bipolar radiofrequency-based plasma device (Coblation, Evac 70, ArthroCare Corp, Sunnyvale, CA, USA) to cold dissection. Paediatric patients (n = 42) aged 5-16 years old with chronic tonsillitis underwent tonsillectomy using cold dissection with suture ligatures or a plasma device (Evac 70, ArthroCare Corp, Sunnyvale, CA, USA). Pain intensity on the first day, use of analgesics, type of diet, and days of pain, fever, nausea, and absence from school were determined. Groups were compared using time-to-event (Kaplan-Meier) curves and statistically evaluated using the Breslow (generalized Wilcoxon) test. Children undergoing plasma tonsillectomy reported significantly less pain on the first post-operative day (1.2 +/- 0.9 vs. 3.5 +/- 1.5, p < 0.001), fewer days of pain (4.8 +/- 1.5 vs. 9.4 +/- 1.2, p <0.001), pain medication withdrawal (2.6 +/- 1.3 vs. 4.5 +/- 1.3, p <0.001) and earlier use of liquid diet (5.1 +/- 1.4 vs. 8.5 +/- 2.1, p <0.001), and fewer school days lost (5.3 +/- 1.7 vs. 8.9 +/- 1.5, p <0.001). After completing this study, plasma tonsillectomy was adopted for the majority of cases. Benefits of the plasma device include the possibility both to excise tissue and coagulate bleeding vessels using the same device whilst improving quality of post-operative recovery over cold dissection with suture ligatures.

Psychological aspects and treatment of patients with nasal septal perforation due to cocaine inhalation.

Use of cocaine, by inhalation, is currently increasing in Western Countries and its use is superseding heroin in the rising generation. Young people of the third millennium use narcotics to avoid the negative conditions of daily life and to escape on "unreal" trips, as happened in the '60s and '70s for the heroin-addicted. Today, on the contrary, people addicted to cocaine want to be more competitive and "winners" and believe that cocaine can help them to reach this goal. A series of 104 patients (75 male, 29 female), aged between 16 and 54 yrs, all habitual inhaling cocaine users (> or = 10 times per month) have been observed for 2 years. Among them, 11 (10.5%) had nasal septal perforation, which is frequently related to cocaine use. Of these 11 patients, 8 (72.7%) had nasal septal perforation of the quadrangular cartilage, while in the other 3 (27.3%) the perforation involved also the bony tract (vomer-perpendicular ethmoidal lamina). Psychological analysis of these 104 patients is reported: 62 patients (59.6%) answered that they inhaled cocaine to improve endurance and to feel stronger and less tired; 34 patients (32.7%) in order to enjoy themselves more during parties and to communicate more effectively with other people; 5 patients (4.8%) to gain confidence and to overcome their shyness, 2 patients (1.9%) to improve their sexual performance and 1 patient (1%) to drink more alcoholic drinks for a longer time without feeling sleepy. All the patients underwent psychotherapeutic treatment, but the lack of compliance and constantly missing the scheduled follow-up visits resulted in complete therapy being performed in only 16 patients (15.3%). All the patients with nasal septal perforation underwent rhino-endoscopy, at T0, with 0 degrees, 45 degrees endoscopes, computed tomography scan of nose and paranasal sinuses and biopsy. At the time of the observational period, none of the 11 patients who presented nasal septal perforation agreed to stop cocaine abuse; therefore, a temporary solution has been offered to all the patients (accepted by 3 of them), i.e., the positioning of a silicone button to close the perforation and, thus, improve the air flow in the nose and reduce progression of local necrosis. Together with the button, the positioning is described, under local anaesthesia, of two layers per septal side of hyaluronic acid, at different levels of esterification, kept in site by the button as a "sandwich" in order to obtain better re-growth of the mucosa and fewer scabs and bleeding.

Cellular immune defects to Epstein-Barr virus-determined antigens in young males.

