The role of cultural competency training to address health disparities in surgical settings

BACKGROUND

Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities.

SOURCES OF DATA

In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities.

AREAS OF AGREEMENT

The unjustness of health care disparities is universally accepted.

AREAS OF CONTROVERSY

Whether the outcome of CCT justifies the cost has not been effectively answered.

GROWING POINTS

These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting.

AREAS TIMELY FOR DEVELOPING RESEARCH

Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.

Iodotyrosines Are Biomarkers for Preclinical Stages of Iodine-Deficient Hypothyroidism in Dehal1-Knockout Mice

Background: Iodine is required for the synthesis of thyroid hormone (TH), but its natural availability is limited. Dehalogenase1 (Dehal1) recycles iodine from mono- and diiodotyrosines (MIT, DIT) to sustain TH synthesis when iodine supplies are scarce, but its role in the dynamics of storage and conservation of iodine is unknown. Methods: Dehal1-knockout (Dehal1KO) mice were generated by gene trapping. The timing of expression and distribution was investigated by X-Gal staining and immunofluorescence using recombinant Dehal1-beta-galactosidase protein produced in fetuses and adult mice. Adult Dehal1KO and wild-type (Wt) animals were fed normal and iodine-deficient diets for 1 month, and plasma, urine, and tissues were isolated for analyses. TH status was monitored, including thyroxine, triiodothyronine, MIT, DIT, and urinary iodine concentration (UIC) using a novel liquid chromatography with tandem mass spectrometry method and the Sandell-Kolthoff (S-K) technique throughout the experimental period. Results: Dehal1 is highly expressed in the thyroid and is also present in the kidneys, liver, and, unexpectedly, the choroid plexus. In vivo transcription of Dehal1 was induced by iodine deficiency only in the thyroid tissue. Under normal iodine intake, Dehal1KO mice were euthyroid, but they showed negative iodine balance due to a continuous loss of iodotyrosines in the urine. Counterintuitively, the UIC of Dehal1KO mice is twofold higher than that of Wt mice, indicating that S-K measures both inorganic and organic iodine. Under iodine restriction, Dehal1KO mice rapidly develop profound hypothyroidism, while Wt mice remain euthyroid, suggesting reduced retention of iodine in the thyroids of Dehal1KO mice. Urinary and plasma iodotyrosines were continually elevated throughout the life cycles of Dehal1KO mice, including the neonatal period, when pups were still euthyroid. Conclusions: Plasma and urine iodotyrosine elevation occurs in Dehal1-deficient mice throughout life. Therefore, measurement of iodotyrosines predicts an eventual iodine shortage and development of hypothyroidism in the preclinical phase. The prompt establishment of hypothyroidism upon the start of iodine restriction suggests that Dehal1KO mice have low iodine reserves in their thyroid glands, pointing to defective capacity for iodine storage.

Impact of COVID-19 pandemic on HbA1c management and results in pediatric and adult outpatients with diabetes

Objectives

Diabetes mellitus intensify the risks and complications related to COVID-19 infection. A major effect of the pandemic has been a drastic reduction of in-person visits. The aim of this study was to evaluate the impact of the COVID-19 pandemic on HbA_1c management and results among pediatric and adult outpatients with diabetes, considering the laboratory and point-of-care testing (POCT) HbA_1c measurements.

Methods

Observational retrospective study including patients from pediatric and adult diabetes units was conducted. HbA_1c results obtained in the laboratory and POCT over 3 years (2019-2021) were collected from the laboratory information system.

Results

After the lockdown, the number of HbA_1c plummeted. Children returned soon to routine clinical practice. The number of HbA_1c increased gradually in adults, especially in POCT. Globally, HbA_1c results were lower in children compared with adults (p<0.001). HbA_1c values in children (p<0.001) and adults (p=0.002) decreased between pre-pandemic and post-pandemic periods, though lower than the HbA_1c reference change value. The percentage of HbA_1c results above 8% remained stable during the study period.

Conclusions

Continuous glucose monitoring and a telemedicine have been crucial, even allowing for improvements in HbA_1c results. During the lockdown, patients with better metabolic control were managed in the laboratory whereas patients with poorer control or a severe clinical situation were attended in diabetes units by POCT. Adults returned to pre-pandemic management slowly because they were more susceptible to morbidity and mortality due to COVID-19. Coordination among all health professionals has been essential to offering the best management, especially in difficult scenarios such as the COVID-19 pandemic.

Real-world use of key performance indicators for point-of-Care Testing network accredited by ISO 22870

Objective

We aimed to evaluate the results of key performance indicators (KPIs) for a period of over three years, as well as their effectiveness as an improvement tool, to provide information about Point-of-Care Testing (POCT) management system performance and quality assurance.

Design and methods

KPIs regarding the global POCT process, extra-analytical phase, quality assurance and staff training and competency were evaluated for blood gases, HbA1c, sweat test and non-connected and connected glucose in an ISO 22870 accredited network. We established the definition of every KPI and its corresponding target. The results of KPIs from all clinical settings were appraised every month during the study period, taking corrective actions when necessary.

Results

Annual global results were generally acceptable. However, some clinical areas displayed deviations in specific months. The monitoring of these KPIs allowed us to detect the deviations immediately and identify their causes. These included errors in patient identification, consumables, strips, reagents, analyzers, calibration, internal and external quality control, sample management, connectivity, and operator identification strategy, among others.

Conclusions

The evaluation of these KPIs over time has shown their appropriateness. This set of quality indicators could be a useful tool for laboratory medicine leading POCT networks for better and safer patient care.

