Remission and long-term remission of pediatric-onset systemic lupus erythematosus

Objectives

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with diverse clinical presentations and prognoses. Remission can be achieved with or without glucocorticoid (GC) use, and several recent studies have suggested that long-term remission can be achieved in a small portion of patients. Nevertheless, few studies have investigated remission or long-term remission in the pediatric-onset SLE subgroup. This study analyzed the characteristics and factors associated with long-term remission and GC use in pediatric-onset SLE.

Methods

We enrolled 226 patients aged <18 years who received a diagnosis of SLE between January 2006 and December 2016. Three remission condition groups were defined: (A) complete remission, (B) clinical remission off GCs, and (C) clinical remission on GCs. Long-term remission was defined as remission for more than 5 years. We analyzed the treatment durations before remission, durations of remission, and risk factors for non-remission with persistent GC use.

Results

During follow-up, 8 patients (3.5%) achieved complete remission, 35 patients (15.5%) achieved clinical remission off GCs, and 93 patients (41.2%) achieved clinical remission on GCs. In groups A, B, and C, 12.5%, 68.6%, and 65.6% of patients, respectively, remained in remission for >1 year.

Conclusion

This study assessed remission of pediatric-onset SLE. Up to 60.2% of patients had clinical remission after treatment, and 19% of patients achieved remission off GCs. Long-term remission is rarer in pediatric-onset SLE than in adult-onset SLE.

The correlation between trajectories of serum C3 variability and clinical course in Pediatric-onset systemic lupus erythematosus

OBJECTIVE

The aim of this study is to investigate the usefulness which 2-year trajectories of C3 variability have in predicting clinical remission and systemic corticosteroids (SCS) use in pediatric patients with systemic lupus erythematosus (pSLE).

METHODS

We recruited 189 confirmed pSLE patients from the electronic database of our hospital, all had undergone SCS treatment. The follow up period was 4.17-14.83 years. We used Group-Based Trajectory modeling to divide the patients into four different trajectory groups by their initial 2-year C3 variability. We divided the patients into groups A, B or C by their clinical course and SCS use. Statistical methods included Kruskal-Wallis and Chi-square tests and logic regression test.

RESULTS

There were 4 separate trajectories. The distribution of groups A, B and C in these 4 trajectories showed a significant difference (p = 0.005). Initial C3 and C4 levels in these 4 revealed significant differences (p ≦ 0.001, p ≦ 0.016). When compared to other trajectories, trajectory1 showed a higher risk for persistent SCS use (p < 0.05). The distributions of severe clinical manifestations, including proteinuria, hematuria, CNS involvement and thrombocytopenia were different in these 4 trajectories (p = 0.003). Nevertheless, none of the above manifestations contributed to the risk of persistent SCS use.

CONCLUSIONS

We have found 4 distinct C3 trajectories in pSLE patients. Distributions of clinical outcome groups were different in these 4 trajectories. Patients with trajectory1 displayed a higher risk for persistent SCS use, thus an earlier institution of immunosuppressant(s) and biological agents can be considered for these children.

The Role of New 3D Pathology and Lymphocyte Expression of Interstitial Inflammation in Pediatric-Onset Lupus Nephritis

Lupus nephritis (LN) is a common and severe manifestation of pediatric-onset systemic lupus erythematosus (pSLE). It is one of the major causes of long-term glucocorticoid/immune suppressants use in pSLE. It causes long-term glucocorticoid/immune suppressants use and even end-stage renal disease (ESRD) in pSLE. It is now well known that high chronicity, especially the tubulointerstitial components in the renal biopsy, predicts a poor renal outcome. Interstitial inflammation (II), a component of activity in LN pathology, can be an early predictor for the renal outcome. With the advent of 3D pathology and CD19-targeted CAR-T cell therapy in the 2020s, the present study focuses on detailed pathology and B cell expression in II. We recruited 48 pSLE patients with class III/IV LN to analyze the risk of ESRD based on different II scores. We also studied 3D renal pathology and immunofluorescence (IF) staining of CD3, 19, 20, and 138 in patients with a high II score but low chronicity. Those pSLE LN patients with II scores of 2 or 3 showed a higher risk for ESRD (p = 0.003) than those with II scores of 0 or 1. Excluding patients with chronicity >3, high II scores still carried a higher risk for ESRD (p = 0.005). Checking the average scores from the renal specimens from different depths, the II, and chronicity showed good consistency between 3D and 2D pathology (interclass correlation coefficient [ICC], II = 0.91, p = 0.0015; chronicity = 0.86, p = 0.024). However, the sum of tubular atrophy plus interstitial fibrosis showed no good consistency (ICC = 0.79, p = 0.071). The selected LN patients with negative CD19/20 IF stains showed scattered CD3 infiltration and a different IF pattern of Syndecan-1 expression. Our study provides unique data in LN, including 3D pathology and different in situ Syndecan-1 patterns in LN patients.

Automatic Screening of Pediatric Renal Ultrasound Abnormalities: Deep Learning and Transfer Learning Approach

BACKGROUND

In recent years, the progress and generalization surrounding portable ultrasonic probes has made ultrasound (US) a useful tool for physicians when making a diagnosis. With the advent of machine learning and deep learning, the development of a computer-aided diagnostic system for screening renal US abnormalities can assist general practitioners in the early detection of pediatric kidney diseases.

OBJECTIVE

In this paper, we sought to evaluate the diagnostic performance of deep learning techniques to classify kidney images as normal and abnormal.

METHODS

We chose 330 normal and 1269 abnormal pediatric renal US images for establishing a model for artificial intelligence. The abnormal images involved stones, cysts, hyperechogenicity, space-occupying lesions, and hydronephrosis. We performed preprocessing of the original images for subsequent deep learning. We redefined the final connecting layers for classification of the extracted features as abnormal or normal from the ResNet-50 pretrained model. The performances of the model were tested by a validation data set using area under the receiver operating characteristic curve, accuracy, specificity, and sensitivity.

RESULTS

The deep learning model, 94 MB parameters in size, based on ResNet-50, was built for classifying normal and abnormal images. The accuracy, (%)/area under curve, of the validated images of stone, cyst, hyperechogenicity, space-occupying lesions, and hydronephrosis were 93.2/0.973, 91.6/0.940, 89.9/0.940, 91.3/0.934, and 94.1/0.996, respectively. The accuracy of normal image classification in the validation data set was 90.1%. Overall accuracy of (%)/area under curve was 92.9/0.959..

CONCLUSIONS

We established a useful, computer-aided model for automatic classification of pediatric renal US images in terms of normal and abnormal categories.

The correlation between VitD3 levels and the disease activity of childhood-onset systemic lupus erythematosus

BACKGROUND

There is growing evidence linking low levels of vitamin D3 to an increased risk of many autoimmune diseases. Compared to the general population, hypovitaminosis D is more prevalent among children with systemic lupus erythematosus (SLE), which can be associated with sun exposure avoidance, long-term corticosteroid treatment, and renal disease. Therefore, we launched this study to assess the correlation between 25 (OH) D3 (VitD3) levels and the disease activity of children with SLE (cSLE) in Taiwan.

METHODS

From September to December 2018, we recruited 31 cSLE patients from the Pediatric Out-patient Department of Taichung Veterans General Hospital. Their basic data, including SLE disease index 2000 (SLEDAI-2K) score, laboratory values, prescribed drugs and VitD3 levels were collected and analyzed statistically.

RESULTS

The mean serum VitD3 concentration was 19.7 ± 7.9 ng/mL and SLEDAI-2K 6.2 ± 5.0. Those patients (N = 16) with an SLEDAI-2K≦4 had higher VitD3 levels when compared to those (N = 15) with an SLEDAI-2K>4 (22.9 ± 7.7 vs 16.3 ± 6.7 points, p = 0.020). Five patients not taking systemic corticosteroids (SCS) had significantly higher VitD3 levels and lower SLEDAI-2K than those who took SCS (N = 26). Additionally, we found VitD3 levels to be negatively correlated to SLEDAI-2K (rs = -0.55, p = 0.001) and daily SCS dosages (rs = -0.49, p = 0.005).

CONCLUSION

This study shows that VitD3 deficiency is common in patients with cSLE. It was also noted that serum VitD3 levels negatively correlate to SLEDAI-2K, which can be partially explained by less usage of SCS.

