Multi-Gram Scale Synthesis and Characterization of Mometasone Furoate EP Impurity C

Mometasone furoate is a synthetic corticosteroid used in the treatment of skin inflammatory conditions, hay fever and asthma. The industrial manufacturing routes to mometasone furoate are generally accompanied by the formation of numerous process impurities that need to be detected and quantified, as requested by regulatory authorities. The ready availability of such impurities in the required quantity and purity is therefore essential for toxicological studies, analytical method development and process validation. Herein, we report the multi-gram scale preparation of 21'-chloro-(16'α-methyl-3',11',20'-trioxo-pregna-1',4'-dien-17'-yl)-furan-2-carboxylate (mometasone furoate EP impurity C), one of the known impurities of mometasone furoate. This study also includes the systematic investigation of the final acylation step, as well as the characterization of the difuroate enol ether intermediate and its conversion to the target impurity C.

Boosting Immunity and Management against Wheat Fusarium Diseases by a Sustainable, Circular Nanostructured Delivery Platform

Fusarium head blight (FHB) and Fusarium crown rot (FCR) are managed by the application of imidazole fungicides, which will be strictly limited by 2030, as stated by the European Green Deal. Here, a novel and eco-sustainable nanostructured particle formulation (NPF) is presented by following the principles of the circular economy. Cellulose nanocrystals (CNC) and resistant starch were obtained from the bran of a high amylose (HA) bread wheat and employed as carrier and excipient, while chitosan and gallic acid were functionalized as antifungal and elicitor active principles. The NPF inhibited conidia germination and mycelium growth, and mechanically interacted with conidia. The NPF optimally reduced FHB and FCR symptoms in susceptible bread wheat genotypes while being biocompatible on plants. The expression level of 21 genes involved in the induction of innate immunity was investigated in Sumai3 (FHB resistant) Cadenza (susceptible) and Cadenza SBEIIa (a mutant characterized by high-amylose starch content) and most of them were up-regulated in Cadenza SBEIIa spikes treated with the NPF, indicating that this genotype may possess an interesting genomic background particularly responsive to elicitor-like molecules. Quantification of fungal biomass revealed that the NPF controlled FHB spread, while Cadenza SBEIIa was resistant to FCR fungal spread. The present research work highlights that the NPF is a powerful weapon for FHB sustainable management, while the genome of Cadenza SBEIIa should be investigated deeply as particularly responsive to elicitor-like molecules and resistant to FCR fungal spread.

Sustainable Protocols for Cellulose Nanocrystals Synthesis from Tomato Waste and Their Antimicrobial Properties against Pseudomonas syringae pv. tomato

Nanotechnology is rapidly gaining ground in crop protection, with the growing quest for sustainable nanopesticides and nanocarriers for plant pathogen management. Among them, cellulose nanocrystals (CNC) are emerging as innovative agrofood-waste-derived antimicrobial materials. In this work, new chemical and enzymatic CNC extraction methods from tomato harvest residues were evaluated. The obtained nanomaterials were characterized and tested for their antimicrobial properties on Pseudomonas syringae pv. tomato (Pto), the causal agent of bacterial speck disease on tomato. Both protocols were efficient. The enzymatic extraction method was greener, producing purer CNC at slightly lower yield. The obtained CNC, although they weakly inhibited cell growth and did not promote reactive oxygen species (ROS) formation, provoked bacterial aggregation and the inhibition of biofilm production and swimming motility. Both protocols produced CNC with similar morpho-chemical features, as well as promising antimicrobial activity against plant bacterial pathogens, suggesting their potential role in sustainable crop protection strategies. The new protocols could be a valuable alternative to conventional methods.

Recent advances in urea- and thiourea-containing compounds: focus on innovative approaches in medicinal chemistry and organic synthesis

Urea and thiourea represent privileged structures in medicinal chemistry. Indeed, these moieties constitute a common framework of a variety of drugs and bioactive compounds endowed with a broad range of therapeutic and pharmacological properties. Herein, we provide an overview of the state-of-the-art of urea and thiourea-containing pharmaceuticals. We also review the diverse approaches pursued for (thio)urea bioisosteric replacements in medicinal chemistry applications. Finally, representative examples of recent advances in the synthesis of urea- and thiourea-based compounds by enabling chemical tools are discussed.

Second-Generation Dual FXR/sEH Modulators with Optimized Pharmacokinetics

Non-alcoholic steatohepatitis (NASH) presents as an epidemic chronic liver disease that is closely associated with metabolic disorders and involves hepatic steatosis, inflammation, and fibrosis as key factors. Despite the enormous global prevalence of NASH, effective pharmacological interventions are lacking. Based on the hypothesis that the multifactorial condition NASH may benefit from combined multiple modes of action for enhanced therapeutic efficacy, we have previously developed dual FXR activators/sEH inhibitors (FXRa/sEHi) and observed remarkable antifibrotic effects upon their use in rodent NASH models. However, these first-generation FXRa/sEHi were characterized by moderate metabolic stability and short in vivo half-life. Aiming to overcome these pharmacokinetic drawbacks, we have systematically studied the structure-activity and structure-stability relationships of the chemotype and obtained second-generation FXRa/sEHi with improved pharmacokinetic parameters. With high plasma exposure, a half-life greater than 5 h, and similar dual potency on the intended targets, 13 presents as a substantially optimized FXRa/sEHi for late-stage preclinical development.

Oxaprozin Analogues as Selective RXR Agonists with Superior Properties and Pharmacokinetics

The retinoid X receptors (RXR) are ligand-activated transcription factors involved in multiple regulatory networks as universal heterodimer partners for nuclear receptors. Despite their high therapeutic potential in many pathologies, targeting of RXR has only been exploited in cancer treatment as the currently available RXR agonists suffer from exceptional lipophilicity, poor pharmacokinetics (PK), and adverse effects. Aiming to overcome the limitations and to provide improved RXR ligands, we developed a new potent RXR ligand chemotype based on the nonsteroidal anti-inflammatory drug oxaprozin. Systematic structure-activity relationship analysis enabled structural optimization toward low nanomolar potency similar to the well-established rexinoids. Cocrystal structures of the most active derivatives demonstrated orthosteric binding, and in vivo profiling revealed superior PK properties compared to current RXR agonists. The optimized compounds were highly selective for RXR activation and induced RXR-regulated gene expression in native cellular and in vivo settings suggesting them as excellent chemical tools to further explore the therapeutic potential of RXR.

Garcinoic Acid Is a Natural and Selective Agonist of Pregnane X Receptor

Pregnane X receptor (PXR) is a master xenobiotic-sensing transcription factor and a validated target for immune and inflammatory diseases. The identification of chemical probes to investigate the therapeutic relevance of the receptor is still highly desired. In fact, currently available PXR ligands are not highly selective and can exhibit toxicity and/or potential off-target effects. In this study, we have identified garcinoic acid as a selective and efficient PXR agonist. The properties of this natural molecule as a specific PXR agonist were demonstrated by the screening on a panel of nuclear receptors, the assessment of the physical and thermodynamic binding affinity, and the determination of the PXR-garcinoic acid complex crystal structure. Cytotoxicity, transcriptional, and functional properties were investigated in human liver cells, and compound activity and target engagement were confirmed in vivo in mouse liver and gut tissue. In conclusion, garcinoic acid is a selective natural agonist of PXR and a promising lead compound toward the development of new PXR-regulating modulators.