Experience on how to implement a preanalytical and POCT unit in Madrid's IFEMA field hospital during this unprecedented COVID-19 emergency

To fight the virus SARS-CoV-2 spread to Europe from China and to give support to the collapsed public health system, the Spanish Health Authorities developed a field hospital located in the facilities of Madrid exhibition centre (IFEMA) to admit and treat patients diagnosed with SARS-CoV-2 infectious disease (COVID-19). The Department of Laboratory Medicine of La Paz University Hospital in Madrid (LMD-HULP) was designated to provide laboratory services. Due to the emergency, the IFEMA field hospital had to be prepared for patient admission in less than 1 week and the laboratory professionals had to collaborate in a multidisciplinary group to assure that resources were available to start on time. The LMD-HULP participated together with the managers in the design of the tests portfolio and the integration of the healthcare information systems (IS) (hospital IS, laboratory IS and POCT management system). Laboratorians developed a strategy to quickly train clinicians and nurses on test requests, sample collection procedures and management/handling of the POCT blood gas analyser both by written materials and training videos. The IFEMA´s preanalytical unit managed 3782 requests, and more than 11,000 samples from March 27th to April 30th. Furthermore, 1151 samples were measured by blood gas analysers. In conclusion, laboratory professionals must be resilient and have to respond timely in emergencies as this pandemic. The lab’s personnel selection, design and monitoring indicators to maintain and further improve the quality and value of laboratory services is crucial to support medical decision making and provide better patient care.

The World Organisation for Animal Health: notification of animal diseases

In a globalised world, accurate, complete and timely notification of the presence of animal diseases plays a crucial role in international trade. It allows countries at risk to take appropriate action to prevent the spread of transboundary diseases or minimise their impact, and thus mitigate the associated risks to animal and public health. In this context, the World Organisation for Animal Health (OIE) is responsible for rapidly and transparently sharing accurate and complete information on the global animal health situation. To do so, it collects, verifies, validates and disseminates the animal health information provided by its Members. Information on animal diseases, including zoonoses, is notified to the OIE in compliance with legally binding instruments between the OIE and its Members. Since the creation of the OIE in 1924, the type of animal disease information to be notified and the communication channels for its subsequent distribution to Members have been standardised and improved over time, taking advantage of the available tools and methods of mass dissemination of information. The continuous improvement of the OIE disease notification process has had positive effects, both in terms of animal disease prevention, control and eradication at a global level, and by facilitating the international trade of animals, their products and by-products.

Intraoperative intercostal nerve cryoablation During the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial

PURPOSE

Minimally-invasive repair of pectus excavatum by the Nuss procedure is associated with significant postoperative pain, prolonged hospital stay, and high opiate requirement. We hypothesized that intercostal nerve cryoablation during the Nuss procedure reduces hospital length of stay (LOS) compared to thoracic epidural analgesia.

DESIGN

This randomized clinical trial evaluated 20 consecutive patients undergoing the Nuss procedure for pectus excavatum between May 2016 and March 2018. Patients were randomized evenly via closed-envelope method to receive either cryoanalgesia or thoracic epidural analgesia. Patients and physicians were blinded to study arm until immediately preoperatively.

SETTING

Single institution, UCSF-Benioff Children's Hospital.

PARTICIPANTS

20 consecutive patients were recruited from those scheduled for the Nuss procedure. Exclusion criteria were age < 13 years, chest wall anomaly other than pectus excavatum, previous repair or other thoracic surgery, and chronic use of pain medications.

MAIN OUTCOMES AND MEASURES

Primary outcome was postoperative LOS. Secondary outcomes included total operative time, total/daily opioid requirement, inpatient/outpatient pain score, and complications. Primary outcome data were analyzed by the Mann-Whitney U-test for nonparametric continuous variables. Other continuous variables were analyzed by two-tailed t-test, while categorical data were compared via Chi-squared test, with alpha = 0.05 for significance.

RESULTS

20 patients were randomized to receive either cryoablation (n = 10) or thoracic epidural (n = 10). Mean operating room time was 46.5 min longer in the cryoanalgesia group (p = 0.0001). Median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days (Mann-Whitney U, p = 0.0001). Cryoablation patients required significantly less inpatient opioid analgesia with a mean decrease of 416 mg oral morphine equivalent per patient (p = 0.0001), requiring 52%-82% fewer milligrams on postoperative days 1-3 (p < 0.01 each day). There was no difference in mean pain score between the groups at any point postoperatively, up to one year, and no increased incidence of neuropathic pain in the cryoablation group. No complications were noted in the cryoablation group; among patients with epidurals, one patient experienced a symptomatic pneumothorax and another had urinary retention.

CONCLUSIONS AND RELEVANCE

Intercostal nerve cryoablation during the Nuss procedure decreases hospital length of stay and opiate requirement versus thoracic epidural analgesia, while offering equivalent pain control.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level I.

Widespread Occurrence of Black-Orange-Black Color Pattern in Hymenoptera

Certain color patterns in insects show convergent evolution reflecting potentially important biological functions, for example, aposematism and mimicry. This phenomenon has been most frequently documented in Lepidoptera and Coleoptera, but has been less well investigated in Hymenoptera. It has long been recognized that many hymenopterans, especially scelionids (Platygastridae), show a recurring pattern of black head, orange/red mesosoma, and black metasoma (BOB coloration). However, the taxonomic distribution of this striking color pattern has never been documented across the entire order. The main objective of our research was to provide a preliminary tabulation of this color pattern in Hymenoptera, through examination of museum specimens and relevant literature. We included 11 variations of the typical BOB color pattern but did not include all possible variations. These color patterns were found in species belonging to 23 families of Hymenoptera, and was most frequently observed in scelionids, evaniids, and mutillids, but was relatively infrequent in Cynipoids, Diaprioids, Chalcidoids, and Apoids. The widespread occurrence of this color pattern in Hymenoptera strongly suggests convergent evolution and a potentially important function. The BOB color pattern was found in species from all biogeographic regions and within a species it was usually present in both sexes (with a few notable exceptions). In better studied tropical regions, such as Costa Rica, this color pattern was more common in species occurring at lower elevations (below 2,000 m). The biology of the tabulated taxa encompasses both ecto- and endoparasitoids, idiobionts and koinobionts, from a diversity of hosts, as well as phytophagous sawflies.