Pseudohyperkalemia accompanying actual hyperphosphatemia and hypocalcemia in an adolescent with T-lymphoblastic lymphoma

Tumor lysis syndrome (TLS) is a life-threatening condition that may occur in patients with lymphoma, leukemia, or cancers with high cellular burdens. Without appropriate treatment, electrolyte imbalances, namely hyperkalemia, hyperphosphatemia, and hypocalcemia, can be fatal in patients with TLS. In pseudohyperkalemia, concurrent hyperphosphatemia and hypocalcemia can render devising a treatment strategy challenging. We report an adolescent with T-lymphoblastic lymphoma who presented with pseudohyperkalemia but actual hyperphosphatemia and hypocalcemia, to highlight the importance of accurate clinical interpretations of laboratory data in patients with TLS.

Frasier Syndrome: A Rare Cause of Refractory Steroid-Resistant Nephrotic Syndrome

Frasier syndrome is a rare disease that affects the kidneys and genitalia. Patients who have Frasier syndrome develop nephrotic syndrome (NS) featuring focal segmental glomerulosclerosis (FSGS) that is resistant to steroid treatment in early childhood. Male patients can have female external genitalia (pseudo-hermaphroditism) at birth and develop gonado-blastoma in their adolescence. Frasier syndrome is caused by mutations in the splice donor site at intron 9 of the Wilms’ tumor WT1 gene; these mutations result in an imbalanced ratio of WT1 protein isoforms and affect the development of the urogenital tract, podocyte function, and tumor suppression. Here, we report on a patient with long-term refractory NS who developed a malignant mixed germ cell tumor arising in a gonado-blastoma of the ovary 8 years after the onset of proteinuria.

Impact of antipyretics on acute asthma exacerbation during respiratory infection-A nationwide population-based study

BACKGROUND

Antipyretics are frequently used in pediatric practice. Both acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) have been reported to increase the risk of asthma exacerbation. The study investigated antipyretic use during respiratory infection in children and analyzed the risk of acetaminophen and NSAID for severe asthma exacerbation (AE) in asthmatic children in Taiwan.

METHODS

We used the data from the National Health Insurance Research Database in 2005. There were 27,095 pediatric asthmatic patients having at least one respiratory infection episode, and 27,095 age- and sex-matched non-asthmatic children with respiratory infection served as controls. These patients were divided into groups with acetaminophen use, NSAID cyclooxygenase-1 (COX-1) use, and no antipyretic use. The rate of AE occurrence within the first 7 days after respiratory infection diagnosis was compared among the groups.

RESULTS

During a single episode of respiratory infection, asthmatic patients used fewer antipyretics than controls (48.51% vs. 55.50%, p < 0.001). No difference was observed in the risk of AE occurrence within 7 days after respiratory infection between antipyretic users and antipyretic nonusers (22/13,144 [0.167%] vs. 12/13,951 [0.086%], p = 0.058). Compared with asthmatic children using acetaminophen, those using no antipyretic and COX-1 have lower risks for AE (OR: 0.26, 95% CI: 0.12-0.54, p < 0.001; and OR: 0.14, 95% CI: 0.03-0.61, p = 0.009).

CONCLUSION

In asthmatic children, the rate of AE after a single respiratory infection episode was around 0.144%. The risk of AE was higher in those who took acetaminophen.

A Novel BTK Gene Mutation in a Child With Atypical X-Linked Agammaglobulinemia and Recurrent Hemophagocytosis: A Case Report

X-linked agammaglobulinemia (XLA), caused by a mutation in the Bruton's tyrosine kinase (BTK) gene, is rarely reported in patients with recurrent hemophagocytic lymphohistiocytosis (HLH). This mutation leads to significantly reduced numbers of circulatory B cells and serum immunoglobulins in patients. Therefore, they exhibit repetitive bacterial infections since infancy, and immunoglobulin (Ig) replacement therapy is the primary treatment. HLH is a life-threatening condition with manifestations of non-remitting fever, hepatosplenomegaly, cytopenias, coagulopathy, lipid disorder, and multiple organ failure. It is caused by the immune dysregulation between cytotoxic T cells, NK cells, and histiocytes. The treatment is based on HLH-2004 protocol including immunotherapy, chemotherapy, supportive therapy, and stem cell transplantation. However, as we know more about the classification and pathophysiology of HLH, the treatment is modified. T-cell-directed immunotherapy is effective in patients with primary HLH, and strong immunosuppression is contraindicated in patients with severe ongoing infections or some primary immunodeficiency diseases (PIDs). Here, we report the case of a 7-year-old boy who presented with ecthyma gangrenosum and several episodes of pyogenic infections during childhood. At the age of 5 years, he exhibited cyclic HLH every 2–3 months. The remission of HLH episodes finally achieved after he received monthly Ig replacement therapy (400 mg/kg) at the 4th HLH. However, transient elevation of IgM was incidentally discovered after 6 cycles of monthly Ig replacement therapy. IgM-secreting multiple myeloma, Waldenström's macroglobulinemia, and lymphoma were excluded. The IgM levels then declined and returned to the normal range within a year. The patient and his parents received whole-genome sequencing analysis. It revealed a novel hemizygous c.1632-1G>A mutation in the BTK gene and XLA was diagnosed. XLA exhibits a spectrum of clinical and immunological presentations in patients. The identification of the mutation in the BTK gene contribute to an accurate diagnosis. Ig replacement therapy is the primary treatment for HLH in patients with XLA.

Risk of acute exacerbation between acetaminophen and ibuprofen in children with asthma

Background

Antipyretics are widely prescribed in pediatric practice. Some reports have mentioned that acetaminophen and non-steroid anti-inflammatory drugs may negatively affect asthma control by causing asthma exacerbation (AE). However, many confounding factors can also influence the risks. We assessed the impact of using acetaminophen or ibuprofen on AE in asthmatic children, especially those with strong risk factors.

Methods

We used the 2010 Taiwan National Health Insurance Research Database and identified 983 children with persistent asthma aged 1-5 years old; among them, 591 used acetaminophen alone and 392 used ibuprofen alone in 2010. Then, we analyzed the risk of AE over 52 weeks in the patients with and without severe AE in the previous year.

Results

The ibuprofen group had a higher risk of an emergency room (ER) visit or hospitalization for AE (odds ratio (OR) = 2.10, 95% confidence interval (CI) [1.17-3.76], P = 0.01). Among asthmatic children who had severe AE in the previous year, the risk of AE was higher in the ibuprofen group than in the acetaminophen group (OR = 3.28, 95% CI [1.30-8.29], P = 0.01), where as among those who did not, the risks of AE were similar between the acetaminophen and ibuprofen groups (OR = 1.52, 95% CI [0.71-3.25], P = 0.28).

Conclusions

Among young asthmatic children, use of ibuprofen was associated with a higher risk of AE than acetaminophen, if they had severe AE with ER visit or hospitalization in the previous year. Pediatricians should use antipyretics among children with asthma after a full evaluation of the risk.

Association between dry eye disease and asthma: a nationwide population-based study

BACKGROUND

Dry eye disease (DED), a chronic ocular disease, is associated with numerous medical issues, including asthma. However, studies on these associations are limited. In this study, we investigated the incidence of DED among patients with asthma and its correlation with other allergic comorbidities.

METHODS

We retrospectively analyzed data from the National Health Insurance Research Database of Taiwan. We compared the data of 41,229 patients with asthma with those of 164,916 sex- and age-matched non-asthma controls. We followed up the patient and control groups from 1998 to 2010, and compared the rate of DED in these two groups. We further analyzed the allergic comorbidities and asthma-related medication use among the patients with asthma to verify whether these factors were associated with DED.

RESULTS

The patients in the asthma group were more likely to have DED than were the controls (6.35% vs. 4.92%, p < 0.0001). In the asthma group, female had a higher risk of DED (odds ratio (OR) = 1.70, 95% confidence interval (CI) [1.57-1.85]) than males did. After adjustment for sex, age, income, urbanization, and the other two allergic comorbidities, patients with allergic rhinitis (adjusted OR = 1.58, 95% CI [1.46-1.72]) and urticaria (adjusted OR = 1.25, 95% CI [1.12-1.38]) were more likely to have DED, but not patients with atopic dermatitis (adjusted OR = 1.17, 95% CI [0.98-1.40]). Patients with asthma who had prescriptions of leukotriene receptor antagonists (LTRAs) (adjusted OR = 1.29, 95% CI [1.01-1.64]), oral antihistamines (adjusted OR = 2.02, 95% CI [1.84-2.21]), and inhaled corticosteroids (adjusted OR = 1.19, 95% CI [1.04-1.36]) exhibited association with DED.

