Acalasia cricofaríngea: diagnóstico y alternativas terapéuticas / Cricopharyngeal achalasia: diagnosis and therapeutic alternatives

Introducción. La acalasia cricofaríngea es un trastorno motor que consiste en la falta de relajación del esfínter esofágico superior. Es poco frecuente en pediatría y de etiología multifactorial. Los síntomas son inespecíficos y pueden quedar enmascarados. Caso clínico. Se presentan dos lactantes con disfagia y episodios de atragantamiento. El tránsito intestinal confirmó el diagnóstico de acalasia. En el primero, se realizaron dilataciones endoscópicas, siendo suficientes. En el segundo, a pesar de numerosas dilataciones y una miotomía, la clínica persistía, por lo que se procedió a inyecciones de toxina botulínica. Comentarios. El diagnóstico de acalasia se obtiene mediante un tránsito intestinal y gracias a un alto índice de sospecha. El uso de las dilataciones es la técnica de elección por su baja agresividad, pero se requieren varias sesiones, y, como segunda línea, la cirugía, técnica más invasiva. Además, contamos con la inyección de toxina botulínica, método menos extendido en pediatría, pero seguro y eficaz como alternativa

Introduction. The cricopharyngeal achalasia is an esophageal motor disorder that entails a lack of relaxation of the upper esophageal sphincter. It is rare in children and its etiology is related to multiple factors. The symptoms are nonspecific and may be masked by other diseases. Clinical case. Report two infants with dysphagia and choking episodes. Upper gastrointestinal series confirmed cricopharyngeal achalasia. The first patient was treated with endoscopic dilatation, and did not require further therapies. In the second patient, despite numerous dilatations and myotomy, the symptoms persisted so he received botulinum toxin injections. Comments. Diagnosis of achalasia is obtained by upper gastrointestinal series and thanks to a high index of clinical suspicion. The use of endoscopic dilatation is the first option because it is not an invasive technique, but it usually requires several sessions. The second-line therapy is surgery, a more aggressive technique. In addition, the injection of botulinum toxin represents a safe and effective alternative, although it is a less widespread method in pediatrics

Possible mechanism of structural transformations induced by StAsp-PSI in lipid membranes.

In the present work we have analyzed the effect of StAsp-PSI (plant-specific insert of potato aspartic protease) on the structural and thermotropic properties of the major phospholipid types of bacterial and animal cells. Results obtained suggest that StAsp-PSI induces a destabilization of the membrane bilayers, depending on the time of interaction between the protein and the bilayers, rather than on its concentration. This temporal delay would be consistent with a lateral diffusion of StAsp-PSI monomers to assemble into aggregates to form pores. Like with the results previously reported for the StAsp-PSI circular dichroism, data obtained here from IR spectroscopy show that there are slight changes in the StAsp-PSI secondary structure in the presence of lipid membranes; suggesting that these changes could be related with the StAsp-PSI self-association. Results obtained from steady-state fluorescence anisotropy and differential scanning calorimetry assays suggest that StAsp-PSI interacts with both uncharged and negatively charged phospholipids, modulates the phase polymorphic behavior of model membranes and partitions and buries differentially in the membrane depending on the presence of negatively charged phospholipids.

Cholesterol and membrane phospholipid compositions modulate the leakage capacity of the swaposin domain from a potato aspartic protease (StAsp-PSI).

Potato aspartic proteases (StAPs) and their swaposin domain (StAsp-PSI) are proteins with cytotoxic activity which involves plasma membrane destabilization. The ability of these proteins to produce cell death varies with the cellular type. Therefore, StAPs and StAsp-PSI selective cytotoxicity could be attributed to the different membrane lipid compositions of target cells. In this work we investigate the possible mechanism by which StAPs and StAsp-PSI produce selective membrane destabilization. Results obtained from leakage assays show that StAsp-PSI is a potent inducer of the leakage of LUVs containing anionic phospholipids, especially those containing phosphatidylglycerol. Based in these results, we suggest that the cytotoxic activity of StAsp-PSI on pathogenic microorganisms could be mediated by the attraction between the exposed positive domains of StAsp-PSI and the negatively charged microorganism membrane. On the other hand, our circular dichroism spectroscopic measurements and analysis by size exclusion chromatography and followed by electrophoresis, indicate that hydrophobic environment is necessary to StAsp-PSI oligomerization and both StAsp-PSI disulfide bounds and membrane with negative charged phospholipids are required by StAsp-PSI to produce membrane destabilization and then induce cell death in tumors and microorganism cell targets. Additionally, we demonstrate that the presence of cholesterol into the LUV membranes strongly diminishes the capacity of StAsp-PSI to produce leakage. This result suggests that the lack of hemolytic and cytotoxic activities on human lymphocytes of StAsp-PSI/StAPs may be partly due by the presence of cholesterol in these cell membrane types.