Transoral glossoepiglottopexy in the treatment of adult obstructive sleep apnoea: a surgical approach

SUMMARY

The treatment of obstructive sleep apnoea syndrome (OSAS) is still a matter of debate; among the different therapeutic alternatives, both surgical and conservative, treatment with continuous positive airway pressure (CPAP) is considered the "gold standard". The recent scientific literature reports that even if CPAP represents an effective solution for sleep apnoeas, 12% of patients do not benefit from its use. In most cases, primary collapse of the epiglottis is responsible for failure. We developed a surgical technique that provides a stable support to the epiglottis without influencing its function during swallowing while preserving laryngeal anatomy and physiology. The procedure we propose is based on that conceived by Monnier for children affected by laryngomalacia. We analysed a group of 20 patients who underwent glossoepiglottopexy between January 2015 and September 2016 and compared data (AHI, ODI, t90, ESS, EAT10, etc.) collected before and 6 months after surgery to demonstrate the safety and effectiveness of our glossoepiglottopexy (GEP). The results allow us to consider GEP as a valid choice to treat adults who suffer from sleep apnoeas.

Rheopheresis for Sudden Hearing Loss (SHL)

Rheopheresis has met an increasing interest and application in different disease conditions affecting microcirculation. Its last applications are for the management of Macular and Cochlear disorders. The sudden hearing loss syndrome is a condition that affects 20 out of 100000 persons per year, reduces the patient's social interaction and quality of life. It is associated with vascular and coagulation risk factors and it is considered as a result of local hypoperfusion secondary both to inflammatory and dysimmune conditions determining inadequate NO release and endothelial dysfunction. Rheopheresis treatment is a new approach which brings to satisfactory clinical results. Cascade filtration, heparin induced lipid precipitation and conventional plasma exchange are equally effective, and only 2 sessions are required for producing long lasting benefits. Our experience is with 60 patients, 90% of which getting from partial to complete recovery after treatment as measured by pure tone audiometry.

Presence of Autoantibodies in the Sera of Meniere's Disease

We examined the sera of patients with Meniere's disease for the presence of antibodies against 8 inner ear antigens by enzyme-linked immunosorbent assay (ELISA). One hundred eight patients with Meniere's disease and 28 control subjects were studied. The antibodies against chicken type II collagen, bovine type II collagen, the cyanogen bromide cleaved peptide 11 (CB11) of each, type IX and XI collagens, C-Raf, and tubulin were measured by ELISA. The sensitivity of each antigen was between 37% and 60% individually, and was 91% when all 8 inner ear antigens were combined. These results showed that 91% of Meniere's disease sera have antibody activities to 1 or more of these inner ear antigens. The results suggest that performing ELISA for these 8 inner ear antigens was useful as a diagnostic tool for Meniere's disease. Further study is required for elucidating the role of these antigens in the pathogenesis of Meniere's disease, which might eventually result in better therapy.

Role(s) of formyl-peptide receptors expressed in nasal epithelial cells

Chronic rhinosinusitis is one of the most frequent chronic diseases in humans. Little is known about stimuli initiating tissue remodeling process that determines the morphological expression of the disease. N-formyl peptide receptors (FPRs) are innate immunity receptors important in tissue remodeling of gastric and intestinal epithelium. The expression and functions of FPRs in nasal epithelial cells were examined to evaluate whether they could be important in the remodeling of nasal mucosa. The aim of this study is to examine FPR expression in a nasal epithelial cell line (RPMI-2650) at mRNA and protein levels. To determine whether FPRs were functional, chemotaxis experiments were carried out. In addition the effects of FPRs agonists on the expression (PCR and ELISA) of VEGF-A and TGF-beta, two key mediators of tissue remodelling, were examined. Here we demonstrate that RPMI-2650 express FPR and FPRL2, but not FPRL1. fMLP, a bacterial product active on FPR, and uPAR(84-95), an inflammatory mediator agonist for FPRL2, stimulated migration of nasal epithelial cells. fMLP and uPAR(84-95) induce expression and secretion of VEGF-A and TGF-beta. Our results suggest a possible mechanisms initiating tissue remodeling observed during chronic rhinosinusitis. This study provides further evidence that FPRs play a more complex role in human pathophysiology than bacterial recognition.