Food allergens and respiratory symptoms

Food allergy may be clinically expressed by a variety of respiratory symptoms, which can be provoked either by IgE- or cellular mediated reactions. Among the diagnostic procedures, newly introduced atopy patch test seems to be important for diagnosis of cellular, delayed immune reactions. We studied the prevalence of positive atopy patch tests with food and inhalant allergens and the correlation between the positivity of atopy patch tests and questionnaire derived atopic and nonatopic espiratory symptoms and diseases in an unselected children population. We found a correlation between the positive patch test result with wheat and cough after physical effort, allergic rhino-conjunctivitis, and bronchitis recidivans. The subjects with positive skin reaction to egg suffered from allergic rhino-conjunctivitis and bronchial asthma. Food and inhalant allergens play an important role in the induction and exacerbation of some respiratory allergic diseases. The positive correlation of positive results of skin tests and history of some respiratory diseases and symptoms also on the population level confirm the importance of these tests in the diagnostic work-up of these allergic diseases.

Reproducibility of atopy patch tests with food and inhalant allergens

Although atopy patch tests (APT) seem a valuable additional tool in the diagnostic work-up for food allergy in children with atopic eczema/dermatitis syndrome, the immunopathology and some technical aspects of testing remain controversial. Few published data are available on the reproducibility of APT with inhalants and only two studies include fresh food allergens. In this study we therefore investigated the reproducibility of duplicate APT (left versus right side of the back) with native and commercially available food (cow s milk, hen s egg, tomato, wheat flour) and with inhalant allergens (Dermatophagoides pteronyssinus and mixed grasses) in a large unselected population of children. We tested a population of 277 Italian school children with three APT allergens: fresh food (cow s milk, hen s egg, tomato and wheat flour), standardised food allergens in petrolatum (the same four foods) and standardised inhalant allergens routinely used for skin prick testing. For the four food allergens (applied in the natural form or as the standardised commercial preparation) from one- to three quarters of the APT gave positive results on one side and negative reactions on the opposite side (Cohen s K coefficient between 0.38, fresh tomato and 0.81, fresh cow s milk). Conversely, APT with inhalant allergens were invariably reproducible (Cohen s K = 1.00). The possible technical and immunologic reasons explaining why reproducibility of APT differed for the two types of allergens await an answer from extensive controlled studies.

Food allergies, cross-reactions and agroalimentary biotechnologies

The discrepancy between what the general public and specialist in allergic diseases regard as a true food allergy can in part depend on the frequent evidence of subjects in whom clinical symptoms elicited by a given food allergen are frequently not reproducible: this suggests the existence of allergens variably present in certain foods. In adults and older children common is a form of food allergy associated with inhaled allergens, especially pollens. In this allergic form pollens and various vegetal food often cross react but the underlying scientific rationale is largely unclear. From the study of the "latex-fruits allergic syndrome" and the "oral allergic syndrome" emerged that the cross reactivity depends on epitopes of pollens and vegetables belonging to one of the 14 classes of the "pathogenesis related proteins" (PRPs). Vegetables produce PRPs in response to infection or after plant injury or application of chemicals: long-term conservation and methods used for rapid artificial ripening of vegetables can cause plant to produce PRPs or other allergens. A genetic selection of vegetables "protecting themselves against infection and infestation" by mean of PRPs production is practiced in agroalimentary biotechnology. We deem it urgent that the two realms, Medical Science (Allergology) and Agricultural Biotechnology begin to communicate openly in order to produce food as efficiently as possible but without harming the large part of the population which is predisposed to allergy and react to PRPs.

Non-invasive assessment of airway inflammation in ship-engine workers

Smoking is harmful for respiratory function. In young to middle-aged men the damage is insidious and difficult to demonstrate. The respiratory impairment could increase under specific stressful conditions in the professional environment. On the hypothesis that exhaled markers are useful for assessing airway susceptibility to inhaled irritants, we measured exhaled markers and lung function in smoking and non-smoking engine-driver military coastguards before and after a patrol at sea. Eighteen men, mean age 39 yrs (range 23-58 yrs), 8 smokers, underwent spirometry, exhaled and nasal nitric oxide (eNO, nNO), exhaled carbon monoxide (CO) and exhaled breath condensate (EBC) for measures of hydrogen peroxide (H2O2), leukotriene B4 (LTB4), proteins (Prots), 8-isoprostanes (8-IsoPs), nitrite (NO2-) and nitrosothiols (RS-NOs) at baseline and after an 8-hour patrol navigation on board small, high-speed diesel-powered ships. At baseline, the smokers showed higher middle flows and CO levels, lower eNO and nNO than non-smokers, but similar levels of EBC markers; geometric means (95% confidence interval), CO: 23.6 (14.5 to 38.3) vs. 3.5 (2.5 to 5.3) ppm; eNO: 7.9 (4.8 to 12.9) vs. 26.7 (15.7 to 45.5) ppb, p=0.000. After navigation, Prots, 8-IsoPs and RS-NOs (but not lung function variables or other markers) significantly increased only in smokers; baseline vs post-navigation RS-NOs: 0.27 (0.11 to 0.65) vs. 1.30 (0.58 to 2.89) micromol, p=0.012. The respiratory consequences of a stressing environment in engine-driver military coastguards who actively smoke are better assessed by measuring EBC markers than by eNO, nNO or lung function. By increasing airway inflammation from oxidative-stress, tobacco smoking appears to interact with other chemical or physical factors elicited during sea navigation. Precisely what these factors are deserves further investigation.

The prevalence of atopy in asthmatic children correlates strictly with the prevalence of atopy among nonasthmatic children

BACKGROUND

Because asthma preferentially burdens persons with atopy, atopy is simplistically considered a primary 'cause' of asthma. Yet at the population level, the percentage of asthma cases 'attributable' to atopy ranges from less than 10% to more than 60%. Seeking to understand the rationale for the variability of atopy-attributable cases of asthma, we systematically reviewed the results of our own previous epidemiological studies and several studies conducted by others in children.

METHODS

From each of the 37 random pediatric populations selected by a Medline search combining the key words 'IgE or skin tests or hypersensitivity, immediate' with 'epidemiological studies, cross-sectional, case-control, prevalence, longitudinal, epidemiology of asthma' (12 from our previous pediatric surveys and a further 25 reported from 19 studies in children), we extracted the population prevalence of asthma and atopy among asthmatic subjects and among the nonasthmatic part of the population.

RESULTS

No correlation was found between the prevalence of asthma (range 1.8-44.1%) and atopy (range 5.8-63.9%) in these 37 populations of children (r = 0.052, p = 0.761). Nevertheless, the prevalence of atopy among asthmatics strictly correlated with the prevalence of atopy in nonasthmatics (r = 0.900, p < 0.001, slope 1.364).

CONCLUSION

The prevalence of asthma and atopy varies worldwide and at various time points and independently undergoes the influence of powerful environmental factors. The almost perfect correlation we found between atopy in asthmatics and atopy in the nonasthmatic part of the childhood population shows that the prevalence of atopy in asthma depends on environmental factors that simultaneously induce atopy in asthmatic and nonasthmatic subjects.

