Cytokine signature in convalescent SARS-CoV-2 patients with inflammatory bowel disease receiving vedolizumab

While differential antibody responses SARS-CoV-2 in patients with inflammatory bowel disease (IBD) receiving infliximab and vedolizumab are well-characterized, the immune pathways underlying these differences remain unknown. Prior to COVID-19 vaccine development, we screened 235 patients with IBD receiving biological therapy for antibodies to SARS-CoV-2 and measured serum cytokines. In seropositive patients, we prospectively collected clinical data. We found a cytokine signature in patients receiving vedolizumab who are seropositive compared with seronegative for SARS-CoV-2 antibodies that may be linked to repeated SARS-CoV-2 infections. However, there were no differences between seropositive and seronegative patients receiving infliximab. In this single-center cohort of patients with IBD with anti-SARS-CoV-2 antibodies at the onset of the COVID-19 pandemic, and therefore without influence of vaccination, there is a cytokine signature in patients receiving vedolizumab but not infliximab. These findings lay the groundwork for further studies on immune consequences of viral infection in patients with IBD, which is postulated to evolve from aberrant host-microbe responses.

Variable susceptibility of intestinal organoid-derived monolayers to SARS-CoV-2 infection

Gastrointestinal effects associated with Coronavirus Disease 2019 (COVID-19) are highly variable for reasons that are not understood. In this study, we used intestinal organoid-derived cultures differentiated from primary human specimens as a model to examine interindividual variability. Infection of intestinal organoids derived from different donors with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) resulted in orders of magnitude differences in virus replication in small intestinal and colonic organoid-derived monolayers. Susceptibility to infection correlated with angiotensin I converting enzyme 2 (ACE2) expression level and was independent of donor demographic or clinical features. ACE2 transcript levels in cell culture matched the amount of ACE2 in primary tissue, indicating that this feature of the intestinal epithelium is retained in the organoids. Longitudinal transcriptomics of organoid-derived monolayers identified a delayed yet robust interferon signature, the magnitude of which corresponded to the degree of SARS-CoV-2 infection. Interestingly, virus with the Omicron variant spike (S) protein infected the organoids with the highest infectivity, suggesting increased tropism of the virus for intestinal tissue. These results suggest that heterogeneity in SARS-CoV-2 replication in intestinal tissues results from differences in ACE2 levels, which may underlie variable patient outcomes.

Enteric viruses evoke broad host immune responses resembling those elicited by the bacterial microbiome

The contributions of the viral component of the microbiome-the virome-to the development of innate and adaptive immunity are largely unknown. Here, we systematically defined the host response in mice to a panel of eukaryotic enteric viruses representing six different families. Infections with most of these viruses were asymptomatic in the mice, the magnitude and duration of which was dependent on the microbiota. Flow cytometric and transcriptional profiling of mice mono-associated with these viruses unveiled general adaptations by the host, such as lymphocyte differentiation and IL-22 signatures in the intestine, as well as numerous viral-strain-specific responses that persisted. Comparison with a dataset derived from analogous bacterial mono-association in mice identified bacterial species that evoke an immune response comparable with the viruses we examined. These results expand an understanding of the immune space occupied by the enteric virome and underscore the importance of viral exposure events.

Abstract PR03: Functional characterization of the enteric animal virome as mediator of host health