Comparison of the diagnosis of malaria by microscopy, immunochromatography and PCR in endemic areas of Venezuela

Whole blood samples (N = 295) were obtained from different locations in Amazonas and Sucre States, in Venezuela. Malaria was diagnosed by microscopy, OptiMAL and polymerase chain reaction (PCR), with Plasmodium vivax, P. falciparum, and P. malariae being detected when possible. We identified 93 infections, 66 of which were caused by P. vivax, 26 by P. falciparum, and 1 was a mixed infection. No infection caused by P. malariae was detected. The sensitivity and specificity of each diagnostic method were high: 95.7 and 97.9% for microscopy, 87.0 and 97.9% for OptiMAL, and 98.0 and 100% for PCR, respectively. Most samples (72.2%) showed more than 5000 parasites/microL blood. The sensitivity of the diagnosis by microscopy and OptiMAL decreased with lower parasitemia. All samples showing disagreement among the methods were reevaluated, but the first result was used for the calculations. Parasites were detected in the 6 false-negative samples by microscopy after the second examination. The mixed infection was only detected by PCR, while the other methods diagnosed it as P. falciparum (microscopy) or P. vivax (OptiMAL) infection. Most of the false results obtained with the OptiMAL strip were related to the P. falciparum-specific band, including 3 species misdiagnoses, which could be related to the test itself or to genetic variation of the Venezuelan strains. The use of the microscopic method for malaria detection is recommended for its low cost but is very difficult to implement in large scale, population-based studies; thus, we report here more efficient methods suitable for this purpose.

[Ultrasound bone densitometry in children and adolescents; Italian refence curves with multi-site device (Omnisense)]

The values of bone density represent one of the best parameters for the prediction of the risk of fracture in the adult. Since the peak of bone mass depends over that on genetic factors also on modifiable environmental factors, the evaluation of the state of bone health in paediatric populations has assumed great importance; the ultrasound techniques seem to represent a potential alternative to DXA and QTC. Using Omnisense device (Omnisense, Sunlight Ultrasound Technologies) we have evaluated the bone strength in a champion of 652 children and teen-agers aged 6-18 (328 females, 324 males). The measurements have been made at the distal third of the radius and midshaft tibia. The purpose has been to record the values of SOS in a healthy paediatric population, building a normal database and to find a correlation between the SOS values and anthropometric data, dietary factors and physical activity. The comparison with an analogous study conducted by other Authors prompted us to conclude that in the paediatric population the construction of proper curves of reference, with which to compare the data of the patients, is essential to avoid errors in the evaluation of bone density, in agreement with how much already underlined in literature. Besides a correct interpretation of the data obtained with ultrasounds systems asks for a change of the thresholds values established by the OMS for the diagnosis of osteopenia/osteoporosis with the DXA. As already happened for the adult population in children also it will be therefore necessary to compare a great number of pathological subjects with the normal database, establishing so the new values of Z-Score and giving a clinical meaning to the effected measurements.

[Association among postural and skull-cervico-mandibular disorders in childhood and adolescence. Analysis of 428 subjects]

The aim of the study is to appraise the prevalence of the mild defects of the spine or paramorphysm in a normal paediatric population, without orthopaedic pathology, and to verify the possible association with the dysfunctions of the dental apparatus. The recovery of a real association among these pathologies could furnish a sprout for a correct therapeutic approach. In the study 428 subjects (211 females and 217 males), aged 9 to 14 years, have been analyzed. The data have been recorded on special schedules, orthopaedic and orthodontic, containing the number of progressive order and the initials of name and last name, in the respect of the privacy of the subjects. From the study a 2.8% scoliosis incidence has emerged, an incidence of scoliotic attitudes 9.5% and an incidence of 83% normality deviations. As deviations by the normality have been classified the isolated skeletal asymmetries, agreements as varying functional not yet pathological, for instance scapular or flank asymmetry, mild genu varum or valgum, femoral anteversion. A statistically significant relationship among that disorders of posture and malocclusion (P < 0.005) and ogival palate (P < 0.002) has been found. Despite these correlations, it is very difficult to explain this association from the point of view of etiopathogenesis. For this we hold to have to continue the study, to give a meaning to such correlations and to find an appropriate therapy.

[High-risk hypertrophic cardiomyopathy associated with a novel mutation in cardiac Myosin-binding protein C]

Hypertrophic cardiomyopathy is an autosomal dominant inherited disease characterized by ventricular hypertrophy and myofibril disarray. Mutations responsible for hypertrophic cardiomyopathy have been identified in 11 genes that encode for cardiac sarcomere proteins. Traditionally, hypertrophic cardiomyopathy due to mutation of the myosin-binding protein C gene (MYBPC3) has been thought to follow a benign course. We report a family with several members affected by hypertrophic cardiomyopathy in which there was a high incidence of sudden death. Disease was presumably caused by the substitution of cytosine by guanine at nucleotide 269 of MYBPC3 mRNA. This mutation, which has not previously been described, modifies codon 79, which encodes for the incorporation of a tyrosine, and gives rise to a stop codon. The mutation described here appears to confer a higher risk than that previously associated with hypertrophic cardiomyopathy due to MYBPC3 gene mutation.

Cochlear schwannomas

In a series of 179 cerebellopontine angle (CPA) tumors, the authors present nine cases (5%) that were cochlear nerve neuromas. There were six men and three women (mean age, 51 years). Preoperative magnetic resonance imaging confirmed the diagnosis in one case with a labyrinthine extension and raised suspicions in the other four cases, which were confirmed during surgery. The remaining neuromas were discovered intraoperatively. The mean time between first observation and surgery was 9 months. Preoperatively, all patients underwent a complete otoneurological assessment. The middle fossa approach was used for the patient with the labyrinthine extension, and the retrosigmoid approach was used for the other eight cases. In all patients facial nerve function was preserved. Sudden or major hearing loss without associated vestibular symptoms or preoperative facial paralysis may be predictive of a cochlear component of a CPA tumor. The near-field relationships of cochlear neuromas located at the level of the acoustic and facial nerves can be appreciated because of their small size and strong contrast enhancement.

