Pre-surgical, surgical and post-surgical experiences of weight loss surgery patients: a closer look at social determinants of health.

Using a novel qualitative approach, Photovoice, researchers assessed social, psychological, physical and economic barriers encountered by patients of weight loss surgery. Applying the Photovoice approach and Williams' theory of narrative reconstruction for qualitative interviewing, the research team set out to investigate the bariatric patient experience from pre-surgery to hospitalization to post-surgery. Fifteen participants were given digital cameras and asked to take photographs that represented their weight loss journeys. Photographs and qualitative interviews were used to theorize the role played by comorbidities, social determinants of health, provider communication experiences and understanding of insurance coverage in patient outcomes. Several themes emerged from the interviews and photographs including themes centred around: (i) racial/ethnic standards of beauty; (ii) gender expectations; (iii) comorbidities, depression/disordered eating and obesity discrimination and (iv) financial hardship impacting adherence. Photographs also illuminated the impact of hospital and state-wide policies on patient lives. Results suggest that Photovoice may be a useful adjunct to standard-of-care to help patients identify barriers, and to identify shortcomings in health services. Additional screening tools for gender- and income-related barriers (and concomitant referrals to support services) provide an opportunity to improve patient care and reduce post-operative readmissions.

Nitrogen and phosphorus availabilities interact to modulate leaf trait scaling relationships across six plant functional types in a controlled-environment study.

Nitrogen (N) and phosphorus (P) have key roles in leaf metabolism, resulting in a strong coupling of chemical composition traits to metabolic rates in field-based studies. However, in such studies, it is difficult to disentangle the effects of nutrient supply per se on trait-trait relationships. Our study assessed how high and low N (5 mM and 0.4 mM, respectively) and P (1 mM and 2 µM, respectively) supply in 37 species from six plant functional types (PTFs) affected photosynthesis (A) and respiration (R) (in darkness and light) in a controlled environment. Low P supply increased scaling exponents (slopes) of area-based log-log A-N or R-N relationships when N supply was not limiting, whereas there was no P effect under low N supply. By contrast, scaling exponents of A-P and R-P relationships were altered by P and N supply. Neither R : A nor light inhibition of leaf R was affected by nutrient supply. Light inhibition was 26% across nutrient treatments; herbaceous species exhibited a lower degree of light inhibition than woody species. Because N and P supply modulates leaf trait-trait relationships, the next generation of terrestrial biosphere models may need to consider how limitations in N and P availability affect trait-trait relationships when predicting carbon exchange.

The combination of gas-phase fluorophore technology and automation to enable high-throughput analysis of plant respiration.

BACKGROUND: Mitochondrial respiration in the dark (Rdark) is a critical plant physiological process, and hence a reliable, efficient and high-throughput method of measuring variation in rates of Rdark is essential for agronomic and ecological studies. However, currently methods used to measure Rdark in plant tissues are typically low throughput. We assessed a high-throughput automated fluorophore system of detecting multiple O2 consumption rates. The fluorophore technique was compared with O2-electrodes, infrared gas analysers (IRGA), and membrane inlet mass spectrometry, to determine accuracy and speed of detecting respiratory fluxes. RESULTS: The high-throughput fluorophore system provided stable measurements of Rdark in detached leaf and root tissues over many hours. High-throughput potential was evident in that the fluorophore system was 10 to 26-fold faster per sample measurement than other conventional methods. The versatility of the technique was evident in its enabling: (1) rapid screening of Rdark in 138 genotypes of wheat; and, (2) quantification of rarely-assessed whole-plant Rdark through dissection and simultaneous measurements of above- and below-ground organs. DISCUSSION: Variation in absolute Rdark was observed between techniques, likely due to variation in sample conditions (i.e. liquid vs. gas-phase, open vs. closed systems), indicating that comparisons between studies using different measuring apparatus may not be feasible. However, the high-throughput protocol we present provided similar values of Rdark to the most commonly used IRGA instrument currently employed by plant scientists. Together with the greater than tenfold increase in sample processing speed, we conclude that the high-throughput protocol enables reliable, stable and reproducible measurements of Rdark on multiple samples simultaneously, irrespective of plant or tissue type.