Trisetum paniceum (wild oats) pollen counts and aeroallergens in the ambient air of Madrid, Spain.

BACKGROUND: Madrid has a short but intensive grass pollen season, in which 79% of the total grass pollen load is released from the middle of May to the middle of June. The main objectives of this study were to quantify Trisetum paniceum (wild oats) aeroallergen in the atmosphere in Madrid from February to December 1996 and to correlate the aeroallergen concentrations with grass pollen counts. METHODS: Two different samplers were used to assess allergen exposure; a Burkard spore trap was used to collect pollen grains and a high-volume air sampler to collect airborne particles. A total of 182 air filters were collected and extracted in 1 ml of PBS and analysed by ELISA inhibition, using pooled sera from highly allergic individuals. RESULTS: T. paniceum aeroallergens were detected not only during the grass pollen season, but also before and after. Wild oat allergens had two main peaks of 1 and 1.9 microg/m(3), occurring in late May and July, respectively. The time series analysis established the existence of lags between the two main variables pollen counts and aeroallergen activity. Analysis of the data by the Spearman rank test and linear regression showed a weak correlation between grass allergenic activity and grass pollen counts (Spearman's rho = 0.29). Data obtained from time series analysis demonstrated that grass allergenic activity correlated strongly with current and 5-week-old grass pollen grain counts (r(2) = 0.73). CONCLUSIONS: Wild oats allergenic activity was detected during the entire year and not only during the pollen season. This fact is an important aspect to be considered in the clinical follow-up and treatment of grass pollen-sensitised patients in Madrid.

Cinco años de experiencia con misoprostol intravaginal para la inducción de parto: uso de una nueva presentación farmaceútica en supositorios / 5 year experience with intravaginal misoprostol suppositories for labor induction

Se presentan los resultados generales de 1534 casos con diversas patologías inducidos con misoprostol en tabletas, 50 ug intravaginal cada 8 horas por 2 veces al día, durante los años 1997 al 2001 en el Servicio de Obstetricia y Ginecología del Hospital Las Higueras de Talcahuano, destacando la baja incidencia de cesárea (6,3 por ciento) y de Apgar bajo a los 5 minutos (0,5 por ciento). En 47 casos se utilizó en forma prospectiva y randomizada para la inducción (enero a marzo de 2002), una nueva presentación farmacéutica (supositorios) aún no comercializada, la cual produjo un alto porcentaje de éxito a las dosis de 50 ug cada 8 horas y 100 ug cada 12 horas, hasta por un período de 48 horas: 96 por ciento y 81,8 por ciento respectivament, con un bajo porcentaje de cesáreas (7,1 por ciento) y de polisistolia (6,4 por ciento) y ningún recién nacido deprimido

Platanus pollen as an important cause of pollinosis.

OBJECTIVE: The existence of Platanus pollinosis is not generally accepted despite the production of very large quantities of airborne Platanus pollen in many cities of the United States and Europe. The aim of this study was to investigate if Platanus pollen really contributes to the symptoms of the patients with pollinosis in the Madrid area. METHODS: We carried out systematic skin prick testing with Platanus pollen extract on 47 patients seen in our allergy center with spring-summer pollinosis symptoms. Each patient maintained symptom score diaries before, during, and after the Platanus pollination season. The average symptom scores were calculated and compared with the Platanus pollen counts. Measurements of specific IgE by ELISA and immunoblotting also were performed in each patient. RESULTS: The Platanus skin tests were positive in 33 of the 39 patients first seen with seasonal symptoms during Platanus pollen season and only in three of the eight patients without symptoms during Platanus exposure (Fisher's exact test; p < 0.05). Twenty-two of the 33 Platanus-positive skin test patients also had a positive ELISA result. Furthermore, the average 24-hour rhinitis symptom scores of the 39 patients first seen with seasonal symptoms during March through April showed significant correlation with Platanus pollen counts (r(s) = 0.57, p < 0.05). The immunoblot results suggest that a 17 kd pollen protein could be a major allergen in patients with Platanus pollinosis. CONCLUSIONS: Platanus pollen is an important cause of pollinosis in Madrid. A protein with a molecular weight of 17 kd appeared to be its major allergen.