[Hypertrophic cardiomyopathy: infrequent mutation of the cardiac beta-myosin heavy-chain gene]

The aim of this study was to identify mutations in the cardiac heavy-chain beta-myosin gene (MYH7b) in a group of Spanish patients with hypertrophic cardiomyopathy. The study included 36 families with at least one member who had hypertrophic cardiomyopathy. DNA from exons 3 to 24 of the MYH7b gene was sequenced. Two mutations were identified: Arg858Cys and Met515Val. They occurred in two families, one of which was of Moroccan origin. This corresponds to a MYH7b gene mutation frequency of less than 5%. In contrast to findings in other Caucasian populations, MYH7b gene mutation occurred infrequently in this group of Spanish families with hypertrophic cardiomyopathy.

Static and dynamic posturography in patients with asymptomatic HIV-1 infection and AIDS

Alterations of the vestibulo-ocular reflex, optokinetic nystagmus, and visuo-vestibular-ocular reflex, have already been described in patients with AIDS and HIV-1 positive asymptomatic subjects. The introduction to the clinical practice of posturographic techniques allows us to study, with precision, postural perturbation that may be present when performing Romberg's test and to study the vestibulo-spinal reflex as a component of the vestibular system. The relative lack of studies on posturography and AIDS, encouraged us to continue our research on the vestibular system both in asymptomatic HIV-1 seropositive patients and in patients with AIDS (IV stage according to the classification proposed by the Centre for Disease Control). Recordings were made in group 1 (control group, 55 normal subjects), in group 2 (15 asymptomatic HIV-positive subjects), and in group 3 (15 patients with AIDS stage IV). Static and dynamic posturography were carried out using Tonnies platform system (Tonnies GmbH & Co., Wurzburg, Germany) and the data were analysed with Tonnies Posturographic Tübingen (TPOST) software vers. 5.19. In asymptomatic HIV+ subjects, we observed an increase in RW, RA and M3 reflex latency. AIDS patients (stage IV) exhibited significant alterations in almost all the posturographic parameters and the electromyographic potentials. Our results validate static and dynamic posturography as a method for otoneurological investigation and appear to confirm that the entire vestibular system is involved since the earliest stages of the HIV infection. In the HIV+ subjects, a variable dysfunction in the reflex control to long latency was observed, which is correlated with the alteration of the central dopaminergic system; in AIDS patients, the central nervous system damage appears more important, globally distributed and correlated also with immunosuppression.

Iris yellow spot virus in Onion in Chile

Iris yellow spot virus (IYSV) (genus Tospovirus, family Bunyaviridae) has become endemic in several parts of the world. Between 2000 and 2004, the virus was reported from several states in the United States and the most recent report was from Georgia (2). In South America, IYSV was first reported from Brazil (3). Symptoms indicative of IYSV infection (1), such as diamond-shaped and irregular chlorotic and necrotic lesions, were observed during 2004 and 2005 in onion fields in Colina and Tiltil (Chacabuco Province) and Rengo (Cachapoal Province) located in central Chile. In the sampled fields, as much as 50% of the crop showed symptoms. In all three locations, the crop was destined for bulb production and the cultivar was a long-day Valenciana-type. Approximately 50 and 5 ha in Chacabuco and Cachapoal provinces, respectively, were surveyed. Symptomatic plants were collected and tested in the laboratory for confirmation of IYSV infection. A commercially available IYSV-specific enzyme-linked immunosorbent assay kit was used (Adgen Limited, Ayr, Scotland, UK) that confirmed the samples were infected with IYSV. Total nucleic acids were extracted, and using primers flanking the nucleoprotein (NP) gene of IYSV, reverse transcription-polymerase chain reaction was used to verify virus identity. Primer sequences were 5'-TAA AAC AAA CAT TCA AAC AA-3' and 5'-CTC TTA AAC ACA TTT AAC AAG CAC-3'. The resulting 1.2-kb DNA amplicons from five samples were cloned and sequenced (GenBank Accession No. DQ150107). Nucleotide sequence comparisons with known IYSV NP gene sequences showed 95 to 98% identity, confirming the virus as IYSV. The presence of IYSV in Brazil and now in Chile indicates its potential to become established in onion crops in the region. References: (1) L. J. du Toit et al. APSnet Image of the Week. http://apsnet.org/online/archive/2003/IW000030.asp , 2003. (2) S. W. Mullis et al. Plant Dis. 88:1285, 2004. (3) L. Pozzer et al. Plant Dis. 83:345, 1999.

[Autoimmune disease in primary antibody deficiencies]

BACKGROUND

Immunodeficiency and autoimmune phenomena may occur concomitantly in the same individual. Many immune deficiency syndromes, mainly humoral defects, are associated with autoimmune disorders. In the present study, we describe the frequency of autoimmune disorders in these patients.

METHODS AND RESULTS

We performed a retrospective review of the medical records of a cohort of 152 patients with primary antibody deficiency in the Clinical Immunology Unit of the Gregorio Maranon University Hospital in Madrid: common variable immunodeficiency (CVID) (n = 35), IgA deficiency (n = 43), specific IgG subclass deficiency (n = 56), antibody deficiency with normal immunoglobulin (n = 14) and X-linked agammaglobulinemia (n = 4). Of the 152 patients with primary antibody deficiencies, autoimmune disorders were found in 35 (23 %). Autoimmune hematologic disease was found in 14 patients (9.2 %), autoimmune diseases of the gastrointestinal tract in eight (5.3 %), autoimmune endocrine diseases in six (3.9 %), autoimmune rheumatic diseases in six (3.9 %) and vitiligo in four. Autoimmune diseases were more frequent in CVID patients (37.1 %) than in those with selective IgA deficiency (25.5 %) or selective IgG subclass deficiency (12.5 %). Thirty-seven percent of autoimmune episodes occurred prior to the diagnosis of primary antibody deficiency. Sixteen patients (10.5 %) had autoantibodies without clinical data of an autoimmune disease.