Three males with the X-linked lymphoproliferative syndrome (XLP) with hypo- or agammaglobulinemia following Epstein-Barr virus (EBV) infection and two males with the chronic mononucleosis syndrome were investigated for immune responses to EBV-determined antigens. Males with XLP showed profound cellular immune defects. Markedly diminished responses of natural killer cell and interferon-activated killer cell activities and impaired leukocyte migration inhibition responses to phytohemagglutinin were determined in patients with XLP. The two patients with chronic mononucleosis showed less severe defects. All patients showed partial or complete impairment of their EBV-specific immune responses as measured by leukocyte migration inhibition. EBV-specific antibodies were markedly diminished against EBV-associated nuclear antigen, early antigen, and viral capsid antigen in males with XLP. In contrast, patients with chronic mononucleosis had elevated antibodies to most EBV-specific antigens. Individuals with life-threatening EBV-induced lymphoproliferative disorders may exhibit multiple defective immune mechanisms against the virus.

Soy protein for the prevention and treatment of children with cow-milk allergy.

Soy-protein formulas are widely used for feeding babies with cow-milk allergy. When they first were marketed, these formulas were the only available cow-milk substitute and they ensured a normal life for many children who were affected by the large spectrum of clinical manifestations of cow-milk allergy. Soy-protein formulas were also given to allergy-prone infants for the prevention of atopic diseases when breast milk was not available. Several researchers studied the prevalence of soy sensitization in allergic disease. Few studies used a challenge test for the diagnosis of soy allergy, even those in patients in whom soy allergy was suspected. In most studies the diagnosis of soy allergy was based on anecdotal case histories reported by parents and was not substantiated by scientific diagnostic criteria: no challenge test to soy was made nor were data available on specific immunoglobulin E to soy. In this paper we critically reviewed literature on the safety of feeding soy-protein formulas to babies with cow-milk allergy as well as on the prevention of cow-milk allergy.

Atopic sensitization in children of Somali immigrants in Italy.

Children of immigrants are known to be at greater risk for developing allergic manifestations than the population in general. In this study we observed children of Somali origin living in Italy in order to find plausible explanations for the high risk of allergic disease in immigrants. Fifty-two children aged 0-14 years (mean = 6.7 years) were examined during the spring season. The mothers of the children were asked to fill in a questionnaire on symptoms and signs of atopic diseases and the family history of atopy. In addition, a physical examination and skin tests were performed. All families used mattresses, pillows and/or blankets made of wool, known to favor the growth of mites. In the majority of these children's families we found at least five people cohabitating in the same room. Skin prick tests were most frequently positive for Dermatophagoides pteronyssinus. Seventy-four percent (14/19) of those with symptoms were positive to D. pteronyssinus. Only 14% (2/14) of those positive to D. pteronyssinus were positive to Lolium perenne. Thirty-seven percent (19/52) had atopic symptoms and 15% (5/33) of those without symptoms were positive to D. pteronyssinus (p < 0.0001 compared to those with symptoms). Sensitization to food allergens occurred less frequently as compared to common inhalant allergens (p < 0.0001). A high prevalence of atopic diseases among children of Somali immigrants in Italy might be attributed to contact with the new environment and poor socioeconomic conditions that promote, for example, the growth of mites. However, further studies are needed to document these differences.

Patch test response to house dust mites is positive in children with atopic dermatitis and in their parents.

We studied the patch test response to Dermatophagoides pteronyssinus in 79 atopic children and in their parents. The atopic children were divided into 3 groups: 1) children with atopic dermatitis (group 1); 2) children who had suffered from atopic dermatitis but the disease was cured (group 2); and 3) atopic children with asthma and without atopic dermatitis (group 3). Our data show that a significantly higher proportion of children with atopic dermatitis (groups 1 and 2) have positive patch tests to Dermatophagoides pteronyssinus in comparison to atopic children without atopic dermatitis (group 3) and the controls (p < 0.001). In addition, we have shown that a positive patch test to Dermatophagoides pteronyssinus is significantly more common in parents of children with atopic dermatitis with respect to parents of children with asthma or parents of control children.