Chromogenic in situ hybridization accurately identifies EGFR amplification in small cell glioblastoma multiforme, a common subtype of primary GBM

Primary glioblastoma multiforme (GBM) commonly overexpresses the epidermal growth factor receptor (EGFR) gene and its ligand-independent mutant, EGFRvIII. Amplification of the EGFR gene has been implicated in the pathogenesis of primary GBM, in particular the small cell phenotype, and this finding may contribute to its aggressive clinical behavior. Anti-EGFR clinical trials for GBM are being conducted, and it would be useful to identify a rapid technique to determine whether EGFR expression and the small cell phenotype are associated with a response to therapy. In the present study we examined 56 cases of GBM using chromogenic in situ hybridization (CISH). CISH analysis and morphology identified 22 small cell (SCGBM) and 22 non-small cell glioblastoma (NSCGBM), and 12 cases of a mixed phenotype. Fourteen cases of SCGBM (14/22) showed EGFR amplification, while only 5 NSCGBM (5/22) cases showed amplification. We have therefore used CISH as an efficient, economic and reliable means for routinely assessing EGFR amplification in GBM, including the small cell variant.

Allergen skin weal/radioallergosorbent test relationship in childhood populations that differ in histamine skin reactivity: a multi-national survey

BACKGROUND

Histamine skin reactivity (HSR, the dimension of the skin weal elicited by histamine 10 mg/mL) is a variable that differs in children from different European countries and increases over time in the same place (Italy).

OBJECTIVE

In this epidemiologic study, we investigated to what extent differences in HSR influence the relationship between positive allergen skin prick tests (ASPTs) and serum-specific IgE concentrations.

METHODS

Between October 2001 and February 2002, 591 unselected 9-10-year-old schoolchildren drawn from five small towns in central Poland (Starachowice), central Italy (Ronciglione, Guardea) and Libya (Al-Azyzia, near the Mediterranean sea and Samno, 900 km south of the coast) were analysed for histamine, common ASPT and for serum total and specific IgE.

RESULTS

HSR differed markedly in children from the three countries (Libya>Italy>Poland) whereas serum total IgE concentrations remained the same. The prevalence of children with measurable serum specific IgE (> or = 0.35 kU) or with a positive ASPT for five common allergens was high in Italy, lower in Poland and far lower in Libya. A 3-mm ASPT weal corresponded to a serum-specific IgE concentration that was two to threefold higher in children with low HSR compared with children with high HSR (P = 0.008).

CONCLUSION

These findings suggest that HSR--a variable that differs in schoolchildren populations from the three countries studied--independently influences the results of ASPT and its influence should be considered when ASPT are assessed in international studies. The HSR differences found in the populations reported here probably reflect a complex, dynamic, environmental interaction that should be monitored in the different parts of the world.

Diffusing capacity for carbon monoxide in children with type 1 diabetes

AIMS/HYPOTHESIS

Few data are available on lung dysfunction in children with diabetes. We studied the association of pulmonary function variables (flows, volumes and alveolar capillary diffusion) with disease-related variables in children with type 1 diabetes mellitus.

METHODS

We studied 39 children with type 1 diabetes (mean age 10.9+/-2.6 years, disease duration 3.6+/-2.4 years, insulin.kg(-1).day(-1) 0.77+/-0.31) and 30 healthy control children (mean age 10.4+/-3.0 years). Pulmonary function tests included spirometry, N(2) wash-out and the single-breath diffusing capacity for carbon monoxide (DL(CO)) corrected for the alveolar volume (DL(CO)/V(A)). Glycaemic control was assessed on the basis of HbA(1)c, with HbA(1)c values of 8% or less considered to indicate good glycaemic control, and HbA(1)c values of 8% or more considered to indicate poor control.

RESULTS

Children with poor glycaemic control had comparable percentage values for predicted flows and volumes but lower DL(CO)/V(A) values than children with good glycaemic control and healthy control children (86.7+/-12.6 vs 99.8+/-18.4 and 102.0+/-15.7; p<0.05). The predicted DL(CO)/V(A) percentages correlated with HbA(1)c levels (r=-0.39, p=0.013). A multiple regression analysis (stepwise model) controlling for HbA(1)c levels and other disease-related variables (age of disease onset, disease duration, daily insulin dose/kg, sex) identified HbA(1)c levels as the sole predictor of DL(CO)/V(A) in percent.

CONCLUSIONS/INTERPRETATION

In children with type 1 diabetes, the diffusing capacity diminishes early in childhood and is associated with poor metabolic control. Although low DL(CO)/V(A) levels in these children probably reflect pulmonary microangiopathy induced by type 1 diabetes, other factors presumably influencing CO diffusion capacity measurements (e.g. a left shift in HbA(1)c resulting in high O(2) binding and low CO binding) could explain the apparent capillary and alveolar basal membrane dysfunction.

[Childhood asthma]

The concept of chronicity in asthma, as emphasized by recent definitions of the disease, rests on the major characteristics of inflammatory response of the airways and progressive development of irreversible structural and functional alterations, or so-called airway remodeling. In childhood, however, such characteristics as chronicity and irreversibility are debatable. Various clinical phenotypes with variable degrees of severity of persistence are found in children. Furthermore, many patients with a history of recurrent wheezing in early infancy do not develop asthma later in life. The prevalence of asthma, especially in its mild forms, has increased markedly in recent years. Although the trend has stabilized in Italy, it continues to rise in other Western countries. Our research has shown that increased cutaneous response to histamine determines a major prevalence of positive skin tests. The rise in clinical forms of the disease accompanied by gastrointestinal symptoms is partly attributable to the dietary intake of food and beverages processed from environmentally engineered products. The features of the new forms of asthma demand accurate clinical and functional assessment. In addition to pulmonary function tests, determinations for eosinophils and inflammation markers in the blood and sputum, noninvasive methods have recently become available to assess airway inflammation. Among these, particularly useful studies include test for nitric oxide in exhaled air, along with tests for other markers of allergic inflammation and oxidative stress in the droplets of the exhaled air. Because in paediatric age, prolonged use of inhaled steroids increase the risk of growth impairment, asthma therapy should be guided by clinical criteria and examinations, rather than by rigid treatment guidelines. Moreover, to secure successful treatment, the parents and the child as well should be involved in monitoring the course of the disease.

Immediate skin reactivity to histamine and to allergens in cohorts of 9-year-old schoolchildren studied 16 years apart

BACKGROUND

Differing or increasing prevalence of positive allergen skin-prick tests observed in Europe could at least in part be explained by population changes in histamine skin reactivity. These changes would also alter the relationship between positive allergen skin-prick tests and serum IgE.

OBJECTIVE

To assess changes in histamine reactivity, allergen skin-prick tests and serum IgE in our geographical setting.

METHODS

We compared the outcome of two epidemiological surveys conducted 16 years apart in unselected 9-year-old schoolchildren (170 in 1983 and 176 in 1999) from a semi-rural region in central Italy. Outcome measures were skin-prick tests with two histamine concentrations (10 and 1 mg/mL) and 11 locally relevant allergens; serum total and specific IgE for positive allergens.

RESULTS

The two histamine concentrations induced significantly larger mean weal diameters in 1999 than in 1983 (10 mg/mL: 5.28+/-0.82 mm vs. 3.25+/-0.97 mm; P<0.001). Whereas the prevalence of subjects with at least one positive allergen-induced weal reaction (>or=3 mm) increased over the 16 years (from 15.3% in 1983 to 25.6% in 1999), the prevalence of positive skin-prick tests, expressed as the allergen/ histamine weal ratio, remained almost unchanged. A given allergen weal diameter yielded less total (P<0.05 by Student's t-test for cumulative weals <8 mm) and specific (P<0.01 by Student's t-test for weals <3 mm, P<0.05 by Kruskal-Wallis test) serum IgE in 1999 than in 1983.