The enteric virome includes viruses that infect eukaryotic cells in the gut and is one constituent of the mammalian microbiome. Although best known for causing acute diarrheal disease, many of these viruses cause subclinical infections, and indeed are often detected in asymptomatic individuals. The consequences of harboring these viruses are unclear. We recently demonstrated that norovirus mono-colonization promotes the development of the intestinal architecture and the mucosal immune system of germ-free mice in a manner similar to symbiotic bacteria and can protect against models of chemical and microbial injury. It is unclear whether this symbiotic virus-host relationship is a unique feature of murine norovirus strain CR6 colonization. Here, we examined the extent to which members of the eukaryotic enteric virome contribute to the state of the host health. Examination of 10 enteric DNA and RNA viruses representing 6 viral families capable of spreading through the fecal-oral route revealed that many establish a prolonged infection, which often is not limited to the intestinal tissues, in the absence of visible disease after oral inoculation. Further histologic analysis of the small intestinal and colonic tissues confirmed no pathogenic effects on the intestinal tissues. To evaluate the direct impact of asymptomatic viral infections independently from the bacterial microbiome, we performed RNA-seq on intestinal tissues and a comprehensive flow cytometry analysis of intestinal and extraintestinal organs, assessing over 20 immune cell subsets and their cytokine production capacity, following viral mono-colonization of germ-free mice. We found profound effects exerted by the enteric viruses on the immune system in all the tissues tested. In addition to confirming anticipated consequences of viral infection such as expansions of Th1 cells and effector memory T cells, we identified novel virus-specific responses, such as norovirus-induced expansion of type 1 regulatory T cells and parvovirus-mediated induction of regulatory T cells. Interestingly, intestinal T cells and innate lymphoid cells from almost all the virome-colonized mice were more predisposed towards the production of proinflammatory Th1 cytokines, such as IFNγ, and of Il22. An increase in the IL22 signature was also detected in the intestinal transcriptome of virome-colonized mice, suggesting that the virome members support the production of this cytokine already at the steady-state level. Of note, only a few viruses were inducing a type I interferon signature in the tissues, suggesting that pathways other than type I interferon mediate the virome effects on the host. Taken together, these data demonstrate that multiple members of the enteric virome can contribute to the development and function of the mucosal immune system.

This abstract is also being presented as Poster A13.

Citation Format: Simone Dallari, Thomas Heaney, Adriana Rosas-Villegas, Ken Cadwell. Functional characterization of the enteric animal virome as mediator of host health [abstract]. In: Proceedings of the AACR Special Conference on the Microbiome, Viruses, and Cancer; 2020 Feb 21-24; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2020;80(8 Suppl):Abstract nr PR03.

IFN-I and IL-22 mediate protective effects of intestinal viral infection

Products derived from bacterial members of the gut microbiota evoke immune signalling pathways of the host that promote immunity and barrier function in the intestine. How immune reactions to enteric viruses support intestinal homeostasis is unknown. We recently demonstrated that infection by murine norovirus (MNV) reverses intestinal abnormalities following depletion of bacteria, indicating that an intestinal animal virus can provide cues to the host that are typically attributed to the microbiota. Here, we elucidate mechanisms by which MNV evokes protective responses from the host. We identify an important role for the viral protein NS1/2 in establishing local replication and a type I interferon (IFN-I) response in the colon. We further show that IFN-I acts on intestinal epithelial cells to increase the proportion of CCR2-dependent macrophages and interleukin (IL)-22-producing innate lymphoid cells, which in turn promote pSTAT3 signalling in intestinal epithelial cells and protection from intestinal injury. In addition, we demonstrate that MNV provides a striking IL-22-dependent protection against early-life lethal infection by Citrobacter rodentium. These findings demonstrate novel ways in which a viral member of the microbiota fortifies the intestinal barrier during chemical injury and infectious challenges.

Functional characterization of the enteric animal virome

The enteric virome includes viruses that infect eukaryotic cells in the gut and is one constituent of the mammalian microbiome. Although best known for causing acute diarrheal disease, many of these viruses are detected in asymptomatic individuals. The immune consequence of harboring these viruses is unclear. We recently demonstrated that norovirus infection promotes the development of the mucosal immune system in mice in a manner similar to symbiotic bacteria, and can protect against models of chemical and microbial injury. These results are reminiscent of findings from the microbiome field demonstrating that intestinal colonization by individual bacterial species directs the differentiation of the immune system. Here, we examined the extent to which the eukaryotic enteric virome contributes to the state of the host immune system. Examination of 10 enteric DNA and RNA viruses, representing 6 viral families, revealed that many establish prolonged infection in the absence of disease. To evaluate the immunological impact of these viral infections that occurs independently of other members of the microbiome, we performed a comprehensive flow cytometry analysis of several organs following infection of germ-free mice that assessed over 20 immune cell subsets and their capacity for cytokine production. We found profound effects of enteric viral infection in all the tissues tested, showing strain-specific responses, such as norovirus-induced expansion of type 1 regulatory T cells, and commonly shared ones, such as the increased potential of colonic T cells to produce Il-22. Taken together, these data demonstrate that enteric virome members contribute to the immune status of the host.