Physical exercises in the treatment of adolescent idiopathic scoliosis: an updated systematic review.

Two years ago we published an update of another of our previous systematic reviews about the effectiveness of physical exercises (PEs), and we found that the evidence on exercises for AIS was of level 1b. Now we have updated these results in the field of exercises for AIS with the final aim to find the strongest evidence as possible about PEs. Our goal was to verify if treatment with specific exercises for AIS has changed in these years. The study design was a systematic review. A bibliographic search with strict inclusion criteria (patients treated exclusively with exercises, outcome Cobb degrees, all study designs) has been performed on the main electronic databases. We found a new paper about active autocorrection (Negrini et al, 2008 b), a prospective controlled cohort observational study on patients never treated before so the number of manuscripts considered in the systematic review was 20. The highest quality study (RCT) compared 2 groups of 40 patients, showing an improvement of the curve in all treated patients after 6 months. All studies confirmed the efficacy of exercises in reducing the progression rate (mainly in early puberty) and/or improving the Cobb angles (around the end of growth). Exercises were also shown to be effective in reducing brace prescription. Appendices of the popular exercise protocols that have been used in the research studies that are examined are included with detailed description and illustrations. This study (like the previously published systematic reviews) showed that PEs can improve the Cobb angles of individuals with AIS and can improve strength, mobility, and balance. The level of evidence remains 1b according to the Oxford Centre for Evidence-based Medicine, as previously documented.

Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease.

An increase of the physiological kyphosis during growth is defined hyperkyphosis (HK) and, according to the level where the apex of the curve can be retrieved, we can distinguish a thoracic HK and a thoraco-lumbar one, also called junctional kyphosis. Since these conditions can cause pain and esthetics impairments, lead in adulthood to an higher incidence of spinal and shoulder pain, and evolve during growth, it is important to manage this deformity. The aim of this paper was to present the state of the art about HK and its treatment. Scheuermann Disease (SCHK) is the better known cause of HK; other causes can be idiopathic or postural, trunk extensor muscles weakness or neurological problems. Despite etiology a specific treatment can be required during growth to prevent evolution and reach a better spinal alignment in adulthood. It is at the base of treatment and allow monitoring. There are some validated methods that can be used in a comprehensive rehabilitation approach. Evidence in this field is scanty, even if there is quite a consensus on possible treatments. They aim at improving posture and esthetics, and abolishing pain; they include: exercises, used mainly in mobile postural/idiopathic HK, and in SCHK without HK; braces (plus exercises, in this case aimed at reducing brace impairments), that in rigid HK and in most of SCHK patients also allow a better vertebral growth; surgery could be used in worst cases, even if it should be carefully considered, because it requires fusion and loss of spinal function.

Bronchial hyperreactivity and spirometric impairment in patients with allergic rhinitis.

BACKGROUND: The Link between allergic rhinitis and asthma is well known. Bronchial hyperreactivity (BHR) may be present in rhinitics. The present study is aimed at evaluating a large group of subjects suffering from allergic rhinitis alone to investigate the presence of spirometric impairment and BHR both during and outside the pollen season. METHODS: 360 rhinitics (subdivided in 3 groups: seasonal, SAR, perennial, PAR, and polysensitized, PolysR) were investigated by spirometry and methacholine challenge. RESULTS: There was a significant seasonal difference concerning the number of rhinitics with impaired FEV1 (p<0.01 for SAR, p<0.02 for PAR, and p<0.03 for PolysR) and FEF25-75 (p<0.05 for SAR, p<0.03 for PAR, and p<0.05 for PolysR) as well as with BHR (p<0.05 for SAR and p<0.03 for PAR). CONCLUSIONS: This study evidences that an impairment of spirometric parameters and BHR may be observed in patients with allergic rhinitis alone. Thus, careful evaluation of lower airways should be performed in patients with allergic rhinitis alone.