CONCLUSIONS

Although the causes and mechanisms remain unclear, the increased histamine skin reactivity over time is associated with an increase in positive allergen skin-prick tests. In the presence of increased tissue and organ susceptibility to histamine, minute amounts of specific IgE could have important biological consequences.

Are infections protecting from atopy?

The 'Hygiene Hypothesis' proposes that overcrowding and unhygienic contacts early in life may protect from atopic diseases by facilitating exposure to microbes. Longitudinal studies have recently shown that among subjects exposed early in life to other children at home, or at day care, the risk of wheezing steadily declined with age to levels significantly lower than controls. Evidences supporting a protective role of respiratory infections or BCG immunization on the development of allergic asthma are still insufficient. By contrast, the observation of a lower prevalence of atopic sensitization among children raised on a farm has been consistently reproduced. Several new studies have recently investigated the role of changes of human microbial flora, declining exposure to foodborne and orofecal infections, to helminths and to environmental sources of endotoxin as putative contributors to the rise of allergy and asthma cases among populations living with a western lifestyle.

Exhaled nitric oxide in asthmatic and non-asthmatic children: influence of type of allergen sensitization and exposure to tobacco smoke

Asthmatic bronchial inflammation is associated with increased nitric oxide concentrations in exhaled air (eNO). Recent data suggest that this effect arises from atopy. Our aim in this study was to find out whether atopy and sensitization to particular allergens influences eNO levels. A total of 213 subjects (41 asthmatics and 172 controls) (96 boys and 117 girls, 7.3-14 years of age) were studied. Parents completed a questionnaire that sought information on their children's respiratory symptoms and exposure to tobacco smoke. Subjects underwent skin-prick tests for the following common allergens: Dermatophagoides pteronyssinus (Dpt), cat fur, Aspergillus fumigatus, Alternaria tenuis, mixed grass, mixed tree pollen, Parietaria officinalis, egg, and cow's milk. eNO was collected in 1-l mylar bags (exhaled pressure 10 cmH2O, flow 58 ml/s) and analyzed by using chemiluminescence. Atopic and non-atopic children without a history of chronic respiratory symptoms had a similar geometric mean eNO (atopics, n = 28, 11.2 p.p.b.; non-atopics, n = 96, 10.0 p.p.b.; mean ratio 1.1, 95% confidence interval [CI]: 0.7-1.6). Conversely, atopic asthmatic subjects had significantly higher eNO values than non-atopic asthmatic subjects (atopics, n = 25, 24.8 p.p.b.; non-atopics, n = 16, 11.4 p.p.b.; mean ratio 2.2, 95% CI: 1.2-3.9, p= 0.000). In children with rhinitis alone (n = 15) and those with lower respiratory symptoms other than asthma (n = 33), eNO increased slightly, but not significantly, with atopy. eNO levels correlated significantly with Dpt wheal size (r = 0.51) as well with the wheal size for cat, mixed grass, and Parietaria officinalis (r = 0.30-0.29), and with the sum of all wheals (r = 0.47) (p= 0.000). Subjects sensitized only for Dpt (but not those subjects sensitized only for grass pollen or other allergens) showed significantly higher eNO levels than non-atopic subjects (16.4 p.p.b. vs. 10.2 p.p.b., mean ratio 1.6, 95% CI: 1.1-2.3, p= 0.002). In asthmatic subjects, Dpt sensitization markedly increased eNO levels (Dpt-sensitized subjects: 28.0 p.p.b.; Dpt-unsensitized subjects: 12.2 p.p.b.; mean ratio 2.3, 95% CI: 1.5-3.5, p= 0.000). Non-asthmatic Dpt-sensitized subjects also had significantly higher eNO values than non-asthmatic, non-Dpt-sensitized subjects (14.2 p.p.b. vs. 10.1 p.p.b.; mean ratio 1.4, 95% CI: 1.1-1.9, p= 0.008). No difference was found between eNO levels in asthmatic subjects and control subjects exposed or unexposed to tobacco smoke. In conclusion, eNO concentrations are high in atopic asthmatic children and particularly high in atopic asthmatics who are sensitized to house-dust mite allergen.

Off-line exhaled nitric oxide measurements in children

The concentration of exhaled nitric oxide (eNO) is a useful marker of asthmatic bronchial inflammation. eNO can now be measured away from the laboratory (off-line), even in children. Short exhalation maneuvers (8 sec) and small samples (1 L) of exhaled gas are probably sufficient in children, but more information is needed about the effect of different measurement conditions. As a preliminary step before conducting epidemiological studies in schoolchildren, we investigated the effects of expiratory flow, dead space, and expiratory time on eNO concentrations collected in 1-L mylar collection bags. We studied 101 cooperative subjects (62 males) aged 5-18 years (30 healthy volunteers, 51 asthmatics, and 20 children with various other respiratory diseases) in our pulmonary function laboratory. On-line and off-line eNO were compared in a single session, and analyzed with a Sievers NOA 280 nitric oxide analyzer. For both methods of collecting expired gas, subjects did a single exhalation without breath-holding against an expiratory pressure 10 cm H(2)O. We investigated the effects of expiratory flow, dead space, and exhalation time on eNO; we also compared on-line and off-line eNO measurements, and the repeatability of both techniques at a given flow rate. Expiratory flows of 58 mL/sec provided more reproducible data than lower flows (coefficient of repeatability 1.1 ppb for 58 mL/sec vs. 2.8 for 27 mL/sec vs. 5.7 for 18 mL/sec). eNO concentrations were about 25% higher in off-line than in on-line recordings if the initial 250 mL of exhaled gas were not eliminated, and 37% higher if exhalation lasted longer (16 sec vs. 8 sec). Eliminating 250 mL of dead space and shortening the filling time to 8 sec yielded off-line eNO values close to those on-line (geometric mean off-line eNO 14.4 ppb, 95% confidence interval: 12.2-17.0) vs. on-line eNO 13.8 ppb (95% confidence interval: 11.6-16.5). On-line and off-line results were highly correlated (r = 0.996, P = 0.000) and had similar coefficients of variation (on-line eNO 2.6%, off-line 2.8%). Neither agreement nor repeatability of eNO measurements were affected by disease status or baseline FEV(1) (% predicted values). Once standardized, the off-line eNO technique using 1-L gas collection bags will provide results similar to those recorded on-line.

ABO/Secretor genetic complex and susceptibility to asthma in childhood

A positive association has recently been reported in adult subjects between O/nonSecretor phenotype and asthma. To confirm this association, this study investigated the joint ABO/Secretor phenotype in a cohort of 165 asthmatic children. Three-hundred and sixty-two consecutive newborn infants from the same population were also studied as controls. The proportion of O/nonSecretor in asthmatic children was higher than in controls, thus confirming the association found in adults. The association was more marked in males than in females. In males, the pattern of association between the joint ABO/Secretor phenotype and asthma is dependent on the age at on-set of symptoms. Since the oligosaccharide composition of cell membrane and mucosal secretions is controlled by the cooperative interaction of ABO and Secretor genes, and since such composition influences the adhesion of infectious agents, the age pattern could reflect a more general interaction between developmental maturation and oligosaccharide structure concerning their effects on susceptibility to viral and bacterial agents.