Self-Renewal and Toll-like Receptor Signaling Sustain Exhausted Plasmacytoid Dendritic Cells during Chronic Viral Infection

Although characterization of T cell exhaustion has unlocked powerful immunotherapies, the mechanisms sustaining adaptations of short-lived innate cells to chronic inflammatory settings remain unknown. During murine chronic viral infection, we found that concerted events in bone marrow and spleen mediated by type I interferon (IFN-I) and Toll-like receptor 7 (TLR7) maintained a pool of functionally exhausted plasmacytoid dendritic cells (pDCs). In the bone marrow, IFN-I compromised the number and the developmental capacity of pDC progenitors, which generated dysfunctional pDCs. Concurrently, exhausted pDCs in the periphery were maintained by self-renewal via IFN-I- and TLR7-induced proliferation of CD4^- subsets. On the other hand, pDC functional loss was mediated by TLR7, leading to compromised IFN-I production and resistance to secondary infection. These findings unveil the mechanisms sustaining a self-perpetuating pool of functionally exhausted pDCs and provide a framework for deciphering long-term exhaustion of other short-lived innate cells during chronic inflammation.

DDX3 suppresses type I interferons and favors viral replication during Arenavirus infection

Several arenaviruses cause hemorrhagic fever (HF) diseases that are associated with high morbidity and mortality in humans. Accordingly, HF arenaviruses have been listed as top-priority emerging diseases for which countermeasures are urgently needed. Because arenavirus nucleoprotein (NP) plays critical roles in both virus multiplication and immune-evasion, we used an unbiased proteomic approach to identify NP-interacting proteins in human cells. DDX3, a DEAD-box ATP-dependent-RNA-helicase, interacted with NP in both NP-transfected and virus-infected cells. Importantly, DDX3 deficiency compromised the propagation of both Old and New World arenaviruses, including the HF arenaviruses Lassa and Junin viruses. The DDX3 role in promoting arenavirus multiplication associated with both a previously un-recognized DDX3 inhibitory role in type I interferon production in arenavirus infected cells and a positive DDX3 effect on arenavirus RNA synthesis that was dependent on its ATPase and Helicase activities. Our results uncover novel mechanisms used by arenaviruses to exploit the host machinery and subvert immunity, singling out DDX3 as a potential host target for developing new therapies against highly pathogenic arenaviruses.

Atomic Absorption Spectrophotometry (AAS) for the Evaluation of Metallosis in Prostheses and Artificial Organs: A New Approach

To study the presence of metals in body fluids and tissues after implantation of metallic biomaterials and possible related diseases, a new approach in Atomic Absorption Spectrophotometry (AAS) was developed. This technique was compared to three traditional methods: mineralisation with acid digestion (method A) also known as “wet method”, dry ashing (with or without oxygen) (method B); classic Kjeldaal (method C). The new approach (method D) modifies the mineralisation phase and the instrument operating instructions. Al, Na, Cr, K, Ni, Co, Ti, Fe, Hg, Pb, V, Sb and Cu levels were tested with the four methods on bone, muscle, cartilage, skin, brain, lymph nodes, blood, urine, and hair. Test results were checked by the addition method. Results demonstrated a significantly higher percentage of Al, Cr, Ni, Ti and Hg recovery with the new approach. The advantages of method D are no residue, no redox reaction, insignificant loss of analytes and enhanced sensitivity (at ppb level vs ppm of the other methods). This approach should be considered especially when testing heavy metals and complex matrices. Its disadvantages are that it is more time consuming and requires the presence of an operator.

Current usefulness of aspiration cytology (FNAC) in the head and neck diagnosis

BACKGROUND

Fine Needle Aspiration Cytology (FNAC) is a well established and widely used method for both a preliminary and sometime final non-invasive pathologic diagnosis. FNAC is a simple and inexpensive diagnostic tool and should represent the standard of care in developing and resource-poor countries while maintaining its diagnostic usefulness in developed and advanced ones.

METHODS

The concordance between preoperative FNAC and final histology was evaluated in 168 patients operated on at the Otorhinolaryngology Unit, "A. Murri" Hospital, Fermo (Italy), from January 2012 to October 2016, including thyroid cases, salivary glands and cervical masses.