Is prevention of food allergy worthwhile?

Several studies performed in high-risk babies have demonstrated a significant reduction in the prevalence and severity of atopic diseases with dietary and environmental manipulations. It has been demonstrated that prolonged breast-feeding and the avoidance of cow's milk, eggs and fish during the first three months of lactation significantly decrease both the prevalence and the severity of atopic disease up to the age of 5 years. We have shown a significant reduction in both the prevalence and the incidence of atopic dermatitis, food allergy and asthma in high-risk children followed up to the age of 5 years who received preventive dietary (prolonged breast-feeding, cow's milk- and egg-free diet to the nursing mothers, supplementation with a soya formula containing sucrose when breast milk was not available, delayed weaning) and environmental measures (no smoking and no pets in the house, measures for the elimination of mites, etc.). However, occasionally, breast-fed infants may experience allergic sensitization to food antigens ingested by the mother during lactation. The factors that determine which infants will develop sensitization to food antigens in breast milk are not fully understood. The genetic predisposition to IgE-mediated hypersensitivity reactions is certainly a prerequisite; however, properties of human milk, such as immune characteristics, may play a role in the phenotypic expression of sensitization. Our studies suggest that the abnormally low levels of the long-chain polyunsaturated derivatives found in infants at risk of atopy are unlikely to be corrected by breast-feeding and may explain the contradictory results from studies on the effectiveness of breast milk against the development of atopic dermatitis.

Cord blood mononuclear leukocytes of neonates at risk of atopy have a deficiency of arachidonic acid.

Essential fatty acids and their delta-6-desaturated derivatives are major components of cellular membrane phospholipids, contributing to their stability and functions. They are also precursors of inflammation mediators such as prostaglandins and leukotrienes, and are involved in cellular immunoregulation. Recent studies have stressed the importance of essential fatty acids in various diseases. Patients with atopic dermatitis have altered essential fatty acids levels in plasma and a clinical improvement has been shown after oral administration of essential fatty acids. The aim of our study was to investigate the distribution of essential fatty acids in the membranes of cord blood mononuclear leukocytes of newborns at risk of atopy, and to correlate the levels of essential fatty acids at birth with total IgE values and with the onset of atopic disease. Newborns at risk of atopic disease have a significant reduction in arachidonic acid in the membranes of cord blood mononuclear leukocytes. Our data show a significant decrease in arachidonic acid in neonates at risk of atopy, suggesting that the abnormality of essential fatty acids is a primary phenomenon associated with atopic status.

Enzyme-potentiated desensitization in children with asthma and mite allergy: a double-blind study.

The aim of this study was to evaluate the efficacy and safety of enzyme-potentiated desensitization (EPD) in children with asthma. Twenty asthmatic children (14 males and 6 females; median age: 8.5 years) were included in the study. They had positive skin tests to Dermatophagoides pteronyssinus (Dpt), no history of other allergy and had suffered from asthma for at least two years. The children were examined before starting the trial, at the first EPD dose, after 8 weeks, at the second EPD dose and 3 months after the second EPD dose. Blood samples for PRIST and RAST were drawn before the first and at the second EPD dose, and at the last follow-up. Conjunctival provocation tests (CPT) and skin test endpoint determinations were performed with dilutions of a freeze-dried Dpt extract (10-100,000 SQ-U/ml) at the start of the trial and at the last follow-up. Parents kept a diary record of the days with asthma and daily drug usage. The children were randomized to receive either two intradermal placebo injections or the active material with an 8-week interval (November 1991 and January 1992). Ten children received EPD and 10 children placebo. The intradermal injection of EPD (0.05 ml) contained 0.01 ml of beta-glucuronidase (40 Fishman units) and 0.04 ml of a mixture of inhalant allergens (1 Noon unit). The placebo injection consisted of buffer solution only. The EPD-treated children had significantly fewer days with asthma (p = 0.00000). In addition, the EPD-treated children used significantly less medication for the management of asthma attacks (p = 0.00000). At the start of the trial, three out of 10 children in the EPD group and two out of 10 in the placebo group reacted only to the highest dose of allergen used in the CPT (100,000 SQ/ml) (NS). At the last follow-up, the threshold dose in the CPT was 100,000 SQ/ml or more in nine out of 10 children in the EPD group and in four out of 10 children of the placebo group (p = 0.0349). At the last follow-up, one child in the EPD group had a negative CPT with all doses tested. Global clinical evaluation by the investigators showed that eight out of 10 EPD-treated children improved, in comparison with three out of 10 children in the placebo group (p = 0.0349). Assessment by the parents was six out of 10 and four out of 10 improved, respectively (NS). Specific IgE to Dpt, total IgE and skin prick test endpoints before and after EPD showed no significant changes. One child in the placebo group experienced mild urticaria several hours following the second injection. No other local or systemic side effects were reported. The results of the present study provide further data on the effectiveness and safety of EPD in patients with asthma.