Is the increase in childhood asthma coming to an end? Findings from three surveys of schoolchildren in Rome, Italy

Time trends in the prevalence of asthma, family history of asthma and atopy in Roman schoolchildren were assessed. The study population consisted of all children (aged 6-14 yrs) attending two primary schools in Rome, situated in urban areas that differed markedly in socioeconomic conditions and environmental pollution. Three questionnaire-based surveys were conducted in 1974, 1992 and 1998 in 2,259, 1,229 and 1,139 children. The prevalence of asthma in males and females increased significantly during 1974-1992 and remained stable from 1992-1998. In age groups born in the subsequent 4-yr periods it increased almost linearly, for children born from 1962-1965 to 1982-1985 (4.4%-12.5%), and remained remarkably stable in children born after 1985. Because the prevalence of asthma had a steeper trend in males than in females (approximately 0.55% x yr(-1) versus 0.25% x yr(-1)), the male:female asthma ratio increased (1:38 in 1974; 1:84 in 1992 and 1:62 in 1998). No single environmental factor, including area of residence, seemed to influence the prevalence of asthma. Family history of asthma and atopy also increased steadily (0.72% x yr(-1) and 0.30% x yr(-1) respectively) more than doubling during the 24-yr study period. The strong relationship between asthma and a family history of atopy not only persisted but also strengthened over time (23.3% of asthmatic children belonged to families with atopic illnesses in 1974 but 44.2% in 1998). The environmental factors that might explain the almost three-fold rise in childhood asthma between 1974 and 1992 remain unknown but the genetic background of the disease has presumably remained unchanged since the early 1970s. The fact that the prevalence of asthma increased no further during the past 6 yrs suggests that the progressive induction of asthma symptoms in genetically predisposed subjects is a self-limiting process that has probably come to an end in the authors' study area.

Changes over 13 years in skin reactivity to histamine in cohorts of children aged 9-13 years

BACKGROUND

Several studies report substantial differences in the prevalence of skin test reactivity to allergens in children from adjacent geographic areas; others report an increased prevalence over time. To find out whether these differences depend on variations in skin reactivity to histamine, we determined the time trend of histamine wheal sizes in successive cohorts of unselected children living in the same area (Viterbo, Italy).

METHODS

We conducted three epidemiologic surveys, each including children aged 9 and 13 years. The 1983-7 study investigated 170 children (150 were tested twice); the 1992 study, 158 children; and the 1996 study, 208 children.

RESULTS

In both age groups, the mean diameter of the wheal induced by histamine skin prick tests (10 mg/ml) increased significantly over time (9-year-olds: 3.25 mm in 1983, 4.68 in 1992, and 5.89 in 1996; 13-year-olds: 3.89 mm in 1987, 5.18 in 1992, and 6.50 in 1996) (P < 0.001 between subsequent studies). The distribution of the wheal diameters for both ages showed a trend to a right shift in the three successive studies (P < 0.001). The dose-response curves for three histamine concentrations (0.2, 1, and 10 mg/ml) had significantly steeper slopes in 1996 than in 1983-7 (P < 0.001).

CONCLUSION

The marked time-related increase in the size of the histamine wheals could help to explain the trend toward an increased prevalence of positive allergen skin test reactions reported during the past years. The causes of increased skin reactivity to histamine remain conjectural.

Cellular and noncellular components of bronchoalveolar lavage fluid in HIV-1-infected children with radiological evidence of interstitial lung damage

Children with acquired immune deficiency syndrome (AIDS) commonly have recurrent infectious and noninfectious lung complications that ultimately end in death. To study the intensity of alveolar inflammation and to evaluate the clinical utility of bronchoalveolar lavage (BAL) in children with HIV-1 infections, we retrospectively analyzed differential cell counts, lymphocyte subsets, and fibronectin and hyaluronic acid concentrations in BAL fluid of 18 HIV-1-positive children (9 boys, mean age 3.5 years, range 5 months-8 years) with radiological evidence of interstitial lung disease, and 19 control children who had undergone BAL for clinical indications not involving the lung parenchyma (13 boys, mean age 3 years, range 2 months-14 years). BAL fluid from 89% of the HIV-1 infected children showed CD8+ve lymphocytic alveolitis expressing HLA-DR, CD54, and CD 69 antigens. BAL fluid from HIV-infected patients typically contained markedly increased percentages and numbers of lymphocytes (P < 0.0001) and eosinophils (P < 0.04) and significantly higher concentrations of albumin (P < 0.05) and fibronectin (P < 0.0006) than fluids from control children. Whereas BAL cellular components did not differ in P. carinii-positive and P. carinii-negative HIV-1-infected children, fibronectin concentrations were significantly higher in P. carinii-positive than negative children. BAL cell differentials and noncellular components were related neither to severity of disease nor to patients' disease progression. These findings indicate that BAL is useful in studying the intensity of lung inflammation in children with HIV-1 infections and radiologically documented interstitial lung disease, but provides no information on the subsequent clinical course.

Nocturnal oximetry in infants with cystic fibrosis

AIM

To investigate whether children with cystic fibrosis under 3 years of age have disordered breathing and episodes of oxygen desaturation during sleep.

METHODS

We studied 19 infants (9 boys and 10 girls) with cystic fibrosis, mean age 13.1 months (range 3-36 months) and 20 age and sex matched healthy subjects. Patients and controls underwent an overnight polysomnographic study and respiratory function testing on the following morning.

RESULTS

Seven patients with ongoing respiratory tract inflammation had disordered breathing and episodes of oxygen desaturation during sleep. Pulse oximetry showed a significantly lower mean oxygen saturation (SaO(2)) and a higher percentage of total sleep time spent with SaO(2) less than 93% in symptomatic children than in controls.

CONCLUSION

Results suggest that infants and young children with cystic fibrosis and mild airways inflammation (rhinitis, cough, red throat) have episodes of oxygen desaturation during sleep.

Mediterranean clone of penicillin-susceptible, multidrug-resistant serotype 6B Streptococcus pneumoniae in Greece, Italy and Israel

In 1996, 19 isolates of serotype 6B Streptococcus pneumoniae with a unique resistance pattern were found in carriers attending daycare centres in Patras, Southwestern Greece. These isolates were penicillin susceptible but resistant to chloramphenicol, tetracycline, erythromycin, clindamycin and trimethoprim-sulphamethoxazole. Subsequently, isolates with the same characteristics were found in 23 additional carriers in central and southern Greece in 1997-98 as well as in 19 carriers in central Italy in 1997, and in seven carriers in southern Israel in 1998. Carriers were all children under 6 years of age, attending daycare centres or outpatient hospital visits. The relatedness of the isolates was determined on representative isolates from the three countries by pulsed-field gel electrophoresis of SmaI digests of chromosomal DNA. Most Greek isolates were identical to each other, while isolates from Italy and Israel showed one to three band differences, with all isolates being closely related to each other as well as to the isolates from Greece. We have therefore documented the presence of this unique clone of S. pneumoniae in these three countries and have named this the 'Mediterranean' clone. While isolates appear to have a common origin, their source and direction of spread are unknown. However, isolates from Italy showed the most diversity, suggesting that this clone had been present in that country for a longer period than it had been in Greece.