DISCUSSION

Our findings reveal that patients with asthma-particularly females-were more likely to have DED, with comorbidities such as allergic rhinitis and urticaria, and prescriptions including LTRAs, antihistamines, and inhaled corticosteroids. The results suggest that in clinical practice, physicians should pay attention to DED, particularly in patients with a high risk of DED.

Pediatric Malignant Atrophic Papulosis

Malignant atrophic papulosis (MAP), also known as Degos disease, is an extremely rare disease that is characterized by its unique skin presentation (namely, central, porcelain-white atrophic lesions with a telangiectatic rim). MAP has the following 2 variants: cutaneous MAP is manifested in the skin alone, whereas systemic MAP affects the gastrointestinal tract, central nervous system, lungs, and other internal organs. Some patients who presented with only cutaneous symptoms at first may develop systemic symptoms several years later. Although the exact pathologic mechanisms are unclear, Magro et al suggested in a recent study that MAP is a vascular injury syndrome that involves complement component C5b-9 complex deposition and high expression of interferon-α. The prognosis of systemic MAP is poor and typically fatal within a few years. Nonetheless, because the C5b-9 complex is detected in MAP, some researchers have suggested combined treatment with eculizumab (a humanized monoclonal antibody against C5) and treprostinil (a prostacyclin analog). Here, we report on a girl with systemic MAP who had severe central nervous system involvement and responded to eculizumab.

Cell Penetrating Peptide Derived from Human Eosinophil Cationic Protein Decreases Airway Allergic Inflammation

Cell penetrating peptide derived from human eosinophil cationic protein (CPPecp) is a 10-amino-acid peptide containing a core heparan sulfate (HS)-binding motif of human eosinophil cationic protein (ECP). It binds and penetrates bronchial epithelial cells without cytotoxic effects. Here we investigated airway-protective effects of CPPecp in BEAS-2B cell line and mite-induced airway allergic inflammation in BALB/c mice. In BEAS-2B cell, CPPecp decreases ECP-induced eotaxin mRNA expression. CPPecp also decreases eotaxin secretion and p-STAT6 activation induced by ECP, as well as by IL-4. In vivo studies showed CPPecp decreased mite-induced airway inflammation in terms of eosinophil and neutrophil count in broncho-alveolar lavage fluid, peri-bronchiolar and alveolar pathology scores, cytokine production in lung protein extract including interleukin (IL)-5, IL-13, IL-17A/F, eotaxin; and pause enhancement from methacholine stimulation. CPPecp treated groups also showed lower serum mite-specific IgE level. In this study, we have demonstrated the in vitro and in vivo anti-asthma effects of CPPecp.

Identification of the trehalose-6-phosphate synthase gene family in winter wheat and expression analysis under conditions of freezing stress

Trehalose plays an important role in metabolic regulation and abiotic stress tolerance in plants. Trehalose contents are potentially modulated by trehalose-6-phosphate synthase (TPS), which is a key enzyme in the trehalose biosynthetic pathway. Using available wheat expressed sequence tag sequence information from NCBI and two wheat genome databases, we identified 12 wheat TPS genes and performed a comprehensive study on their structural, evolutionary and functional properties. The estimated divergence time of wheat TPS gene pairs and wheat-rice orthologues suggested that wheat and rice have a common ancestor. The number of TPS genes in the wheat genome was estimated to be at least 12, which is close to the number found in rice, Arabidopsis and soybean. Moreover, it has been reported earlier in other plants that TPS genes respond to abiotic stress, however, our study mainly analysed the TPS gene family under freezing conditions in winter wheat, and determined that most of the TPS gene expression in winter wheat was induced by freezing conditions, which further suggested that wheat TPS genes were involved in winter wheat freeze-resistance signal transduction pathways. Taken together, the current study represents the first comprehensive study of TPS genes in winter wheat and provides a foundation for future functional studies of this important gene family in Triticeae.

Influential factors of insufficient physical activity among adolescents with asthma in Taiwan

PURPOSE

Little research has been reported concerning insufficient physical activity in Taiwanese adolescents with asthma. The aims of this paper are to compare the amount of physical activity between asthmatic and non-asthmatic adolescents in Taiwan, as well as to investigate the influential factors associated with insufficient physical activity in asthmatic adolescents.

METHODS

Self-reporting structured questionnaires (socio-economic status, scale of family support for physical activity, amount of physical activity) and peak expiratory flow were assessed from 286 adolescents with asthma and 588 non-asthmatic adolescents in a cross-sectional design. Insufficient amount of physical activity was based on less than 300 minutes per week of moderate and vigorous physical activity.

RESULTS

Adolescents with asthma have a greater amount of physical activity and a higher level of family support than those who are non-asthmatic. In Taiwan, adolescents with asthma, girls relative to boys, obesity relative to average weight, and low family support relative to high family support were found to be associated with insufficient physical activity.

CONCLUSION

Physical activity in adolescents with asthma is insufficient especially in girls, in asthmatics with obesity, and in those with low family support. We suggest that physical activity programs should be applied to Taiwan adolescents with asthma in order to match the criteria of 300 minutes per week of moderate and vigorous physical activity, especially for girls, the obese and those with a low level of family support.

Treatment of recurrent complicated urinary tract infections in children with vesicoureteral reflux

BACKGROUND

Urinary tract infections (UTIs) in children with vesicoureteral reflux (VUR) are often caused by uropathogens with a high rate of drug resistance and are associated with a high rate of recurrence with a single pathogen. In this study, we evaluated the incidence of recurrent UTI and the drug resistance pattern of Escherichia coli in children with VUR. We also evaluated whether combination therapy comprising fosomycin plus one other antimicrobial agent is effective for treatment of recurrent UTIs.

METHODS

We retrospectively reviewed the medical records of all children with VUR who developed at least one episode of UTI during the period January 1, 2003 to December 31, 2013 at a single medical center. The effectiveness of fosfomycin plus amikicin for Enterobacteriaceae or ceftazidime for Pseudomonas aeruginosa infections was prospectively studied in six children with recurrent relapsing UTIs.

RESULTS

The study population comprised 129 children (age range, from 1month to 15 years; mean ± standard deviation, 2.37 ± 2.91 years) with VUR who developed at least one UTI during the 10-year study period; 68 (52.7%) had recurrent UTIs. The presence of an underlying urinary tract anomaly was predictive of recurrence (p = 0.028). The rates of susceptibility of E. coli to cefazolin (p < 0.001) and cefotaxime (p < 0.001) were significantly lower in patients with recurrent UTIs. Combination therapy with fosfomycin plus amikacin or ceftazidime was shown to be an effective therapeutic option for recurrent UTIs due to a single uropathogen.

CONCLUSION

The rates of susceptibility of E. coli to commonly used antimicrobials were significantly lower in children who developed more than one episode of UTI. The empiric choice of cefazolin or cefotaxime was usually ineffective. Administration of fosfomycin plus amikacin or ceftazidime was an effective therapeutic and preventive strategy in children with VUR and recurrent relapsing UTI.

Evaluation of the effect of Lactobacillus paracasei (HF.A00232) in children (6-13 years old) with perennial allergic rhinitis: a 12-week, double-blind, randomized, placebo-controlled study

INTRODUCTION

Dietary supplementation with probiotics alters intestinal microflora of children and may have immunomodulatory effects in prevention of allergic diseases. The aim of this study was to evaluate the effects of Lactobacillus paracasei (LP), strain HF.A00232, as a supplementary agent to levocetirizine in treating children with perennial allergic rhinitis (AR).