Detection of undegraded beta-lactoglobulins and evaluation of the molecular weight of peptides in hydrolysate cow's milk formulae.

Hydrolysate formulae have been developed with the purpose of reducing the allergenicity of cow's milk proteins, thus providing a suitable formula for feeding babies with cow's milk allergy. More recently, hydrolysate formulae have also been used with babies at high risk of atopy in order to prevent cow's milk allergy. The aim of the present study was to investigate the presence of intact cow's milk proteins and the molecular weights of peptides in several batches of two extensively hydrolyzed formulae and two partially hydrolyzed formulae. The results show the presence of a significant amount of intact beta-lactoglobulin in one partially hydrolyzed formula and of peptides with high molecular weights (>16,900 D) in the two partially hydrolyzed formulae. In conclusion, the present study confirms that partially hydrolysed formulae contain a large proportion of peptides with high molecular weights: in addition, undegraded beta-lactoglobulin was detected in a partially hydrolyzed whey formula. These data strongly indicate that partially hydrolyzed formulae may be not only allergenic in an already sensitized individual, but also immunogenic in a predisposed baby.

Effect of flunisolide on nasal eosinophils and IgE, and symptom score in children with allergic rhinitis.

We evaluated the effect of treatment with flunisolide nasal spray (100 micrograms/day for 3 months) in 24 children with allergic rhinitis on the following parameters: clinical symptoms, absolute number of peripheral and nasal eosinophils, and total IgE levels in nasal secretion. Therapy with flunisolide induced a significant reduction of clinical symptoms (p < 0.001), nasal eosinophils (p < 0.001) and nasal IgE concentration (p < 0.02), while it did not affect the number of peripheral eosinophils. These results indicate that flunisolide can reduce the allergic inflammation of the nasal mucosa.

Evaluation of the efficacy of oral cromolyn sodium or an oligoantigenic diet in children with atopic dermatitis: a multicenter study of 1085 patients.

One thousand eighty-five children with atopic dermatitis were enrolled in a multicenter study to evaluate the efficacy of 4 weeks of oral sodium cromoglycate or 4 weeks of a restricted diet. One thousand-eleven children (93%) concluded the study. At the end of the trial there was a significant improvement in skin lesions in the two groups: 61% of the patients in the sodium cromoglycate group and 69% in the restricted diet showed a significant improvement in atopic dermatitis. We concluded that, at least in our experimental design, both sodium cromoglycate and a restricted diet are equally effective in atopic dermatitis.

Clinical and therapeutic aspects of sinusitis in children with bronchial asthma.

Eighty children between 4 and 14 years of age suffering from bronchial asthma were investigated. Fifty-five of them showed clinical and radiological findings of sinusitis. Of these, 13 patients with purulent postnasal drip were treated with ampicillin, phenylephrine and triprolidine (therapy A) and for the other 42 ampicillin was replaced by beclomethasone (therapy B). Thirty-four of 55 children showed improvement in sinus X-rays; 20 children had a considerable decrease in the severity of asthma and many symptoms cleared up after the therapy for sinusitis (P less than 0.001). In conclusion, owing to the high prevalence of sinusitis in children with bronchial asthma, all asthmatic children should be investigated to check for a sinus disease.