Sleep apnoea in children with diabetes mellitus: effect of glycaemic control

AIMS/HYPOTHESIS

Patients with diabetes mellitus commonly have cardiovascular autonomic dysfunction and an abnormal ventilatory pattern during sleep. Few data are available on these changes in childhood diabetes. We investigated whether young diabetic children with or without diabetic neuropathy have ventilatory dysfunction during sleep and if so, whether these autonomic changes are related to the duration of diabetes and glycaemic control.

METHODS

We studied 25 children with insulin-dependent diabetes mellitus (19 boys, mean age 7.72 +/- 1.99 years). All patients were insulin-dependent at diagnosis; blood samples for HbA1c assay were collected on the morning before testing and at 3-month intervals during the preceding year. Patients and control subjects (20 age-matched healthy children, 15 boys) underwent overnight polysomnography.

RESULTS

More diabetic patients than control subjects had sleep apnoeas (p = 0.006); apnoeas in patients also lasted longer (p = 0.07). Patients with poorly controlled diabetes had more apnoeas than patients with well-controlled diabetes and than healthy control subjects (p < 0.0001). Respiratory events during sleep correlated significantly with glycaemic control (r = 0.360; p = 0.09) and with the duration of diabetes (r = 0.430; p = 0.04).

CONCLUSION/INTERPRETATION

We conclude that respiratory control is compromised very early in children with diabetes. These anomalies are closely related to the duration of diabetes and to glycaemic control. In young children with diabetes, screening of ventilatory control using recording techniques that are simpler than polysomnography could provide an early indication that an adverse cardiopulmonary reaction has begun.

Effects of sleep stage and age on short-term heart rate variability during sleep in healthy infants and children

STUDY DESIGN

Power spectrum analysis of heart rate variability (HRV) is a noninvasive technique that provides a quantitative assessment of cardiovascular neural control. Using this technique, we studied the autonomic nervous system changes induced by sleep in 14 healthy subjects: 7 infants (mean age, 9.40 +/- 2.32 months) and 7 children (mean age, 8.93 +/- 0.65 years) during a standard all-night polysomnographic recording. Our primary aim was to assess the effect of sleep stage and age on short-term HRV during sleep in healthy infants and children. Power spectral density was estimated by autoregressive modeling over 250 consecutive R-R intervals. In this study, we mainly considered two spectral components: the high-frequency (HF) component (0.15 to 0.40 Hz), which reflects parasympathetic cardiovascular modulation; and the low-frequency (LF) component (0.04 to 0.15 Hz), generally considered due to both parasympathetic and sympathetic modulation.

RESULTS

Heart rate was higher (p < 0.01 in all sleep stages) and total power lower (p < 0. 02) in infants than in children. HF power was higher in children than in infants (p < 0.05). In infants and children, the ratio between LF and HF powers changed with the various sleep stages (p < 0.02 in infants; p < 0.01 in children): it decreased during deep sleep and increased during rapid eye movement sleep. However, it was invariably lower in children than in infants.

CONCLUSION

These findings show that the sleep stage and age both significantly influence short-term HRV during sleep in healthy infants and children. Hence, to provide unbiased results, HRV studies investigating the effects of age on autonomic nervous system activity should segment sleep into the five stages. In addition, despite a relatively small study sample, our data confirm greater parasympathetic control during sleep in children than in infants.

Prevalence of mefE, erm and tet(M) genes in Streptococcus pneumoniae strains from Central Italy

One hundred and seventy-three Streptococcus pneumoniae strains isolated from surveillance studies conducted in daycare centres were studied. The mefE, erm and tet(M) genes were detected in 16.2, 45.1 and 47.4% of isolates respectively. Agreement between PCR results and antibiotic susceptibility patterns was 100%. Macrolide resistance was due to the presence of erm in 73.6% of strains and to the presence of mefE in the remaining 26.4%. All tetracycline resistant strains carried the tet(M) gene. erm was associated with tet(M) in 98.7% of strains, whereas no isolate carrying mefE carried tet(M). A significant association was found between mefE and serogroup 6 (P < 0.0005) and between erm and tet(M) and serogroup 19 (P < 0.00001).

Bronchoalveolar lavage in children with chronic diffuse parenchymal lung disease

The aim of the present study was to compare cellular and noncellular components of bronchoalveolar lavage fluid (BAL) in a group of children with a diagnosis of chronic diffuse parenchymal lung disease (cDPLD) and a group of children without parenchymal lung disease undergoing BAL for various clinical indications (control group). We evaluated cellular and non-cellular components (total proteins, albumin, hyaluronic acid, and fibronectin) in BAL fluid from 14 children (7 boys and 7 girls; mean age 9.2 years, range 5 months to 18.4 years) fulfilling the clinical and radiological diagnosis of chronic cDPLD, and in 19 controls without evidence of lung disease. The 14 patients were assigned to two study groups: early-stage cDPLD (6 patients; age range 5 months to 5.2 years; duration of illness, 5-7 months) and long-standing cDPLD (8 patients; age range 9.6-18.4 years; duration of illness, 1.2-17.6 years). Ninety-three percent of the patients with cDPLD had at least two BAL constituents outside normal limits, with high numbers of cells, including all types of alveolar cells, but especially lymphocytes and foamy macrophages. These findings indicate a mixed, predominantly lymphocytic alveolitis. Our patients also had a significant increase in two noncellular BAL components, namely fibronectin and hyaluronic acid. BAL samples from children with long-standing cDPLD contained increased numbers of lymphocytes, whereas samples from children with early-stage cDPLD contained increased percentages and numbers of foamy macrophages and increased concentrations of fibronectin, hyaluronic acid, and albumin. In conclusion, we clearly identified an abnormal BAL profile in our group of cDPLD patients. Moreover, BAL findings differentiated younger cDPLD patients in the early stages of their illness from old patients with long-standing disease.

Resistance patterns of Streptococcus pneumoniae from children in central Italy

Nasopharyngeal swabs were collected from children aged 3-5 years in central Italy who were attending day-care centres or hospital outpatient clinics. One hundred and twenty-one strains of Streptococcus pneumoniae isolated were tested for susceptibility to penicillin, cefotaxime, erythromycin, clindamycin, tetracycline, chloramphenicol and cotrimoxazole. A high prevalence of penicillin-resistant (14%), erythromycin-resistant (60%) and multiply resistant strains (53%) were found. An unusual finding was that 49 of the 64 (76.6%) multiply resistant strains were penicillin-susceptible, 28 serogroup 6 strains also being resistant to the other antibiotics tested. Such strains have not previously been reported from Italy but have the same features as strains recently found in child carriers in the eastern Mediterranean area.

Detection of Pneumocystis carinii among children with chronic respiratory disorders in the absence of HIV infection and immunodeficiency

A nested polymerase chain reaction (PCR) assay was investigated for detection of Pneumocystis carinii in 96 respiratory tract specimens from 82 children, of whom 28 were immunocompetent but with chronic lung disorders (CLD), eight had AIDS and P. carinii pneumonia (PCP), 16 had AIDS but no respiratory symptoms, and 30 were healthy immunocompetent children. Gomori methenamine silver stain (GMS) and indirect immunofluorescence assay (IFA) were performed in parallel. Of 36 specimens from children with CLD, 12 were P. carinii PCR-positive compared to 10 positive by GMS-IFA. Of eight specimens from children with AIDS and PCP, seven were P. carinii-positive by PCR and six by GMS-IFA, and of 22 specimens from HIV-positive children without respiratory symptoms, two were positive by PCR and none by GMS-IFA. P. carinii DNA was also detected by PCR in blood samples from four children with P. carinii-positive nasopharyngeal aspirates. Specimens from healthy children were negative for P. carinii by both PCR and GMS-IFA. Of the seven children with CLD, who were P. carinii-positive, two had clinical and microbiological improvement with co-trimoxazole treatment, two improved initially but relapsed, and one had P. carinii cysts persistently in follow-up specimens despite co-trimoxazole treatment. These results suggest an association between P. carinii and exacerbations of CLD in childhood, in the absence of HIV infection or other immunodeficiency syndromes.