Allergenic pollen pollinosis in Madrid.

OBJECTIVE: A 15-year pollen count was performed in the atmosphere of Madrid, Spain, to determine the months in which the highest concentrations of allergenic pollens occur. METHODS: Pollen counts were done with a Burkard spore trap (Burkard Manufacturing, Rickmansworth, Herst., U.K.). The results were subsequently compared with results of skin tests in patients with pollinosis born and living in and around Madrid. RESULTS: The highest airborne presence (percent of total yearly pollen counts, mean of counts from 1979 to 1993) was for Quercus spp. (17%); followed by Platanus spp. (15%), Poaceae (15%), Cupressaceae (11%), Olea spp. (9%), Pinus spp. (7%), Populus spp. (4%), and Plantago spp. (4%). The most predominant pollens from January to April are tree pollens (Cupressaceae, Alnus, Fraxinus, Ulmus, Populus, Platanus, and Morus), although these are also abudant in May and June (Quercus, Olea, and Pinus spp.). The grass pollination period shows a double curve: the first peak occurs from February to April (8% of yearly grasses), and the second peak occurs from May to July (90% of yearly grasses). Among allergenically significant weeds, the most notable is Plantago; in contrast, Rumex, Urticaceae, Cheno-Amaranthaceae, and Artemisia spp. have very low concentrations (< or = 2% yearly total pollens). The most significant allergenic pollen is that of grasses, with a prevalence of positive prick test results of 94%, followed by Olea europaea (61%), Plantago lagopus (53%), Platanus hybrida (52%), and Cupressus arizonica (20%). CONCLUSION: The population of Madrid is exposed to high concentrations of allergenic pollen from February to July, although the most intense period is from May to June. Grass pollens are the most important cause of pollinosis in this area.

Seasonal asthma caused by airborne Platanus pollen.

This work describes three patients suffering from bronchial asthma after being naturally exposed to airborne plane-tree pollen. The three patients gave immediate response in skin tests and dual response in bronchial provocations using Platanus hybrida extract. There was specific seric IgE activity against this/these antigen(s) with the CAP system. The three patients also showed significant correlation (P < 0.001) between their rhinitis and asthma symptom-scores registered on their diary cards and plane-tree pollen counts, collected using the Burkard spore trap. Among 187 patients living in Madrid and who came to our centre with a history of rhinitis and/or seasonal asthma, we found a prevalence of positive skin-prick tests to Platanus of 56%, only surpassed by gramineous pollen (Dactylis glomerata and/or Trisetum paniceum) 92% and Olea europaea 63%. The aerobiological sampling of the pollen content of the air in Madrid, carried out between 1 January 1979 and 31 December 1993 revealed an airborne presence (per cent of total yearly pollen count, mean of 1979-1993) of 14.9% for the Platanus, 14.8% for grasses, 9.8% for Olea and 3.6% for Plantago. The Platanus is one of the most frequently found pollens in the atmosphere over Madrid. At present, in this geographical area, a high percentage of patients with pollinosis are sensitive to this pollen. At least in some of these patients Platanus pollen is capable of inducing rhinitis and bronchial asthma.

Prediction of annual variations in atmospheric concentrations of grass pollen. A method based on meteorological factors and grain crop estimates.