METHODS

This study was a 12-week, double-blind, randomized, placebo-controlled trial. Sixty children with AR aged 6-13 years with nasal total symptoms score (NTSS) ≥5 who fulfilled the inclusion criteria were enrolled. Patients were randomized into two groups with 28 participants receiving levocetirizine plus placebo and 32 participants receiving regular levocetirizine plus LP (HF.A00232) for the first 8 weeks, with a shift to levocetirizine as rescue treatment during the following 4 weeks. Parameters evaluated, including nasal, throat, and eye TSS (NTSS, TTSS, and ETSS, respectively), TSS and levocetirizine use, were recorded daily. Physical examinations and Pediatric Rhinoconjunctivitis Quality of Life Questionnaires (PRQLQs) were administered at each visit. In addition, blood samples were obtained for evaluation of cytokines including interleukin-4, interferon-γ, interleukin-10, and transforming growth factor-β at baseline, Week 8, and Week 12.

RESULTS

The LP (HF.A00232) group had significantly lower PRQLQ scores even after discontinuing regular levocetirizine from Week 9 to Week 12 (p < 0.01). There was more improvement in individual parameters in the PRQLQ, including sneezing (p = 0.005), itchy nose (p = 0.040), and swollen puffy eyes (p = 0.038), in the LP (HF.A00232) group. No significant differences in TSS, NTSS, TTSS, ETSS, or cytokine levels were found between the two groups.

CONCLUSION

Dietary supplementation with LP (HF.A00232) provided no additional benefit when used with regular levocetirizine in treating AR in the initial 8 weeks of our study, but there was a continuing decrease in PRQLQ scores, as well as a significant improvement in individual symptoms of sneezing, itchy nose, and swollen eyes, after discontinuing regular levocetirizine treatment.

Systemic lupus erythematosus and thyroid disease: A 10-year study

BACKGROUND

This large-scale study aims to analyze the association of systemic lupus erythematosus (SLE) with thyroid diseases.

METHODS

In this retrospective, nationwide cohort study, 1633 newly diagnosed SLE patients from the National Health Insurance Research Database in 2000 were examined and data on patients with diagnoses of hyperthyroidism, hypothyroidism, and autoimmune thyroiditis were collected from 2000 to 2009. We subdivided these SLE patients by the presence of overlap syndrome. Comparison with 6532 age- and sex-matched controls was performed.

RESULTS

The cumulative incidence of thyroid disease in SLE patients was lower than in controls (8.1% vs. 16.9%, p < 0.001). Among SLE patients, 39.7% had overlap syndrome. The overlap syndrome group had a higher cumulative incidence of thyroid diseases (10.96% vs. 4.57%, p < 0.0001), hypothyroidism (3.86% vs. 1.93%, p = 0.017), and autoimmune thyroiditis (4.63% vs. 0.71%, p < 0.0001) than SLE patients without overlap syndrome. Comparing the data with the non-SLE-matched control group by logistic regression model revealed a decreased risk of thyroid diseases with odds ratios (ORs) of 0.25 and 0.62 [95% confidence interval (CI) 0.18-0.33, 0.48-0.80], and hyperthyroidism with ORs of 0.21 and 0.30 (95% CI 0.14-0.31, 0.20-0.45) in SLE patients without and with overlap syndrome. SLE patients without overlap syndrome had a lower risk of hypothyroidism with an OR of 0.53 (95% CI 0.53-0.86) and autoimmune thyroiditis with an OR of 0.26 (95% CI 0.12-0.56). SLE patients with overlap syndrome showed a similar risk of hypothyroidism with an OR of 0.92 (95% CI 0.66-1.53) and a higher risk of autoimmune thyroiditis with OR of 1.69 (95% CI 1.14-2.51).

CONCLUSION

SLE patients had a significantly lower rate of thyroid diseases and hyperthyroidism than matched controls. Among SLE patients, risks of hypothyroidism and autoimmune thyroiditis were different in the presence of overlap syndrome. This finding is novel and important for clinical practices.

Asthma exacerbation in children: a practical review

Asthma is the most common chronic lower respiratory tract disease in childhood throughout the world. Despite advances in asthma management, acute exacerbations continue to be a major problem in patients and they result in a considerable burden on direct/indirect health care providers. A severe exacerbation occurring within 1 year is an independent risk factor. Respiratory tract viruses have emerged as the most frequent triggers of exacerbations in children. It is becoming increasingly clear that interactions may exist between viruses and other triggers, increasing the likelihood of an exacerbation. In this study, we provide an overview of current knowledge about asthma exacerbations, including its definition, impact on health care providers, and associated factors. Prevention management in intermittent asthma as well as intermittent wheeze in pre-school children and those with persistent asthma are discussed. Our review findings support the importance of controlling persistent asthma, as indicated in current guidelines. In addition, we found that early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations. Besides the use of medication, timely education after an exacerbation along with a comprehensive plan in follow up is also vitally important.

Heparin protects BALB/c mice from mite-induced airway allergic inflammation

More and more studies have demonstrated the anti-inflammatory effects of heparin. However, in the aspect of allergic airway inflammation, data about its daily use in animal model is scarce. To evaluate the efficacy of 22-day intranasal heparin administration in mite-induced airway allergic inflammation in BALB/c mice, the murine model of house dust-mite allergen-induced asthma was used to assess the effect of heparin (h) and low molecular weight heparin (l mwh) administered intra-nasally (IN) throughout the full study period (22 days). Effects were monitored by histopathology, cell counts in broncho-alveolar lavage fluid (BALF), local cytokine production, serum, specific antibody levels, and airway resistance measurements. Compared to the positive control group, both hIN and lmwhIN groups had lower peri-bronchiolar/alveolar inflammatory pathology score and lower goblet cell scores (p less than 0.01); lower eosinophil and neutrophil counts in BALF (p less than 0.0001); and lower cytokine levels including IL-17A/F, IL-5, IL-13, IL-8 and eotaxin in lung tissue (p less than 0.001). Serum Der p-specific IgE level was also lower in heparin-treated groups (p less than 0.004). The two heparin-treated groups also revealed lower value of Penh after Mch stimulation. In conclusion, heparin and lmw heparin decrease serum Der p-specific IgE level and possess anti-inflammatory effects on mite-induced airway allergic inflammation model in BALB/c mice.

The association between Kawasaki disease and allergic diseases, from infancy to school age

Kawasaki disease (KD) is the most common acquired heart disease among preschool children in most industrialized countries. An atopic trend after KD illness has been observed in epidemiological studies. This is consistent with the findings of elevated IgE levels and increased IL-4 in KD patients. However, studies on the early allergic association among children with KD are still limited. This study aimed to evaluate the association between KD and allergic diseases, from infancy to school age. Allergic diseases included atopic dermatitis, allergic rhinitis (AR), asthma, and urticaria. This matched case-control study used the National Health Insurance Research Database of Taiwan as its data source. Patients born between 1997 and 2004 and with a main diagnosis of KD were retrieved for analysis. A 1:4 matched control group was selected by zip code, gender, and age. The prevalence rates and progression sequence of allergic manifestations were analyzed. During the first 5 years of life, children with KD had higher rates of allergic manifestations. Both groups have similar atopic march. In 2010, at the age of 6-13 years, there were 7072 children with KD and 27,265 children without KD. Children with KD had more AR (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.22-1.38) and asthma (OR, 1.16; 95% CI, 1.05-1.27) than controls. Children with KD have a higher allergic susceptibility recognized from their 1st year of life. The atopic tendency persists until school age. Additional studies are needed to elucidate the underlying determinants of this distinct immune phenotype.

The natural course of eczema from birth to age 7 years and the association with asthma and allergic rhinitis: a population-based birth cohort study

Although "atopic march" is a popular concept, the relationship between eczema and subsequent asthma is far from clear. However, some cohort studies have shown the possibility of two different allergic phenotypes in those who present with early eczema in terms of their persistency. We checked the cohort data from 308,849 children born in 2000 in Taiwan, to evaluate the different courses of eczema and their relationships to subsequent asthma and allergic rhinitis (AR) at age 7 years. We examined the age prevalence of eczema, asthma, and AR up to 7 years of age. We grouped all cases according to their course of eczema, as well as wheezing, and determined the rates of asthma and AR at age 7 years. We checked the adjusted risk factors by multiple logistic regression model. We also examined the distributions of wheezing types in different eczema groups. We found the "atopic march" pattern of allergic diseases based on their age prevalence. Early eczema was associated with asthma and AR at the age of 7 years. Those with eczema symptoms persisting after 36 months of age had a higher risk than those with transient eczema. Early wheeze also contributed to asthma and AR later in childhood. In addition, late-onset eczema had a completely different wheeze distribution compared with other groups and also had a higher risk for asthma and AR than transient eczema. In conclusion, different eczema phenotypes could be found in this population-based cohort. This article emphasizes the special attention to the persistency and late-onset eczema in clinical practice.