Validation of automated sleep analysis in normal children

With the aim of determining normal reference values for our sleep laboratory and evaluating the reliability of automated analysis for scoring polysomnographic studies in children, we recorded polysomnograms in 16 healthy boarding-school children. Sleep recordings were obtained with a computer system (Medilog SAC, Oxford Instruments). Polysomnographic variables were monitored continuously on a 16-channel recorder equipped with a video. Data were acquired on optical disk for computer-assisted data interpretation. Sleep stages and respiratory events were also scored visually by operator. Comparison with visual scores showed that the computer system significantly overscored wakefulness (W) (p<0.02) and stage IV (p<0.001) and underscored stage II (p<0.001) and rapid eye movement (REM) sleep (p<0.001). It also assigned respiratory events a higher score than did visual scoring, as shown by the higher apnoea index (AI) and hypopnoea index (HI) (AI p<0.03; HI p<0.001). Regression analysis showed a significant correlation between visual and automated scores for central (r=0.679; p<0.004) and obstructive apnoea (r=0.631; p<0.008). Computer apnoea scores did not correlate with visual scores. Much remains to be done before computer-based scoring systems can be relied upon, without visual scoring, for polysomnographic sleep studies in children. Their main advantage at present is that they offer a convenient means of saving paper, space and time.

Bronchoalveolar lavage cell analysis in a child with chronic lipid pneumonia

In an asymptomatic 4 yr old child with radiographic evidence of parenchymal lung disease, bronchoalveolar lavage (BAL) yielded the diagnosis of chronic lipid pneumonia caused by chronic aspiration of mineral oil given as a laxative. BAL analysis showed a marked reduction in the total number of alveolar macrophages; almost 70% of these cells contained intracytoplasmic lipid vacuoles. It also disclosed lymphocytic (cytotoxic/suppressor) alveolitis. A high percentage of lymphocytes expressed antigen markers of activation (human leucocyte antigen (HLA)-DR), CD54 and CD25). BAL analysis 18 months after mineral oil intake revealed that lymphocytes bearing antigen markers of activation had markedly decreased whereas alveolar macrophages (normal and lipid-laden) had increased. A subsequent whole lung BAL was considered unnecessarily invasive in this otherwise healthy child.

Bi-level positive airway pressure (BiPAP) ventilation in an infant with central hypoventilation syndrome

A 4-month-old baby girl, after a period of apparent good health, began to have aphonia, dyspnea, difficulties with swallowing, cyanosis, apnea, and hypopnea during sleep that resulted in admission to an intensive care unit for intubation and mechanical ventilation. At the age of 9 months she was admitted to our hospital with a possible diagnosis of central hypoventilation syndrome. A polysomnographic study showed apnea and hypopnea (apnea + hypopnea index = 47.1), hypercapnia (mean end-tidal PCO2 89 +/- 15.0 mmHg), and arterial desaturation (mean SaO2 91 +/- 1.7%; lowest SaO2 < 50%; 68% of total sleep time at SaO2 below 93%); the study also showed an absent ventilatory response to CO2, absent cardiac responses to apnea during sleep, and right ventricular hypertrophy. Nocturnal nasal bi-level positive airway pressure (BIPAP), applied initially at 6 cmH2O and gradually increased to 16 cmH2O, caused the sleep-related abnormal respiratory events to disappear. End-tidal PCO2 decreased to 39 mmHg, and SaO2 increased to 94%. After 6 months of nocturnal BiPAP ventricular right hypertrophy reversed and arrested growth and hypotonia normalized. The child has tolerated and has remained on BiPAP support up to her current age of 3 years and continues to use this form of ventilatory assistance without difficulties.

Asthma self-management programmes in a population of Italian children: a multicentric study. Italian Study Group on Asthma Self-Management Programmes

This study was designed to answer three main questions: 1) Does asthma self-management education reduce asthma morbidity? 2) Are the two programmes "Living With Asthma" and "Open Airways" equally effective in doing so? 3) Is a shortened version of these programmes (4 weeks) as effective as the longer original programme (8 weeks)? Twelve Italian centres of paediatric bronchopneumology selected 312 children with asthma, who were stratified by disease severity, gender and age, and then randomly assigned to an Experimental group which received an educational programme or to a Comparison group, which did not. Of the 312 children selected, 209 (114 Experimental and 95 Comparison) completed the educational protocol and a 1 year follow-up. Data recorded during the last 2 months of follow-up, 10 months after the educational intervention, showed that the Experimental group required significantly fewer emergency treatments: this reduction was more evident in the more severe asthma cases. In the Experimental, but not in the Comparison group, patients with more severe asthma consumed more medications than patients with milder asthma "Open Airways" yielded, in some cases, better results than "Living with Asthma": but a type 2 error is possible. The standard and the shortened programmes proved equally effective. In conclusion, following education, regardless of receiving a short or long educational programme, asthma patients use emergency care services less and use medications more appropriately in comparison with standard care without education. This suggests that short educational programmes can be highly cost-effective in children with asthma.

Physical performance in patients with thalassemia before and after transfusion

Patients with thalassemia who are on chronic transfusion programs have chronic ventilatory and cardiocirculatory abnormalities. We studied flow-volume curves, blood gas exchange, and cardiorespiratory responses to exercise in 12 patients with thalassemia major (TM) before and 24 hours after transfusions. Cardiorespiratory fitness was assessed with an exercise tolerance test on a cycle-ergometer. Ten healthy controls underwent the same protocol twice, first at baseline and then 24 hours later, without having had transfusions. We identified two subgroups of patients with a questionnaire: 1) those with no history of airway disease; and 2) those with a history of airway obstruction. Patients with no history of airway disease had normal baseline expiratory flows and no posttransfusion changes; those with a history of airway obstruction had lower pretransfusion expiratory flows rates and significantly decreased posttransfusion forced expiratory volume in 1 second (FEV1) and forced expiratory flow at 25-75% of forced vital capacity (FEV25-75%). As a group, TM patients had significantly lower pretransfusion cardiorespiratory function than controls; TM patients' maximum workload was 33% lower, maximum ventilation was 38% lower, maximum oxygen uptake was 25.7% lower, oxygen pulse was 28.6% lower, dyspnea index was 10.6% lower, and ventilatory equivalent for oxygen was 27.1% lower than in control subjects. Although cardiorespiratory responses to exercise improved in both subgroups after transfusion, patients with a history of airways obstruction had a significant posttransfusion increase in their dyspnea index (P = 0.05) and further increased their already abnormally high values of PETCO2 (43 mmHg). These results suggest that the transfusion worsened relative hypoventilation at the maximum workload only in the subgroup with a history of airway obstruction.