We performed an aerobiologic observation of the grasses present in Madrid for 14 years (1978-1991), using volumetric air samplers. The counts obtained show that the major grass pollen release period (average daily grass pollen counts greater than 50 grains/m3 of air) occurs in the months of May and June, although lower counts can occur some days from the end of January onward. There are wide year-to-year variations in total atmospheric grass pollen counts, expressed as the total sum of the mean daily concentrations from April 1st to July 30th (ranging from 2568 to 6624). A strong, statistically significant correlation, based on Spearman's rank test and/or simple and multiple linear regressions, was found between the total grass seasonal count and preseasonal rainfall from October to March (R2 = 0.64; P = 0.0429). The meteorological variable which gave the correlation with greatest statistical significance (R2 = 0.97; P = 0.0016) was the average monthly preseasonal humidity from October to March. A good correlation was also found between March estimates of wheat, rye and barley crops and the total grass count (R2 = 0.73; P = 0.006). A model was designed from the above mentioned humidity variable through a multilinear regression analysis, and it was possible to predict, at the beginning of April, total seasonal counts for 1989 (predicted = 5468; actual = 4410; average error = 24%), 1990 (5033; 6090; -17%) and 1991 (3930; 2568; 53%). These data may help clinicians to predict and prepare themselves for the intensity of the grass pollen season and to explain yearly variations in the severity of symptoms.

Occupational asthma caused by Brazil ginseng dust.

The inhalation of different substances of plant origin can cause immediate and late onset asthma. The list of these agents responsible for such reactions is continuously increasing. We discuss a patient who developed symptoms of asthma after exposure to Pfaffia paniculata root powder used in the manufacturing of Brazil ginseng capsules. Airway hyperreactivity was confirmed by a positive bronchial challenge to methacholine. Sensitivity to this dust was confirmed by immediate skin test reactivity, a positive bronchial challenge (immediate response), and the presence of specific IgE detected by ELISA technique to an aqueous extract. The bronchial response was inhibited by sodium cromoglycate. Unexposed subjects did not exhibit reactivity to this ginseng extract with any of the tests referred to above. The same study performed with Korean ginseng (Panax ginseng) elicited negative results. This study is the first, to our knowledge, that links ginseng-root dust to occupational asthma.

Allergic conjunctivitis to chamomile tea.

Eye washing with chamomile tea is a folk remedy used by the general public to treat conjunctivitis and other ocular reactions. Chamomile is also found in many cosmetic products. Some cases of contact dermatitis (but not reactions of type I) were reported following its topical applications. We present seven hay fever patients that suffered from conjunctivitis; two of them also had lid angioedema after eye washing with chamomile tea. All seven patients had positive skin prick tests to the chamomile tea extract, Matricaria chamomilla pollen and Artemisia vulgaris pollen extracts. Positive conjunctival provocations were also observed in all the patients with the chamomile tea extract. In contrast, no symptoms were observed after oral challenges with this infusion. IgE activity against chamomile tea and Matricaria and Artemisia extracts (composite pollens) was detected by ELISA in the seven patients' sera. A cross reactivity among the above extracts was observed by an ELISA inhibition study. In all cases, the IgE activity to chamomile tea could fully be absorbed by Matricaria pollen extract. Skin prick tests and conjunctival provocation tests also performed in 100 hay fever controls revealed a positive immediate skin response to Artemisia in 15 patients, eight of them also to Matricaria pollen and five of them to Chamomile tea as well. Only two of the last patients had a positive conjunctival response. The results were negative in the rest of the controls. We conclude that the chamomile tea eye washing can induce allergic conjunctivitis. Matricaria chamomilla pollens contained in these infusions are the allergens responsible for these reactions.

Anaphylactic reaction after the ingestion of chamomile tea: a study of cross-reactivity with other composite pollens.

We report a case of an 8-year-old atopic boy in whom ingestion of a chamomile-tea infusion precipitated a severe anaphylactic reaction. The patient suffers from hay fever and bronchial asthma caused by a variety of pollens (grass, olive, and mugwort). This severe reaction was developed after his first ingestion of chamomile tea. Studies revealed the presence of immediate skin test reactivity and a positive passive transfer test to chamomile-tea extract. Moreover, both specific antichamomile-tea extract and anti-Matricaria chamomilla-pollen extract IgE antibodies were detected by an ELISA technique. Cross-reactivity among chamomile-tea extract and the pollens of Matricaria chamomilla, Ambrosia trifida (giant ragweed), and Artemisia vulgaris (mugwort), was demonstrated by an ELISA-inhibition study. These findings suggest a type I IgE-mediated immunologic mechanism as being responsible for the patient's anaphylactic symptoms and also suggest that the patient cross-reacted the pollens of Matricaria chamomilla contained in the chamomile tea because he was previously sensitized to Artemisia pollen.