RESULTS

The percentages of correct diagnosis provided by FNAC were good in all groups of pathologies and in accordance with the mean data of the literature. In particular the kappa statistic for the degree of agreement between FNAC and definitive histology (good > 0.6 and excellent > 0.8) was 0.74 for the thyroid, 0.83 for the parotid and 0.71 for both the submandibular and the cervical masses.

DISCUSSION

Thy 3 group is still the most challenging for a successful FNAC diagnostic prediction. Especially in the developed and advanced countries, both the immediate review of the smear with its repetition, if needed, and the aspiration performed under CT/MRI guidance, when necessary, seem to further empower FNAC diagnostic resolution and should be pursued. Being routinely used for more than 40 years, FNAC is still a valuable and cost-effective tool to distinguish between cases that don't need any treatment, cases to be treated medically and those that require surgical excision. In the Authors' opinion every institution should periodically review its data in order to monitor and assess the accuracy of its diagnostic activity.

Central and local adaptations sustain Type I Interferon exhaustion during chronic viral infection

During chronic infections, sustained cell adaptation via functional exhaustion has been mostly studied in the adaptive immune compartment but much less is known on how innate immune cells adjust to a persistently infectious milieu. Thus, to understand how innate cells adapt to persistent infections, we studied plasmacytoid dendritic cells (pDCs), which specialize in Type I Interferon (IFN-I) production and often become functionally exhausted in chronic settings. Using a murine chronic viral infection model we demonstrated that pDC IFN-I exhaustion is caused by concerted events at central (bone marrow) and local (spleen) compartments. On one hand, undifferentiated bone marrow pDC progenitors exhibited quantitative and qualitative defects and failed to generate functional pDCs ex vivo. Analysis of transcription and chromatin landscapes via RNA-seq and ATAC-seq revealed that IFN-I signaling pathway was enhanced in bone marrow pDC progenitors. Consistently, IFN-I receptor blockade restored the quantitative (albeit not the qualitative) defects of bone marrow pDC progenitors, which was accompanied by restoration of E2-2, a transcription factor critical for pDC development. On the other hand, splenic pDCs received sustained TLR7 signaling, which promoted their maturation but also rendered them unable to produce IFN-I upon ex vivo TLR re-stimulation or in vivo secondary infection. RNA-seq and ATAC-seq analysis in splenic pDCs revealed significant alterations in multiple pathways and transcriptional regulators that are currently being studied. Our work provides an anatomical, cellular and molecular framework to understand how innate immune exhaustion can be triggered and sustained during a chronic viral infection.

Src family kinases Fyn and Lyn are constitutively activated and mediate plasmacytoid dendritic cell responses

Plasmacytoid dendritic cells (pDC) are type I interferon-producing cells with critical functions in a number of human illnesses; however, their molecular regulation is incompletely understood. Here we show the role of Src family kinases (SFK) in mouse and human pDCs. pDCs express Fyn and Lyn and their activating residues are phosphorylated both before and after Toll-like receptor (TLR) stimulation. Fyn or Lyn genetic ablation as well as treatment with SFK inhibitors ablate pDC (but not conventional DC) responses both in vitro and in vivo. Inhibition of SFK activity not only alters TLR-ligand localization and inhibits downstream signalling events, but, independent of ex-vivo TLR stimulation, also affects constitutive phosphorylation of BCAP, an adaptor protein bridging PI3K and TLR pathways. Our data identify Fyn and Lyn as important factors that promote pDC responses, describe the mechanisms involved and highlight a tonic SFK-mediated signalling that precedes pathogen encounter, raising the possibility that small molecules targeting SFKs could modulate pDC responses in human diseases.

Upregulation of integrin expression on monocytes in multiple sclerosis patients treated with natalizumab

Natalizumab is a humanized monoclonal antibody against the α4 subunit of VLA-4 integrin that is used to treat conditions such as multiple sclerosis (MS). Although its effects on lymphocytes have been widely described, little is known about its effects on monocytes. Here we described the effects of natalizumab treatment on peripheral blood monocytes from a small cohort of MS patients in terms of relative frequencies and surface integrin (CD49d and CD18) expression. We showed that natalizumab treatment altered the surface integrin expression on monocyte subsets in the peripheral compartment, suggesting a role for them as mediators of natalizumab effects.