Bronchoalveolar lavage studies in children without parenchymal lung disease: cellular constituents and protein levels

We evaluated bronchoalveolar lavage fluid (BAL) for cellular constituents, concentration of total protein (TP), albumin (AL), fibronectin (FN), and hyaluronic acid (HA) in 16 children aged 2-32 months without pulmonary inflammatory or parenchymal disease to establish reference values. We compared our data to those reported in older children and in normal adult volunteers. BAL results were obtained simultaneously from the right middle lobe and the lingula. Results indicated that children younger than 3 years of age had a higher number of cells/mL than older children and adults (59.9 x 10(4) vs. 17.6 x 10(4) and 12 x 10(4)). Differential cell count revealed that the percentages of alveolar macrophages (AM), lymphocytes (LYM), and eosinophils (EOS) were similar to those obtained in older children and in adults, whereas the percentage of neutrophils (NEU) was higher in younger children (NEU 5.5 vs 1.6 and 1.2%, respectively) than in older children and adults. The latter difference was even greater in infants under 12 months of age (NEU 7.6%). The concentrations of TP, AL, FN, and HA in children's BAL samples were compared to values reported for adults. There were no differences between infants and children 13-32 months of age or normal adults. BAL fluid obtained simultaneously from the middle lobe and lingula were not significantly different. In conclusion, this is the first report on BAL values (cellular and noncellular constituents) in children younger than 3 years. The results may be used as reference values for further studies in children with parenchymal lung disease in this age group.

The effect of transfusion on pulmonary function in patients with thalassemia major

Pulmonary involvement has been documented in thalassemia major (TM). We studied 12 patients with TM before and 24 hr after transfusion to evaluate the effect of transfusion on baseline lung function. Personal and family histories of respiratory illnesses were obtained by a questionnaire. Spirometry and carbon monoxide diffusion capacity (KCO) measurements were made. Blood gases (PO2 and SO2) were determined on arterialized samples. Baseline expiratory volumes and flows were within normal range in all patients. Transfusion resulted in a significant reduction of forced expiratory volume in 1 sec (FEV1) and forced expiratory flow between 25 and 75% vital capacity (FEF25-75%). In two subgroups of patients identified by the questionnaire, those with no history of airway disease had normal baseline flows and no posttransfusion changes; those with history of airway obstruction had lower pretransfusion flows and significantly decreased posttransfusion FEV1 and FEF25-75%. The mean pretransfusion KCO value of 80% predicted for the whole group, significantly increased after transfusion (P < 0.05). Blood gases also significantly increased after transfusion (P < 0.05). When tested for the spirometric response to albuterol, patients with a history of asthma had a slightly greater increase in FEV1 and FEF25-75% than those who had never had asthma. We conclude that in our small study group, transfusion resulted in improved gas exchange and lung perfusion. The effect on flow limitation evident in some patients could, in part, be related to a preexisting bronchial hyperreactivity. Accurate evaluation of pulmonary function and of bronchial reactivity is advisable for patients with TM.

Relationship between cotinine levels, household and personal smoking habit and season in 9-14 year old children

The aim of this study was to determine the relationship of salivary cotinine levels with individual and household smoking habits and with the season in a sample (n = 146) of Italian schoolchildren aged 9-14 yrs. Active smoking and environmental tobacco smoke were measured by means of a confidential standardized interview with each participating child and by a self-reported questionnaire administered to the parents. Saliva samples were obtained twice: during winter from all children and during spring from a randomly selected subgroup. "Active smokers" were significantly more likely to be males and to live with smoking family members. Frequency of detectable cotinine both in "nonsmokers" and "active smokers" was significantly correlated with the number of cigarettes smoked by household members. However, for any level of smoking by parents detectable cotinine was more likely to be found in "active smokers" than in "nonsmokers". In "nonsmokers", the proportion of subjects with detectable cotinine decreased significantly in spring compared to winter, a finding not observed in "active smokers". In conclusion, we have demonstrated that passive smoking produces most effect in winter, and is linked to the amount and style of the parents' smoking, mainly related to smoking in presence of children. Conversely, salivary cotinine detected in spring appears to be derived mainly from active smoking.

Respiratory syncytial virus lung infection in infants: immunoregulatory role of infected alveolar macrophages

Thirteen previously healthy children with acute onset of severe lower respiratory tract signs and symptoms underwent bronchoscopy and bronchoalveolar lavage (BAL) for diagnostic purposes. BAL samples were assessed for viral, bacterial, mycobacterial, and fungal cultures. Cytospin preparations of BAL cells were assessed for expression of respiratory syncytial virus (RSV), HLA-DR, interleukin-1 beta, and tumor necrosis factor proteins. Purified alveolar macrophages from 2 RSV-infected children were assessed for viral replication. Three children had bacterial pneumonia and 6 were infected with RSV. BAL cells from RSV-infected children demonstrated viral protein expression. Alveolar macrophages were the predominant cell type recovered by BAL and demonstrated coexpression of RSV, HLA-DR, interleukin-1 beta, and tumor necrosis factor proteins. Purified alveolar macrophages from 2 RSV-infected children replicated RSV by infectious center assays. Thus, alveolar macrophages are infected by RSV in vivo and coexpress potent immunomodulatory molecules that potentially regulate the local immune response or lung injury due to this virus.

A comparative study of the efficacy and safety of loratadine syrup and terfenadine suspension in the treatment of 3- to 6-year-old children with seasonal allergic rhinitis

The efficacy and safety of loratadine and terfenadine in the treatment of 3- to 6-year-old children with seasonal allergic rhinitis were compared in a third-party-blind, randomized, parallel-group study. A total of 96 children were included in the efficacy analysis: 49 children received 5 or 10 mg of loratadine once daily, and 47 received 15 mg of terfenadine twice daily, for 14 days. The mean total score for both nasal and non-nasal symptoms was decreased significantly from baseline at days 3, 7, and 14 in both treatment groups. At endpoint, these scores had improved 73% in each group. There were no statistically significant differences between the two groups in the total symptom scores at any point during the study. Both treatments were effective in relieving individual nasal and nonnasal symptoms. Therapeutic response to treatment was good or excellent in 82% of loratadine-treated children and in 60% of terfenadine-treated children. Few adverse events were reported during the study; all were mild or moderate and were not significantly different between the two treatment groups. There were no reports of sedation or dry mouth in either group. Once-daily treatment with 5 or 10 mg of loratadine was as effective as twice-daily treatment with 15 mg of terfenadine in improving the symptoms of seasonal allergic rhinitis in children 3 to 6 years old. Both treatments were well tolerated.

Enhanced allergic sensitisation related to parental smoking

The objective of this study was to assess the role of parental smoking in changes, after a four year interval (1983-7), in the prevalence and severity of the atopic state in 166 pre-adolescent children. Allergy skin prick tests were related to parental smoking habits and their changes during this same interval. The total number of cigarettes smoked by parents decreased in 56 families while it increased in only 16. Boys had significantly more persistently positive skin tests and changed more frequently from negative to positive. The skin test index did not show significant changes in girls. This index did not change in children of persistent non-smokers or those starting to smoke during this period, while it increased among sons of those that quit smoking and of persistent smokers. This was not only due to those boys who became skin test positive during follow up. When analysis was restricted to 14 boys who had been skin test positive in 1983 and whose parents were persistent smokers, the index increased in eight, remained unchanged in four, and decreased in only two. This report supports the hypothesis that parental smoking is a factor that, together with specific allergenic exposure, may enhance allergic sensitisation in children.