CONCLUSIONS

Primary antibody deficiencies have variable autoimmune manifestations. For early detection and appropriate treatment, autoimmune disease should be suspected in patients with immunodeficiency.

Restoration of immune-mediated sensorineural hearing loss with sodium enoxaparin: a case report

The aim of the study was to assess the efficacy of sodium enoxaparin in the treatment of autoimmune sensorineural hearing loss. A small number of patients with unilateral sensorineural hearing loss were selected and divided randomly into two numerically equal groups (groups A and B) if they fulfilled the inclusion criteria, i.e. being between 20 and 65 years of age, had been affected by systemic lupus erythematosus, had presented with a hearing loss of at least 30 dB of audibility threshold involving the medium frequencies (2000-4000 Hz), and had provided informed consent. Group A received sodium enoxaparin while group B (control) received placebo. In group A, all patients except one showed an improvement in hearing after sodium enoxaparin treatment. In group B, no patients showed an improvement in auditory function. In conclusion, our results underline the important role of sodium enoxaparin in the therapeutic management of this disease. The low number of patients suggests that further studies are required to confirm this initial data but this study suggests that sodium enoxaparin provides encouraging results in the treatment of autoimmune sensorineural hearing loss.

OSAS in children

BACKGROUND

Major risk factors for obstructive sleep apnea syndrome (OSAS) in children include adenotonsillar hypertrophy, neuromuscular disease and syndromes such as Down's or Pierre-Robin's syndrome; there is currently no consensus concerning diagnosis and therapy.

METHODS

The study analyses 40 children, aged 2 through 14 years, with macroscopic tonsillar hypertrophy (without recurrent tonsillitis but with OSAS) underwent adenotonsillectomy. Parents were invited to indicate the intensity of their children's symptomatology using a subjective evaluation scale, each patient underwent cephalometric analysis and polysomnography (PSG) before and after surgery.

RESULTS

The subjective scale of symptoms passed from 3.01 before treatment to 0.42 after treatment, rhinomanometry, passed from 3.456 to 0.896 p after 1 month the surgical operation (P<0.05). The polysomnography showed a resolution of the number of obstructive events in 37 patients and a reduction in 3 patients and RDI index fell from a mean of 26.9-2.6 after therapy. The average of oxygen saturation changed from 79% before treatment to 95% after therapy.

CONCLUSIONS

Adenotonsillectomy plays a major role in the treatment of OSAS.

High frequency surgery in the treatment of turbinate hypertrophy: 11 years' experience

For over a century, surgical management of lower turbinate hypertrophy has given rise to much discussion. Aim of the present investigation was to establish, by means of the analysis of a large patient population, the efficacy and reproducibility of high frequency surgery in the treatment of this condition. A total of 1689 non-allergic patients with nasal obstruction, presenting hypertrophy of the lower turbinates, were submitted, under local anaesthesia, to turbinates decongestion using a high frequency instrumental unit with a bipolar terminal electrode. Efficacy of the procedure was evaluated on the basis of objective examination, results of questionnaires, active anterior rhinomanometry and mucociliar transport time. Results revealed a reduction of hypertrophy, an improvement in symptoms, a reduction in nasal resistances and an improvement of mucociliar transport time. The large patient population, low post-operative complication rate and the good patient compliance, due also to the fact that no haemostatic procedure is necessary, would suggest that this method is particularly valid, effective and safe for the treatment of hypertrophy of the lower turbinates.

Betahistine dihydrochloride in the treatment of peripheral vestibular vertigo

The present study compares the efficacy and safety of betahistine dihydrochloride to that of a placebo in recurrent vertigo resulting from Meniere's disease (MD) or in paroxysmal positional vertigo (PPV) of probable vascular origin. The design was double-blind, multicentre and parallel-group randomised. Eleven Italian centres enrolled 144 patients: 75 of the patients were treated with betahistine (41 MD/34 PPV) and 69 with placebos (40 MD/29 PPV). The betahistine dosage was 16 mg twice per day for 3 months. Compared to the placebo, betahistine had a significant effect on the frequency, intensity and duration of vertigo attacks. Associated symptoms and the quality of life also were significantly improved by betahistine. Both the physician's judgement and the patient's opinion on the efficacy and acceptability of the treatment were in agreement as to the superiority of betahistine. The effective and safe profile of betahistine in the treatment of vertigo due to peripheral vestibular disorders was confirmed.

Airbags and permanent auditory deficits. A real correlation?

OBJECTIVES

To evaluate the relationship between airbag-induced noise and individual metabolic risk factors in determining persistent hypoacusia in drivers after road accidents.

METHODOLOGY

We selected 22 patients previously involved in a car accident with deployment of airbags. Patients underwent general and audiological clinical history, tonal audiometric examination, vocal audiometric examination, impedance meter examination and blood tests.

RESULTS

We divided patients, according to audiometric data, into 2 groups: group A with no residual otological disturbances (6 subjects) and group B with persistent hypoacusia (16 subjects). Blood parameters were into physiological levels in all group A patients; on the contrary 12 (subgroup B1) out of 16 group B patients had altered blood levels of glucose, urea and cholesterol, with mean values of 155.8 +/- 38.6 mg/dl, 48.2 +/- 8.3 mg/dl and 250.8 +/- 28.1 mg/dl, respectively, revealing statistically significant differences in these parameters when compared with the other 4 hypoacusic cases (Sub-group B2) and with the normal subjects (Group A) (p < 0.01 for glucose, p < 0.05 for urea and p < 0.001 for cholesterol).