Src family kinase members Fyn and Lyn mediate type I interferon production by plasmacytoid dendritic cells. (INM7P.345)

Plasmacytoid dendritic cells (pDCs) are the most powerful type I interferon (IFN-I) producing cells and are therefore important for antiviral defense and for autoimmune diseases such as systemic lupus erythematosus. However, the signaling factors that regulate pDC IFN-I production are not completely understood. Here we investigate the role of Src Family Kinases (SFKs), a family of non-receptor tyrosine kinases, in pDC responses to toll like receptor (TLR) stimulation. We first found that while human pDCs expressed mostly Lyn, mouse pDCs expressed both Lyn and Fyn, two members of SFKs. Importantly, we observed that pDCs from either Fyn or Lyn deficient mice exhibited impaired IFN-I and pro-inflammatory cytokine production after TLR-9 and TLR-7 stimulation, whereas no difference was observed in conventional DCs. Consistently, incubation of murine or human pDCs with a pan-SFKs inhibitor resulted in a dramatic ablation of pDC IFN-I and cytokine production in a dose dependent manner. Finally, treatment of a human pDC cell line (CAL-1) or pDCs from human peripheral blood with Bafetinib (a selective dual Bcr-Abl/Lyn inhibitor) profoundly ablated their IFN-I production after TLR stimulation. Taken together, our data indicate that the SFKs members Fyn and Lyn promote pDC IFN-I and pro-inflammatory cytokine production and suggest that Bafetinib could be considered as a therapeutic candidate for attenuating pDC responses in autoimmune diseases.

Investigation of polyomaviruses replication in pediatric patients with nephropathy receiving rituximab

Rituximab is a chimeric monoclonal antibody reacting with the CD20 antigen on B cells. It has been proposed as treatment for the idiopathic nephrotic syndrome, recurrent idiopathic nephropathy, and focal segmental glomerulosclerosis refractory to steroids. Rituximab influences T-cell immunity and may predispose the patients to opportunistic infections, such as progressive multifocal leukoencephalopathy caused by the polyomavirus JC (JCV). The risk of latent viruses infections/reactivations in pediatric patients receiving monoclonal antibodies is not well known yet. In this longitudinal 6-month study, the effects of rituximab on JCV and BK virus (BKV) replication have been investigated. Blood, serum, and urine samples have been collected monthly from 11 pediatric patients (mean age: 11 years) with the idiopathic nephrotic syndrome and recurrent idiopathic nephropathy, under rituximab therapy. JCV and BKV real-time PCRs and sequencing of the viral protein 1 and the non-coding control region have been conducted. The same investigations have been undertaken on samples collected from eight pediatric patients (controls, mean age: 6 years), with idiopathic nephrotic syndrome or focal segmental glomerulosclerosis, treated with conventional chemotherapy. JCV was detected in the urine of one patient (9%), and one control (12.5%); BKV was found in the urine of 7/11 patients (63.6%) and 2/8 controls (25%) and in blood samples from four patients. No significant difference was found in the mean viral loads and in the viral molecular characterizations between the two groups. The polyomaviruses replication was not associated with rituximab therapy in children.

Descending necrotizing mediastinitis. Diagnosis and surgical treatment

AIM

Descending necrotizing mediastinitis (DNM) is an unusual and severe disease with a high mortality rate. Surgical management remains controversial. Our investigations reviews the most effective surgical treatment in the management of this rare pathology.

METHODS

Seven patients with DNM and treated over a 20-year period are reported. All patients were evaluated according to the classification suggested by Endo et al. of the degree of mediastinal diffusion, based on CT scan findings. Five patients underwent combined cervical drainage and thoracotomy, 2 patients were treated with cervical drainage alone.

RESULTS

The outcome was favorable in 5 patients, 4 treated with a combined cervical and thoracic approach and 1 with a cervical approach alone. Two patients that underwent a combinated cervical and thoracic approach alone, died of septic shock. Overall mortality rate was 28.5%.

CONCLUSION

Early diagnosis and early, aggressive surgical treatment are required to improve the poor prognosis of DNM. Although a unique surgical management is still not completely accepted, we state, in agreement with other authors, a wide approach consisting of a cervical drainage and mediastinotomy in case of upper mediastinitis and a combined cervical and thoracic approach in case of lower mediastinitis. In the course of thoracotomy a wide excision of necrotic and particularly fat mediastinal tissue is needed, to avoid a recurrent infection. A continuous cervico-mediastinal irrigation system is suggested during the postoperative period.