Prevalence of attention-deficit/hyperactivity disorder in patients with pediatric allergic disorders: a nationwide, population-based study

BACKGROUND

Allergic disorders are common, chronic conditions in pediatric populations. The characteristic symptoms of allergic disorders mainly include bronchial asthma (BA), allergic rhinitis (AR), and atopic dermatitis (AD), all of which may disturb sleep, leading to daytime inattention, irritability, and hyperactivity, which are also components of attention-deficit/hyperactivity disorder (ADHD). Conflicting data exist in the literature regarding the relationship between ADHD and allergic disorders. The aim of this nationwide, population-based study is to examine the prevalence and risk of developing ADHD among allergic patients in a pediatric group.

METHODS

Data from a total of 226,550 pediatric patients under 18 years of age were collected from Taiwan's National Health Insurance Research Database recorded from January 1 to December 31, 2005 and analyzed. We calculated the prevalence of allergic diseases based on various demographic variables, including ADHD. We also used multivariable logistic regression to analyze the risk factors of ADHD.

RESULTS

In 2005, the period prevalence rates of allergic disorders and ADHD in persons under the age of 18 were 21.5% and 0.6%, respectively. Pediatric patients with allergic disorder(s) had a substantially increased rate of developing ADHD (p < 0.001) in terms of period prevalence and odds ratio (OR). This significance existed across various demographic groups regardless of age, gender, location, or degree of urbanization of their residence. BA and AR, but not AD, were determined to be risk factors for ADHD. Co-morbidities of allergic disorders, including AR+AD, AR+BA and AR+BA+AD, but not BA+AD, were also determined to increase the risk of ADHD.

CONCLUSION

Allergic disorders appear to increase the risk of ADHD in pediatric patients. Our detailed analysis shows that the main contributing factor is AR. Co-morbidity with AD, BA, and BA+AD in AR patients further increases the risk of ADHD.

Use of electroporation and reverse iontophoresis for extraction of transdermal multibiomarkers

Background

Monitoring of biomarkers, like urea, prostate-specific antigen (PSA), and osteopontin, is very important because they are related to kidney disease, prostate cancer, and ovarian cancer, respectively. It is well known that reverse iontophoresis can enhance transdermal extraction of small molecules, and even large molecules if reverse iontophoresis is used together with electroporation. Electroporation is the use of a high-voltage electrical pulse to create nanochannels within the stratum corneum, temporarily and reversibly. Reverse iontophoresis is the use of a small current to facilitate both charged and uncharged molecule transportation across the skin. The objectives of this in vitro study were to determine whether PSA and osteopontin are extractable transdermally and noninvasively and whether urea, PSA, and osteopontin can be extracted simultaneously by electroporation and reverse iontophoresis.

Methods

All in vitro experiments were conducted using a diffusion cell assembled with the stratum corneum of porcine skin. Three different symmetrical biphasic direct currents (SBdc), five various electroporations, and a combination of the two techniques were applied to the diffusion cell via Ag/AgCl electrodes. The three different SBdc had the same current density of 0.3 mA/cm², but different phase durations of 0 (ie, no current, control group), 30, and 180 seconds. The five different electroporations had the same pulse width of 1 msec and number of pulses per second of 10, but different electric field strengths of 0 (ie, no voltage, control group), 74, 148, 296, and 592 V/cm. Before and after each extraction experiment, skin impedance was measured at 20 Hz.

Results

It was found that urea could be extracted transdermally using reverse iontophoresis alone, and further enhancement of extraction could be achieved by combined use of electroporation and reverse iontophoresis. Conversely, PSA and osteopontin were found to be extracted transdermally only by use of reverse iontophoresis and electroporation with a high electrical field strength (>296 V/cm). After application of reverse iontophoresis, electroporation, or a combination of the two techniques, a reduction in skin impedance was observed.

Conclusion

Simultaneous transdermal extraction of urea, PSA, and osteopontin is possible only for the condition of applying reverse iontophoresis in conjunction with high electroporation.

Prevalence of attention deficit/hyperactivity disorder in pediatric allergic rhinitis: a nationwide population-based study

Allergic rhinitis (AR) is the most common chronic condition in pediatric populations. Characteristic symptoms in AR may bother daily activities and disturb sleep, leading to daytime inattention, irritability, and hyperactivity, which are also components of attention deficit/hyperactivity disorder (ADHD). Conflicting data exist in the literature regarding the relationship between ADHD and AR. The aim of this nationwide population-based study was to examine the prevalence and risk of ADHD among AR patients in a pediatric group. Data from a total of 226,550 pediatric patients <18 years old were collected from Taiwan's National Health Insurance Research Database from January 1 to December 31, 2005 and analyzed. We calculated the prevalence of allergic diseases based on various demographic variables, as well as in ADHD patients. We also used multivariable logistic regression to analyze the risk factors of ADHD. In 2005, the period prevalence rates of atopy and ADHD in patients <18 years of age were 15.35 and 0.6%, respectively. Pediatric patients with AR had a substantially increased rate of ADHD (p < 0.001) in terms of period prevalence and odds ratio. This significance existed across various demographic groups regardless of age, gender, area, or degree of urbanization. Neither comorbidity of atopic dermatitis nor bronchial asthma carried high risk for ADHD in AR patients. The present study revealed an increased rate of ADHD among AR patients. Therefore, evaluation of ADHD is advised for treatment of AR children.

Sodium sulfite aggravated allergic sensitization and airway inflammation in mite allergen sensitized BALB/c mice

Sulfur dioxide is a typical air pollutant. Sulfite, which is formed at the bronchial mucosa from inhaled sulfur dioxide, might play a role in the exacerbation of asthma. In this study, we investigated the effects of sodium sulfite and its interaction with a house dust mite (Dermatophagoides pteronyssinus, Der p) on allergic sensitization and airway inflammation. BALB/c mice were divided into four groups: control (n = 10), mite intranasal (mIN, n = 12), sodium sulfite intranasal (sIN, n = 12) and mIN + sIN (n = 12). In non-control groups, the mice were sensitized on day 8 and day 15 with mite allergen subcutaneously. Mite allergen was then administrated intranasally from day 15 to day 22 in mIN and mIN+sIN groups. Sodium sulfite was administrated in sIN and mIN + sIN groups intranasally from day 1 to day 22. Plasma Der p-specific IgE, IgG2a, lung histopathology and cytokine levels (IL-5 and IFN-γ) were analyzed. In comparison between mIN (or sIN) and mIN + sIN group, Der p-specific IgE levels were significantly higher in mIN + sIN group (p < 0.01). Besides, Der p-specific IgG2a level was significantly lower in mIN + sIN group than mIN (or sIN) group (p < 0.01). The peribronchiolar, alveolar and total inflammatory scores were increased in the mIN + sIN group comparing with the control group (p < 0.05, p < 0.01, p < 0.01, respectively). Lung supernatant in mIN + sIN group has higher IL-5/IFN-γ ratio than control, mIN or sIN group (all p < 0.05). Our study concluded sodium sulfite may enhance allergic sensitization as well as airway inflammation in mite allergen sensitized BALB/c mice.

A preliminary study to evaluate a patient-centred asthma education programme on parental control of home environment and asthma signs and symptoms in children with moderate-to-severe asthma

AIMS AND OBJECTIVES

To evaluate the effectiveness of a nurse-led patient-centred asthma education programme on home environmental control behaviours of parents of children with moderate or severe asthma.

BACKGROUND

Reducing allergic triggers is important self-management behaviour for preventing asthma attacks and patient-centred asthma education has been shown to effectively manage chronic disease.

DESIGN

A preliminary quasi-experimental, non-equivalent control group design was used.

METHOD

Dyads (n = 75) of parents and their children with moderate or severe asthma (ages 6-14 years) were purposively recruited from the asthma clinics of two hospitals in central Taiwan. The experimental group of 38 children/parents from one hospital received patient-centred asthma education. The comparison group of 37 children/parents from the other hospital received routine individual education. At pretest and at the end of the three-month patient-centred asthma education programme, we measured parents' control of home environmental triggers, children's asthma signs/symptoms and children's pulmonary function. Data were analysed by the general linear model for repeat measures.