CONCLUSIONS

Our findings confirm the transitory otological damage due to airbag deployment: the intensity of the acoustic wave hitting the ear after airbag deployment is responsible for a temporary rise in the acoustic threshold but the persistence of an auditory deficit can be due to co-factors able to interfere with the acute acoustic trauma recovery processes through a metabolic, angiopathic, neuropathic or unknown mechanism. Moreover, also the age of the patients could affect in a significant way the recovery from the acoustic trauma.

[Computerized modification of Fukuda test]

OBJECTIVES

To study a new method to apply to Fukuda test in order to overcome the interpretational difficulty associated with a subjective evaluation of the exam.

MATERIALS AND METHODS

During the exam, the patient wears a specially-designed headpiece, with a band at the back fitted with a sensor accommodating both a gyroscope and a bi-axial accelerometer. When asked to step in place, he does so in the Romberg position, eyes closed, successively rotating his head to the right and to the left.

RESULTS

On analyzing the data obtained through the laterality variable (right/left oscillation) and time variable, it resulted that the difference between the averages referring to the laterality variable of right-handed and left-handed subjects was statistically significant (P = 0.001), while the difference between the averages of the time variable was not.

CONCLUSIONS

To be able to propose an evaluation of the clinical validity of the test, further research must be carried out on pathological subjects, thus verifying the applicability of the method to the full.

[Behavior of serum IgE and IgA in patients with allergic rhinitis treated with iodine bromide thermal water]

The aim of this study was to test the effects of the iodine bromide water of the thermal baths of Salsomaggiore on patients suffering from specific nonseasonal rhinitis (Dermatophagoides Farinae and Dermatophagoides Pteronyssinus). The patients, 80 in all, were divided in two groups (group A and group B). All of the patients underwent rhinoscopic examination, anterior rhinomanometry, prick test, rast screening, total IgE assay together with that of the other immunoglobulins (IgA, IgM, IgG), mucociliary clearance evaluation and were asked to evaluate their degree of nasal obstruction, before and after 30 days of treatment. Group A carried out the experiment by applying endonasal Acqua Sal spray seven times a day for 30 days; group B used oily drops for the same time and with the same frequency. At the end of the trial period, the patients in group A showed a 100% improvement in their subjective perception of their symptomatology, in comparison with a 33% improvement in the control group. A characteristic decrease in the IgE and increase in the IgA was observed in the serum of the patients who had been treated with Acqua Sal spray. Iodine bromide water has a general and local anti-inflammatory effect, which is also due to the activation of the corticosurrenal system (with a relative increase in cortisol). The cleansing action of hypertonic water in the nasal cavities must also be cited, as it minimizes contact between the mucosa and allergens.

[Allergic rhinitis: evaluation of prick test positivity for German and American cockroaches (Blatella Germanica, Periplaneta Americana)]

Allergies are a widespread phenomenon and one that is in continuous expansion, especially in large cities. A heretofore underestimated allergen, at least in Italy, is the cockroach. Between April and June 2000, we administered a prick test (including the cockroach antigen in the allergen kit) to 163 patients. The prick test was executed utilizing histamine as the positive control and a normal diluent as the negative control; both indoor allergens (including dermatophagoids and dog and cat epithelium) and outdoor allergens (including trees, grasses, pollens and spores) were employed. The results obtained were evaluated by comparing the reaction provoked by these allergens to that of the histamine. About 20% of the patients who reacted to the other indoor allergens also tested positive to the cockroach antigen. Also on the basis of experiences previously carried out in other countries (United States, Korea, Japan, Turkey), the cockroach must be borne in mind as a possible significant cause of allergic reactions in Italy, too.

A preventive measure for otitis media in children with upper respiratory tract infections

Recurrent upper respiratory tract infections (URTI) are very common in patients of all ages. Rhinitis, bronchitis, chronic sinusitis and otitis appear to be the prevalent forms of recurrent respiratory infections in the paediatric population. The aim of treatment is so the solution of the respiratory pathology and the also the prevention of their complications. Antibacterial therapy is still the classical treatment approach in patients both with respiratory tract infections and with otitis media, despite the fact that antibacterials have several well known drawbacks, especially when used to treat recurrent infections. Eighty-four paediatric patients of both sexes (range: 4-14 years) with otitis were enrolled in the study. Patients were included if they had a >2 years' history of recurrent or chronic respiratory infections, and/or had experienced at least three episodes requiring medical consultations and/or treatment during the winter prior to the study. The young patients were randomised to receive Immucytal (group A) or placebo (group B) treatment according to the following protocol: (1) starting therapy (1 month): one tablet daily in the morning 4 days per week for 3 consecutive weeks; (2) maintenance period (5 months): one tablet daily in the morning 4 days per week for 1 week every month. Placebo and Immucytal tablets were identical in shape and size, in order to maintain double-blind conditions. Patients of group A with recurrent URTI had a significantly decreased incidence of ENT infections, fever and shorter duration of illness, decreased requirement for ancillary medications and fewer work-days lost. The reduction in the incidence of infectious episodes became significant vs. placebo. A significantly improved outcome vs. placebo was also observed on the incidence of fever, frequency and duration of infectious episodes, ancillary therapies. Immucytal treatment was associated with significant changes in both immunological and auditory function parameters. Serum concentrations of immunoglobulins were significantly increased in Immucytal. For both evaluations, a significant difference between treatment groups was found (P>0.001). Preventive strategies, such as ribosomal immunotherapy, may represent a valid alternative approach.