Atomic absorption spectrophotometry (AAS) for the evaluation of metallosis in prostheses and artificial organs: a new approach

To study the presence of metals in body fluids and tissues after implantation of metallic biomaterials and possible related diseases, a new approach in Atomic Absorption Spectrophotometry (AAS) was developed. This technique was compared to three traditional methods: mineralisation with acid digestion (method A) also known as "wet method", dry ashing (with or without oxygen) (method B); classic Kjeldaal (method C). The new approach (method D) modifies the mineralisation phase and the instrument operating instructions. Al, Na, Cr, K, Ni, Co, Ti, Fe, Hg, Pb, V, Sb and Cu levels were tested with the four methods on bone, muscle, cartilage, skin, brain, lymph nodes, blood, urine, and hair. Test results were checked by the addition method. Results demonstrated a significantly higher percentage of Al, Cr, Ni, Ti and Hg recovery with the new approach. The advantages of method D are no residue, no redox reaction, insignificant loss of analytes and enhanced sensitivity (at ppb level vs ppm of the other methods). This approach should be considered especially when testing heavy metals and complex matrices. Its disadvantages are that it is more time consuming and requires the presence of an operator.

Acute mastoiditis with complications: a report of two cases

The authors report two cases of lateral sinus thrombosis (LST) which were recently observed after more than a 20-year absence of such pathology at their Institutions. After reviewing the epidemiologic data, the clinical observations are described in detail. Changes in symptomatology mainly due to the improper use of antibiotics are then discussed as well as the diagnostic improvement offered by modern imaging techniques. Problems still under debate concern the therapeutic strategy: internal jugular vein ligation or anticoagulation therapy versus aminoglycoside administration for patients refractory to the conventional antibiotic therapy. The necessity of close cooperation between general practitioner, pediatrician and otolaryngologist is stressed.

Avascular tympanojugular paraganglioma

The avascular paraganglioma described in this article appears to be the second such tumor reported in the international literature and the first to be reported in the tympanojugular region. Despite a highly suggestive history and clinical appearance, the tumor showed no signs of vascularization on radiologic studies. The pathologic postoperative study confirmed the diagnosis of paraganglioma with extensive stromal fibrosclerosis and without the typical well-vascularized thin fibrous septa. In the authors' opinion, this observation is notable because of the difficulties encountered in the correct diagnostic interpretation of an avascular mass in the tympanojugular region. In such cases, the possibility of a paraganglioma should always be considered.

[Logopedic rehabilitation of laryngeal granulomas]

Posterior laryngeal granuloma is an infrequent pathology of multidisciplinary interest. Actually, its real prevalence is difficult to quantify because in some cases it is asymptomatic and in other instances it may either be reabsorbed or eliminated spontaneously. It is located at the vocal apophysis of the arytenoid or, less frequently, above it or on the laryngeal side of the arytenoid. The many etiologic factors (laryngeal intubation, gastro-esophageal refluxes, blunt trauma of the larynx, vocal dysfunction), sometimes concomitant and with the possible addition of enhancing circumstances (upper aerodigestive tract inflammation, naso-gastric tube, smoking and alcohol abuse), converge to a single pathogenetic mechanism: an ulceration of the mucosa and the pericondrium, sometimes complicated by an infection, which does not heal but instead produces a typical granulation tissue with capillaries oriented radially from the center of the lesion. Post intubation granulomas, extremely rare in children, are more frequent in females. It appears that there is no correlation with duration of intubation in that granulomas, can also occur after short general anesthesia. Idiopathic or contact granulomas are more frequent in the males. They are the result of vocal laryngeal hyperfunction, habitual throat clearing or cough-like throat clearing. Gastro-esophageal reflux of gastric juice, coughing or throat clearing may injure the mucosa. A blunt trauma of the larynx may cause a granuloma if the cartilage of the vocal process is exposed. Symptoms, when present, are dysphonia, tiredness during or after voicing, bolus, laryngeal unilateral pain, sensation of something in the throat which is mobile during breathing and swallowing, traces of blood in the expectoration. Therapeutic options are surgical, medical or logopedic. Surgery, although followed by frequent recurrences, is mandatory when the granuloma causes dispnea or if a pathologic essay is needed. Medical treatment aims at solving gastroesophageal reflux and/or inflammations of the district. Logopedic rehabilitation is the most successful therapy. Since January 1992 the Authors have been adopting the rehabilitation protocol planned by the French phoniatrician Brigitte Arnoux-Sindt for post-intubation granulomas, which, moreover, is utilyzed for all type of granulomas, including those arising during the early postoperative period after cordectomy. This protocol is analytically presented and discussed. In the cases of contact granulomas, and when there is concomitant vocal dysfunction, logopedic treatment is prolonged after granuloma dissapearance with some sessions aiming at restoring correct vocal behaviour. In all the ten patients rehabilitated up to now, granulomas disappeared after a mean of 16.3 sessions held twice a week. After several months of follow-up we had no recurrences. This clinical experience, while limited in number, seems to confirm the good results already reported in French Literature.