RESULTS

The level of improvement in dust and cleaning methods was significantly greater among parents in the experimental group than among those in the comparison group (p < 0.05). Children with moderate or severe asthma in the experimental group had fewer signs/symptoms of asthma and better lung function than children in the comparison group.

CONCLUSIONS

Our patient-centred asthma education programme improved parents' home environmental control and children's asthma sign/symptoms and lung function.

RELEVANCE TO CLINICAL PRACTICE

Nurses can play primary roles as patient educators in asthma clinics. Well-trained patient educators can continuously monitor self-management behaviours to improve patients' compliance with home environmental control, thus leading to better physical outcomes in children with asthma than routine individual asthma education alone.

Caffeic acid phenethyl ester suppresses the induction of eotaxin in human lung fibroblast cells

BACKGROUND

Eotaxin, a CC chemokine, plays an important role in inflammation of airway allergic diseases. The authors investigated the activities of caffeic acid phenethyl ester (CAPE), the active component of propolis, in regulating eotaxin production in human lung fibroblast.

MATERIAL AND METHODS

The authors used human lung fibroblasts, CCD-11Lu cells, stimulated with interleukin-13 (IL-13) and tumor necrosis factor-alpha (TNF-alpha), to induce eotaxin secretion. The cells were treated with CAPE of different concentrations and pretreatment duration to check its inhibition in eotaxin production. Enzyme-linked immunosorbent assay (ELISA) was used to measure eotaxin secretion; electrophoretic mobility shift assay (EMSA) to check nuclear factor kappa B (NF-kappaB)-promoter binding; and Western blot to quantitate the cyplasmic inhibitor of NF-kappaB (IkappaB) and nuclear NF-kappaB p65.

RESULTS

CAPE inhibited the production of eotaxin in CCD-11Lu cells stimulated by IL-13 and TNF-alpha combination in a dose- and time-dependent manner. The authors also demonstrated CAPE to be able to inhibit NF-kappaB activation in CCD-11Lu cells.

CONCLUSION

The authors suggest that CAPE is a promising agent in controlling eosinophils influx in human airway.

Concurrence of Incontinentia Pigmenti and Behçet's Disease

We report here a rare case of incontinentia pigmenti (IP) in a 10-year-old girl who developed Behçet's disease. IP was diagnosed in infancy and Behçet's disease was diagnosed at 10 years of age. The initial presentations of Behçet's disease were spiking fever and recurrent painful oral and genital ulcers that were refractory to antibiotics. After corticosteroid treatment, her fever subsided and ulcers subsequently healed. The patient's mother and sister were also diagnosed with IP. Her mother had suffered from Behçet's disease since her teenage years and it was complicated with colon perforation. Although there are several reports on the combination of IP and Behçet's disease, this is the first reported case of a family with such concurrence.

Asthma drugs counter-regulate interleukin-8 release stimulated by sodium sulfite in an A549 cell line

BACKGROUND

Clinical manifestations suggest that air pollution may induce deterioration of respiratory health. Some air pollutants, including sulfite, may play a role in the exacerbation of asthma. Sulfites are formed at bronchial mucosa from inhaled sulfur dioxide. It has been previously reported that sodium sulfite (Na(2)SO(3)) has pro-inflammatory properties and enhances neutrophil adhesion to A549 cells. Interleukin-8 (IL-8) plays a critical role in attracting inflammatory cells and is an excellent marker of pulmonary cell activation. To date, there have not been any reports on the effect of asthma drugs on the suppression of IL-8 production induced by sulfite in A549 cells or the involvement of specific signal transduction pathways. Thus, our study assessed the effects of salmeterol, fluticasone, and montelukast on human epithelial lung cell inflammation as well as the inhibitors in different signal transduction pathways.

METHODS

A549 human lung epithelial cells were cultured under the following conditions: (1) treated with sodium sulfite (0, 100, 500, 1000, 2500 uM) for 16 hours; (2) cultured for 1 hour in the presence of SB203580, PD98059, SP600125, or wedeloactone, then co-incubated with sodium sulfite for another 16 hours; (3) cultured for 4 hours in the presence of salmeterol, fluticasone, or montelukast, then stimulated with sodium sulfite at a concentration of 1000 uM for 16 hours. We collected the supernatants from the above conditions and performed enzyme-linked immunosorbent assay (ELISA) to measure the IL-8 concentration.

RESULTS

IL-8 production increased after treatment with sodium sulfite at 1000 to 2500 uM (p <or= 0.001). SB203580, PD98059, and wedeloactone decreased IL-8 production stimulated by Na(2)SO(3) (p < 0.01). Salmeterol, fluticasone, and montelukast significantly suppressed IL-8 secretion from sodium sulfite-stimulated A549 cells (p < 0.01).

CONCLUSIONS

Sodium sulfite has pro-inflammatory properties in vitro and can induce potent chemotactic factor IL-8 production. Possible signal transduction pathways required for IL-8 gene expression following exposure to sulfite are the NF-kappa B, ERK, and p-38-dependent pathways. Salmeterol, fluticasone, and montelukast all have inhibitory effects on sodium sulfite-induced IL-8 production in A549 cells.

HLA-DR, -DQB typing of steroid-sensitive idiopathic nephrotic syndrome children in Taiwan

BACKGROUND

The association between human leukocyte antigens (HLA) and idiopathic nephrotic syndrome (INS) in children has been discussed in various studies.

METHODS

In this study, 59 Chinese children with steroid-sensitive nephritic syndrome (SSNS) in Taiwan were enrolled, and 33 patients underwent renal biopsy.

RESULTS

The frequency of HLA-DR11 was found to be significantly higher and HLA-DR14 was lower in SSNS patients as compared with the healthy control group. In frequent relapsers, HLA-DR4 was more frequent, while HLA-DQB1*0602 was less frequent, as compared with infrequent relapsers. However, there was no significant difference between steroid-dependent and non-steroid-dependent patients. In patients who showed a response to levamisole, the HLA-DR9 and -DQB1*0303 alleles were more frequent, while HLA-DR13 was less frequent. In a comparison of HLA in different INS pathologies, HLA-DQB1*0401 was significantly frequent in IgM nephropathy. Even though we compared each group with the control group separately, the HLA distributions of both groups still differed from each other. Our data suggest that the immunogenic characteristics of children with SSNS in Taiwan are different from those of other populations. The common motif between different HLA alleles and the three-dimensional crystal structures may offer an explanation for the varying results from different populations.

CONCLUSION

According to HLA typing, the results support the hypothesis that IgM nephropathy is a different entity from minimal change nephrotic syndrome.

Influence of cetirizine and levocetirizine on two cytokines secretion in human airway epithelial cells

Recent studies suggest that several second-generation antihistamines can modulate various inflammatory reactions besides their H(1)-receptor antagonism. The antihistamine cetirizine is a racemic mixture of levocetirizine and dextrocetirizine. The aim of this study was to investigate the effects of these two antihistamines (cetirizine and levocetirizine) on granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin (IL)-8 secretion in A549 human airway epithelial cells. A549 cells were preincubated with cetirizine (0.1, 1, 2.5, 5, and 10 microM) or levocetirizine (0.1, 1, 2.5, 5, and 10 microM) individually for 16 hours and were then stimulated with IL-1beta for 8 hours. The levels of GM-CSF and IL-8 in cultured supernatants were measured by enzyme-linked immunosorbent assay (ELISA). Our data showed that cetirizine (5 and 10 microM) and levocetirizine (2.5, 5, and 10 microM) significantly suppressed GM-CSF secretion from A549 cells stimulated with IL-1beta (p<0.05). Cetirizine (10 microM) and levocetirizine (5 and 10 microM) significantly suppressed IL-8 secretion after A549 was stimulated. The suppressive effect was comparable between levocetirizine, 2.5 microM, and cetirizine, 5 microM, as well as levocetirizine, 5 microM, and cetirizine, 10 microM. Moreover, levocetirizine, 5 microM, was better than cetirizine, 5 microM, on suppressing IL-8 secretion, but such a difference did not appear in other conditions. Our results suggest that cetirizine and levocetirizine at higher concentrations can reduce the release of GM-CSF and IL-8 from A549 cells stimulated with IL-1beta. These observations indicate that the two second-generation antihistamines may exert anti-inflammatory effects beyond histamine H(1)-receptor antagonist, and levocetirizine plays a major role in terms of this activity.