Sociodemographic characteristics and HIV risk behaviour patterns of male sex workers in Madrid, Spain

This paper describes the sociodemographic and work characteristics, prevalence of HIV infection and associated risk behaviours among male sex workers (MSWs) in Madrid (Spain). Using an anonymous semi-structured questionnaire, educators attached to a mobile unit under a street-based prostitution programme surveyed 84 MSWs from several Madrid areas. Of the total surveyed: 35% were immigrants, mean age was 23 years, mean period in prostitution was four years; 21% had no primary education; 16% had injected drugs at some time; 11% reported private sexual relationships exclusively with women; 89% always used condoms in anal practices with clients; and 41% were in sexual relationships with their partners. Only 11% had ever used fortified condoms. In the preceding month, 37% had experienced condom failure, 82% without having used any lubricant. In all, 67% reported having undergone HIV testing, with a higher percentage of positive results among injecting (60%) versus non-injecting drug users (17%). Immigrants had a lower level of education, made less use of condoms, had more condom failures and, in their private lives, a greater proportion reported sexual relationships exclusively with women. In Spain, MSWs should be included in HIV prevention programmes, which ought to be specifically adapted to immigrants. Priority should be given to reducing the condom failure rate in anal intercourse, by improving access to fortified condoms.

Hysteresivity of the lung and tissue strip in the normal rat: effects of heterogeneities

We measured lung impedance in rats in closed chest (CC), open chest (OC), and isolated lungs (IL) at four transpulmonary pressures with a optimal ventilator waveform. Data were analyzed with an homogeneous linear or an inhomogeneous linear model. Both models include tissue damping and elastance and airway inertance. The homogeneous linear model includes airway resistance (Raw), whereas the inhomogeneous linear model has a continuous distribution of Raw characterized by the mean Raw and the standard deviation of Raw (SDR). Lung mechanics were compared with tissue strip mechanics at frequencies and operating stresses comparable to those during lung impedance measurements. The hysteresivity (eta) was calculated as tissue damping/elastance. We found that 1) airway and tissue parameters were different in the IL than in the CC and OC conditions; 2) SDR was lowest in the IL; and 3) eta in IL at low transpulmonary pressure was similar to eta in the tissue strip. We conclude that eta is primarily determined by lung connective tissue, and its elevated estimates from impedance data in the CC and OC conditions are a consequence of compartment-like heterogeneity being greater in CC and OC conditions than in the IL.

Decreased surfactant protein-B expression and surfactant dysfunction in a murine model of acute lung injury

This study examines the relationships between inflammation, surfactant protein (SP) expression, surfactant function, and lung physiology in a murine model of acute lung injury (ALI). 129/J mice received aerosolized endotoxin lipopolysaccharide [LPS] daily for up to 96 h to simulate the cytokine release and acute inflammation of ALI. Lung elastance (E(L)) and resistance, lavage fluid cell counts, cytokine levels, phospholipid and protein content, and surfactant function were measured. Lavage and lung tissue SP content were determined by Western blot and immunohistochemistry, and tissue messenger RNA (mRNA) levels were assessed by Northern blot and in situ hybridization. Tumor necrosis factor-alpha and neutrophil counts in bronchoalveolar lavage fluid increased within 2 h of LPS exposure, followed by increases in total protein, interleukin (IL)-1beta, IL-6, and interferon-gamma. E(L) increased within 24 h of LPS exposure and remained abnormal up to 96 h. SP-B protein and mRNA levels were decreased at 24, 48, and 96 h. By contrast, SP-A protein and mRNA levels and SP-C mRNA levels were not reduced. Surfactant dysfunction occurred coincident with changes in SP-B levels. This study demonstrates that lung dysfunction in mice with LPS-ALI corresponds closely with abnormal surfactant function and reduced SP-B expression.

Oral administration of collagen conjugated with cholera toxin induces tolerance to type II collagen and suppresses chondritis in an animal model of autoimmune ear disease

B10.RIII (H-2r) mice were orally administered cyanogen bromide peptide 11 (CB11) or cholera toxin B (CTB)-conjugated CB11 to induce tolerance in collagen-induced autoimmune ear disease. Oral administration of a high dosage of CB11 provided partial protection from chondritis. However, administration of a tiny amount of CTB-CB11 conjugate effectively suppressed chondritis. Oral administration of CTB-CB11 conjugate did not alter the stimulation of T cells in vitro or the fine specificities of B cells. The oral administration of CTB-CB11 caused a higher level of type II collagen-specific IgG and its subclass. Interestingly, increases of TH1 cytokine (interferon-gamma) in Peyer's patches and of TH1/TH2 cytokines (interleukin-2 and interleukin-4) in lymph nodes were detected in mice that had been fed CTB-CB11. An increase of CD8+ T cells in the Peyer's patches with a decrease of CD8+ T cells in lymph nodes was seen in mice that had been fed CTB-CB11. These results suggest that protection from chondritis by oral administration of minute amounts of CTB-CB11 conjugate can be achieved by a mechanism distinct from that of conventional oral tolerance induction.

[Paraplegia after left thoracotomy in a patient carrying an epidural catheter]

A 61-year-old man undergoing left thoracotomy, in whom a lumbar epidural catheter had been inserted, experienced paraplegia in the immediate recovery period. Diagnostic tests and clinical examinations ruled out neurological causes attributable to the catheter, indicating that the cause was surgical. Paraplegia after thoracotomy is rare but has been described in the literature. We discuss ways that injuries may produce medullary lesions related to thoracic surgery.