Integrin expression in middle ear cholesteatoma

Cholesteatoma is lined by a squamous keratinizing epithelium exhibiting most of the features of normal epidermis. In this study, we investigated by immunohistochemistry the expression of integrin adhesion molecules in primary acquired and recurrent cholesteatomas, and compared it with common epidermal cysts and normal human skin. The results showed that cholesteatoma epithelium exhibited a markedly augmented expression of alpha v integrin subunit and a corresponding increased deposition of vitronectin (alpha v ligand) in the surrounding stroma as compared to epidermal cyst and normal human skin. In contrast, the expression pattern of alpha 2 beta 1, alpha 3 beta 1, and alpha 6 beta 4 integrins as well as the distribution of laminin, collagen IV and fibronectin were similar in cholesteatomas, epidermal cysts and normal human skin. Similar staining pattern was observed in primary acquired and recurrent cholesteatoma.

Efficacy and tolerability of brodimoprim in bacterial otitis media in children. Controlled study versus cefaclor

78 pediatric patients affected by acute otitis media were selected and randomized into two balanced groups of treatment: brodimoprim, at the dosage of 200 mg once-a-day on the first day and of 100 mg once-a-day on the following days, and cefaclor at a dosage of 40 mg/Kg/day in three doses. Brodimoprim resulted more efficacious in the reduction of symptoms, especially hypoacusis and tinnitus (p < 0.05 between treatments); tympanometry showed a higher number of normalizations in the brodimoprim group, without significant differences between treatments. Both drugs resulted active against most of isolated bacterial strains. Side effects were reported in 4 patients treated with brodimoprim and in 6 patients in the control group.

Efficacy and tolerability of brodimoprim in pharyngotonsillitis in children

160 children with an average age of 9 years (range 6-15) affected by acute bacterial tonsillitis, were selected and assigned, following an open, parallel group design to: a) brodimoprim at the dose of 10 mg/kg on the first day, in single administration, and of 5 mg/kg on the following days; b) cotrimoxazole suspension, at the dosage of 6 mg of trimethoprim/kg/day, in two daily administrations; c) amoxicillin with clavulanic acid suspension (amoxi-clavulanate) 50 mg/kg every 12 hours. Quantity of pharynx and tonsillar exudate, pharynx pain, dysphonia and dysphagia were checked at the basal time, 3rd, 7th and at the last day of therapy. These symptoms were evaluated using a four-step rating scale. The evolution of body temperature was measured at two different times (1 and 5 o'clock p.m.), until the end of treatment, foreseen five days after disappearance of fever. Microbiological evaluation through a pharynx swab was performed at the beginning and at the end of therapy. Side-effects were registered during all the observation period. Lab-tests were carried out at the enrollment and at the end of treatment. The frequency and intensity of symptoms decreased significantly in all treatment groups. In comparison with amoxi-clavulanate, the brodimoprim group showed an earlier improvement (3rd day) of the clinical situation and a significantly better regression of pharynx exudate (p < 0.01), pharynx pain (p < 0.05) and dysphonia (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Turbinoplasty: personal technique and long-term results

An original conservative technique for surgical reduction of the inferior turbinates, called turbinoplasty, is described. We analyzed, in 308 cases, the functional objective and subjective outcome of turbinoplasty itself and in comparison with more destructive procedures called turbinotomies. The results show that both procedures (in skilled hands!) are good. Turbinoplasty is in any case a quick, safe, efficacious operation, well-accepted by the patient, and should therefore be considered one of the first choices.