Changes in serum specific IgG4 and IgG4/ IgE ratio in mite-sensitized Taiwanese children with allergic rhinitis receiving short-term sublingual-swallow immunotherapy: a multicenter, randomized, placebo-controlled trial

The aim of this study was to evaluate the clinical and immunologic effects of sublingual-swallow immunotherapy (SLIT). A six-month, multicenter, double-blind, placebo-controlled trial was carried out in 59 patients aged 6 to 18 years with allergic rhinitis who were sensitized to mites only. Patients were randomly assigned to placebo or SLIT with a standardized Dermatophagoides pteronyssinus (D.p.)/D. farinae (D.f) 50/50 extract. Nasal symptom scores and use of medications were recorded. Skin sensitivity, mite-specific IgE, IgG4, and IgG4/IgE were evaluated before and after treatment. The skin sensitivity, total nasal symptom scores and medication consumption did not differ significantly after treatment. Specific IgG4 (both p <0.001) and IgG4/IgE to D.p. and D.f (p = 0.010, p = 0.001, respectively) increased significantly in the treatment group. Specific IgE increased significantly in both placebo and SLIT groups after treatment but did not differ between the two groups. The medication was well tolerated. SLIT did not significantly improve clinical manifestations of allergic rhinitis when used for 6 months. We demonstrated SLIT did significantly increase specific IgG4 and IgG4/IgE compared to treatment with placebo.

The air pollutant sodium sulfite enhances mite crude extract-stimulated detachment of A549 airway epithelium cells

BACKGROUND AND PURPOSE

It has been previously reported that the pollutant sodium sulfite (Na2SO3) can activate airway epithelial cells; however, there is as yet no evidence of any direct relationship between house dust mite allergen exposure and Na2SO3 with regards to the pathogenesis of airway allergy. This study investigated the effect of sulfite on mite-stimulated human airway epithelial cells.

METHODS

The A549 human lung epithelial cell line was used as an in vitro model. Cells were treated with 10 microg/mL mite crude extract for 8 h and/or Na2SO3 (0, 10, 100, 500, 1000 and 5000 microM) for 16 h, and cell adhesion and dissociation on a cell culture plastic surface were quantitated with a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide colorimetric assay. Changes in cell adhesion were also analyzed by monitoring the expression of the cell surface of adhesion molecules integrin alpha2 (CD49b) and integrin alpha6 (CD49f) using flow cytometry.

RESULTS

A549 cells treated with either mite crude extract only or Na2SO3 only did not show a significant increase in dissociation from the cell culture plastic surface. However, when cells were pretreated with mite extract for 8 h, followed by 16-h incubation with various concentrations of Na2SO3, cell dissociation was enhanced in a dose-dependent manner. A dose-dependent decrease of CD49b and CD49f expression was also seen in cells treated with Na2SO3 only and in mite-pretreated cells. Mite treatment decreased CD49b expression, and a cumulative effect was seen in cells further treated with Na2SO3.

CONCLUSION

Significant dissociation of airway epithelial cells with Na2SO3 stimulation only occurred in cells pretreated with mite extract. Mite pretreatment enhanced Na2SO3-induced CD49f down-regulation; Na2SO3 and/or mite extract down-regulated CD49b expression of A549 cells. These findings indicate that a synergistic effect of mite extract and sulfite can severely disrupt the airway bronchial epithelial barrier.

Physical activity and physical self-concept: comparison between children with and without asthma

AIM

This paper reports a study comparing levels of physical activity and physical self-concepts between children with and without asthma.

BACKGROUND

Childhood asthma has become one of the world's most prevalent chronic illnesses. Its symptoms are thought to prevent children from participating in some forms of physical activity. However, asthma treatment guidelines are increasingly suggesting that children with asthma can participate in the same physical activities as healthy children for the same reasons-- to promote normal growth, physical development and psychological health.

METHOD

Between October 2001 and May 2002, 120 children between the ages of 9 and 11 with mild and moderate asthma were recruited from three paediatric asthma clinics in Taiwan, and 309 non-asthmatic children in the same age group were selected from four elementary schools in Taiwan's three largest cities. Participants were asked to record physical activity levels for 3 days out of the past 7 days and to fill out a 29-item Physical Self-Concept Inventory. Physical activities were classified as moderate-to-vigorous physical activity or vigorous physical activity. Physical self-concept was measured in terms of perceived flexibility, endurance, appearance, agility, obesity and strength.

RESULTS

Asthma was the primary factor determining vigorous physical activity levels, but gender was the primary factor determining physical self-concept, especially in terms of endurance, obesity and strength. No statistically significant relationships were noted between asthma and gender in terms of effects on physical activity and physical self-concept.

CONCLUSIONS

Asthma interferes with children's ability to participate in vigorous physical activity but not in moderate-to-vigorous physical activity. Gender determines primary differences in physical self-concept. Appropriate exercise recommendations are necessary to encourage children with asthma to engage in vigorous physical activity for normal growth.

Changes of soluble CD26 and CD30 levels correlate with response to interferon plus ribavirin therapy in patients with chronic hepatitis C

BACKGROUND

Clearance of hepatitis C virus (HCV) is attributed to host cellular immune responses, in which T helper cells play a critical role. The purpose of the present paper was therefore to study the serial changes of serum soluble markers released from T helper 1 (Th1) and 2 (Th2) and their correlations with treatment responses in chronic hepatitis C patients receiving interferon-alpha plus ribavirin for 24 weeks.

METHODS

Serum markers (soluble CD26 and CD30 levels) of T helper cells were quantified before and 6 months after combination therapy in 33 chronic hepatitis C patients and in 20 healthy controls.

RESULTS

Compared to healthy controls, chronic hepatitis C patients had significantly lower serum soluble CD26 levels before (140.4 +/- 63.9 ng/mL vs 200.6 +/- 60.3 ng/mL, P < 0.0001) and after (115.9 +/- 32.9 ng/mL vs 200.6 +/- 60.3 ng/mL, P < 0.0001) combination therapy. The level was even lower in those with non-sustained virologic response (non-SVR; 139.0 +/- 50.9 ng/mL vs 117.7 +/- 40.3 ng/mL, P = 0.039). In contrast, soluble CD30 levels at 6 months after combination therapy were significantly lower in patients with SVR than those with non-SVR (6.4 +/- 3.5 U/mL vs 10.4 +/- 5.4 U/mL, P = 0.021).

CONCLUSION

Chronic hepatitis C patients have a weak Th1 response as reflected by lower soluble CD26 levels and the levels are even lower in non-sustained responders. In sharp contrast, downregulation of Th2 response with serial changes of soluble CD30 level is associated with successful treatment of HCV infection.

Fanconi's syndrome, interstitial fibrosis and renal failure by aristolochic acid in Chinese herbs

Aristolochic acid-associated nephropathy (AAN) has been identified as a separate entity of progressive tubulo-interstitial nephropathy. Its characteristic pathological findings, including hypocellular interstitial fibrosis, intimal thickening of interlobular and afferent arterioles with glomeruli sparing or mild sclerosis, have been identified. Many cases of AAN in adults have been reported in Taiwan as well as throughout the world, but it has seldom been described in children. We report on a 10-year-old boy who presented with severe anemia, Fanconi's syndrome, and progressive renal failure. Renal biopsy revealed typical findings of AAN. Aristolochic acids I and II were identified from a Chinese herb mixture ingested by the boy. AAN was diagnosed after other etiologies had been excluded. The case demonstrates the hazards of Chinese herbs with regard to children's health in Taiwan and suggests that more attention should be paid to this issue.