[Histamine as the principal pathogenetic factor in gastroduodenal ulcer. Research priorities]. / L'istamina principale fattore patogenetico dell'ulcera gastro-duodenale. Nostre prioritarie ricerche.

A research group led by L. Businco between 1937 and 1942 was able, by applying new measuring methods in a variety of experimental situations, to demonstrate for the first time a concrete pathogenetic link between histamine and gastroduodenal ulcer. These personal researches produced the following objective data: increase in blood histamine in more than 70% of patients with ulcers; presence of histamine in the gastric juice of ulcer patients; diminution of blood histamine after gastric resection; increase in blood histamine in patients with postoperative peptic ulcer; increase in tissue histamine in ulcerous zones; diminution in blood histamine, parallel clinical improvement and contemporaneous diminution in total and hydrochloric acidity in patients treated with histaminase. The discover by Black et al of cimetidine as an antagonist of H2 receptors to which is added the gastric secretory stimulus of histamine, underscores the role played by this substance in determining gastroduodenal ulcer.

Food allergy and asthma.

Food allergy (FA) is one of the causes of atopic dermatitis (AD), of acute urticaria, of reactions of the gastrointestinal tract, and of acute systemic anaphylaxis, but its role in asthma appears to be less clear. The prevalence and incidence of subjects with food-induced wheezing have not been well studied. In addition, the number of subjects with proven food-induced wheezing by double-blind, placebo-controlled oral food challenge (DBPCOFC) has been small. At the moment wheezing is considered unusual in food-hypersensitive subjects, and wheezing as the unique symptom of FA is rare. Furthermore, most cases of food-induced asthma have been observed in children. Food allergy may trigger allergic respiratory symptoms through two main routes: ingestion or inhalation. Children with asthma, who are allergic to foods, present some particular features such as AD and a related significantly elevated total serum IgE level. Alternatively, FA may occur in patients who are "high IgE responder" and more prone to become sensitive to many allergens, including foods. Therefore, children with asthma and a history of AD and/or elevated total serum IgE level should be carefully assessed for FA. We have shown that a significant proportion of children with IgE-mediated cow's milk allergy experienced asthma following DBPCOFC with cow's milk.

Prevention and management of food allergy.

The phenotypic expression and natural history of food allergy vary widely according to the patient's age, disease presentation and type of offending food. Prevention of food allergy might be achieved by altering the dietary factors responsible for the sensitization and phenotypic expression of the disease. Owing to the peculiarity of the atopic status, a minute amount of allergens can trigger both sensitization and symptoms in atopic individuals. The oral dose of beta-lactoglobulin causing sensitization can be estimated to be between 1 ng and several milligrams. In food allergy, sensitization and treatment are allergen specific; therefore, for primary prevention (avoiding sensitization) and secondary prevention of food allergy (avoiding symptoms in an already sensitized subject), a product without immunogenic and allergenic epitopes should be given in each case. Babies of atopic parents are particularly prone to develop food allergy and for this reason they are called high-risk babies. Cow's milk is the most commonly offending food in both gastrointestinal and cutaneous manifestations. Cow's milk proteins are potent allergens and around 2.5% of infants experience cow's milk allergy in the first years of life. The major risk factors for cow's milk allergy are positive family history of atopy and early exposure to cow's milk proteins. Hydrolysate formulae have been developed for the purpose of reducing the allergenicity of cow's milk proteins. More recently, partially and extensively hydrolysed formulae have also been used for feeding babies with a high risk of atopy for the prevention of cow's milk allergy. However, according to the results of a recent randomized controlled study, only an extensively hydrolysated formula, and not a partially hydrolysated formula, significantly decreased the prevalence of cow's milk allergy.