Comparison of the activities of granulocyte-macrophage colony-stimulating factor and interleukin-8 secretion between two lung epithelial cell lines

The aim of this study was to survey the cytokine secretions in 2 human bronchial epithelial cell lines - a normal human bronchial epithelial cell line (HBEpC) and cell line A549, derived from malignant type II pneumocytes. The behavior of A549 cells is similar to epithelial cells and this line is widely used as an alternative model for studying human bronchial epithelial cell behavior. We measured the levels of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-8 (IL-8) after tumor necrosis factor-alpha (TNF-alpha) or interleukin-1beta (IL-1beta) stimulation in the 2 cell lines. Both cell lines responded to TNF-alpha or IL-1beta stimulation, as shown by increased GM-CSF and IL-8 secretion. The relative cost, convenience and similarity of working with these 2 cell lines suggest that A549 is preferable for use as a first-line model and that results of studies of GM-CSF and/or IL-8 secretion under various stimulation conditions with this line could be confirmed using HBEpC.

Levamisole in steroid-sensitive nephrotic syndrome children with frequent relapses and/or steroid dependency: comparison of daily and every-other-day usage

Steroid dependency (SD) and frequent relapses (FR) are common with steroid-sensitive nephrotic syndrome (SSNS). We assessed the effectiveness of daily levamisole in 36 children with SSNS with FR and/or SD. Twenty patients (group 1) were given levamisole 2-3 mg/kg q.o.d. for 4-24 months. Sixteen (group 2) had relapses within 3 months: 5 received levamisole q.d. for 3-18 months, and 11 q.d. for 6 months and then q.o.d. for 4-18 months. Follow-up was 4-36 (mean 20.4 +/- 9.2) months. After therapy, relapses (4.82 +/- 3.15 vs. 2.01 +/- 2.5 in group 1; 5.97 +/- 3.38 vs. 1.34 +/- 2.1 in group 2; p < 0.05) and prednisolone doses (0.57 +/- 0.37 vs. 0.15 +/- 0.33 mg/kg/day in group 1; 0.61 +/- 0.42 vs. 0.19 +/- 0.35 mg/kg/day in group 2; p < 0.05) decreased. Relapse frequency, prednisolone dose, response percentage, and survival curves for remission did not differ between groups. Group 1 had five episodes of leukopenia, and group 2 had four. White blood cell counts normalized after levamisole was discontinued. Serum blood urea nitrogen/creatinine and alanine aminotransferase/aspartate aminotransferase levels were normal. Levamisole is effective in maintaining remission in children with SSNS and FR and/or SD. Daily levamisole can be considered when responses to q.o.d. usage are unsatisfactory.

Lupus vasculopathy combined with acute renal failure in lupus nephritis

Several risk factors have been associated with the prognosis of lupus nephritis. However, few studies have focused on renal vascular lesions (such as thrombi due to immune complexes) as a prognostic factor in this disease. Here we present a case of systemic lupus erythematosus (SLE) in a 12-year-old girl who exhibited acute renal failure and severe hypertension on admission. Renal pathology findings included diffuse proliferative glomerulonephritis (class IVb) and lupus vasculopathy (LV) with immune complex deposition within glomerular capillaries and the preglomerular arteriolar lumen. Her clinical condition deteriorated rapidly, even after cyclophosphamide and methylprednisolone pulse therapy. It improved after 5 days of plasmapheresis and remained stable for up to 6 months under regular treatment. We suggest that renal biopsy performed early in SLE patients with renal involvement should be studied carefully for the presence of vascular lesions. Additionally, plasmapheresis can be considered in patients with LV refractory to other modalities of therapy.

Mycobacterium avium complex-associated hemophagocytic syndrome in systemic lupus erythematosus patient: report of one case

Hemophagocytic syndrome (HPS) in systemic lupus erythematosus(SLE) patients has not commonly been reported. In this case study, we report the first case of Mycobacterium avium complex (MAC)-associated hemophagocytic syndrome in a patient with systemic lupus erythematosus (SLE). This SLE patient, a 15-year-old girl, had been on a high dose of prednisolone (> 0.5mg/kg/day) for more than 3 years. She presented with a spiking fever, hepatosplenomegaly, pancytopenia, hyperferritinemia and adult respiratory distress syndrome. Bone marrow examination revealed hemophagocytosis as well as non-caseating granulomatosis. There was no indication of SLE fare-up. She responded poorly to initial treatment with methyl-prednisolone, intravenous immumoglobulin, etoposide, and drugs for Mycobacterium tuberculosis including rifampin, ethambutol, isoniazid and pyramide. However, gastric lavage culture revealed MAC. Following treatment with clarithromycin, ciprofloxacin and amikacin, her condition gradually improved and she was discharged 3 months after admission. In SLE patients with pancytopenia and hyperferritinemia, MAC-associated HPS should be considered in the differential diagnosis.

Is combination antimicrobial therapy required for urinary tract infection in children?

This retrospective study examined the characteristics of 338 pediatric patients presenting with a first episode of symptomatic urinary tract infection at Taichung Veterans General Hospital from November 1996 to December 2001. Escherichia coli was the most common pathogen (72.5%), followed by Proteus mirabilis (8.3%), Enterococcus (5.6%), and Klebsiella pneumoniae (4.7%). They were more susceptible to first-generation cephalosporin in comparison with other first-line antimicrobial agents such as trimethoprim/sulfamethoxazole, ampicillin, and gentamicin. Two hundred and eighty-seven (84.9%) of the 338 patients were divided into 3 groups according to the type of antibiotic treatment received, and the susceptibility rate and the averaged day of defervescence after effective antibiotic therapy were compared among the groups. Group 1 consisted of those patients treated with cefazolin or cephalexin alone (95%, 2.1 days); Group 2, cefazolin plus gentamicin (88.9%, 2.8 days); and Group 3, ampicillin plus gentamicin (76.1%, 2.3 days). A total of 38 (13.2%) cases from the 3 antibiotic groups did not respond to empiric antibiotics. For non-susceptible infections, when the antibiotic regimen was switched from cefazolin plus gentamicin to ampicillin alone, only 4 (20%) strains became susceptible, compared with 10 strains (62.5%) becoming susceptible after switching from ampicillin plus gentamicin to cefazolin alone (p < 0.01). The results indicated that first-generation cephalosporin alone is an appropriate treatment for pediatric cases of community-acquired urinary tract infection and suggest that antimicrobial combinations should be reserved for serious or critical cases.

Peritoneal dialysis in children with acute renal failure after open heart surgery

Acute renal failure is a frequently reported complication after open heart surgery in children and carries a high mortality. Conservative treatment often makes post-operative care difficult and ambiguous. Peritoneal dialysis (PD) or hemofiltration is another therapeutic choice. Hemofiltration has some limitations in pediatric patients. Many aspects of PD are currently under discussion. We retrospectively reviewed 184 children who underwent open heart surgery with cardiopulmonary bypass. Four patients fulfilled the criteria of acute renal failure. PD was performed after conservative treatment failed. All patients successfully survived through the post-operative period. No electrolyte imbalance, fluid overload or acute hemodynamic changes was observed after the initiation of PD. In our limited experience, PD is a safe and effective method for managing patients with acute renal failure after open heart surgery.

Management of acute decompensation of neonatal maple syrup urine disease with continuous arteriovenous haemofiltration: report of one case

A 22-day-old female infant was referred to our hospital due to unusual urine odor suspecting inborn error of metabolism. Physical examination revealed a stuporous and hypotonic infant with poor reflexes. Intravenous thiamine and high glucose along with appropriate protein were given under the suspicion of maple syrup urine disease (MSUD), which was confirmed by blood and cerebrospinal fluid amino acid assays, and urinary organic acid assay. Progressive neurological deterioration was observed despite the non-invasive treatment. So, we performed pump assisted continuous arteriovenous haemofiltration (CAVHF). Dramatic improvement in neurological function was observed hours after initiation of CAVHF, along with decrease in the level of isoleucine, leucine and valine. In our experience, CAVHF is a well-tolerated procedure for managing the acute phase of neonatal MSUD. Further study on indications, duration of treatment, and preventing complications is needed.

Intra-abdominal actinomycosis with hepatic pseudotumor and xanthogranulomatous pyelonephritis in a 6-y-old boy

We report the case of a 6-y-old boy with actinomycosis, presenting as xanthogranulomatous pyelonephritis (XGP), hepatic pseudotumor and abdominal abscess. Symptoms included intermittent fever, abdominal pain and significant weight loss. Hepatic and renal tumor masses were suspected on sonography and computerized tomography. XGP and actinomycosis were proven by pathology. The patient recovered well with antibiotic alone.