The validity of clinical examination in adolescent spinal deformities.

STUDY DESIGN: retrospective study on the accuracy and reliability of two clinical tests for scoliosis in young patients. AIM: to evaluate the inter-observer reliability of three non-invasive clinical measurements: hump height (HH), axial trunk rotation (ATR), and distance of the spinous process from the plumb line (DP) in standing; to compare these results with the corresponding radiographic measurements, the Cobb angles (CA). POPULATION: 116 patients, 78 females and 38 males; 410 examinations have been performed (144 patients with brace and 266 without). METHODS: a database was created using the measurements of different clinical parameters obtained from two examiners that measured them independently and in the same conditions. The Cobb method has been used as a gold standard. RESULTS: our results show a very high inter-rater reliability for HH and ATR measurements. The DP shows a different inter-rater reliability for the thoracic (C7) and lumbar (L3) spine, in both cases lower than that in the frontal plane; the ICC of the thoracolumbar DP (D12) was very low. The correlation with the radiographic value was weak.

Clinical study on Alternaria spores sensitization.

BACKGROUND: sensitization to fungi spores is often associated with sensitization to other allergens and so it is difficult to estabilish the exact cause of illness. OBJECTIVE: the aim of the study was to evaluate a group of patients monosensitized to Alternaria and to establish the prevalence, periodicity and clinical profile of this kind of sensitization. METHODS: 37 subjects who were monosensitized to Alternaria (prick-test positive), according to a previous epidemiological study were evaluated. Clinical symptoms and the period of their occurrence were taken into consideration as well as immunological parameters (RAST). RESULTS: 20 patients (over 50%) included in the study proved to be affected by asthma associated with other allergic symptoms and 22 patients (60%) presented perennial symptoms. The RAST carried out on 34 monosensitized subjects proved positive in 11 and negative in 23. CONCLUSIONS: Alternaria sensitization is characterized by a perennial periodicity with severe respiratory symptoms (asthma) which occur primarily in children. Prick test is preferable to and more reliable than RAST as a diagnostic test.

Management of patients at risk for adverse reactions to local anesthetics: analysis of 386 cases.

Local anesthetics are among the most used drugs in clinical practice. Various types of reactions have been reported and many patients are told that they are allergic to caines or are at risk of allergic reactions. We report our experience with 386 patients using skin test and progressive subcutaneous challenge in order to select a local anesthetic that could be safely used. The patients underwent specific protocol including clinical history, prick and intradermal tests, and subcutaneous incremental challenge with a local anesthetic from the amide group which was free of preservatives and vasoconstrictors. Thirteen patients showed a positive skin test: 10 with positive prick test underwent the subsequent challenge with no reactions; the three who were also positive by the intradermal route were carefully evaluated with a different drug. Eight of the patients with negative skin tests complained of various clinical symptoms after the challenge. All the patients found the local anesthetic to be well tolerated and nobody reported reactions after the clinical use. These results show that skin tests and subcutaneous challenge are safe and sufficient to reliably identify a local anesthetic that patients with a prior history of adverse reaction or at higher risk could tolerate.

Prevalence of sensitization to Alternaria in allergic patients in Italy.

BACKGROUND: The actual prevalence of sensitization to Alternaria is not known, partly due to the unreliability of diagnostic extracts. OBJECTIVE: To assess skin positivity to extracts of Alternaria in a wide population of Italian patients suffering from respiratory symptoms using a biologically standardized extract. METHODS: A total of 2942 patients were skin prick tested with Alternaria, and a panel of common inhalant allergens. Blood samples for specific IgE quantitation were taken both from patients positive and from patients negative (control group) to Alternaria extract. RESULTS: Three hundred six patients (10.4%, ranging from 1.8% in Turin to 29.3% in Cagliari) were positive to Alternaria; 37 were sensitized to only this mold, while the remaining 269 were sensitized to at least one other allergen. Of the Alternaria-positive patients, 79.7% suffered from rhinitis and 53.3% from asthma, either alone or associated with other symptoms. CONCLUSIONS: We suggest that, at least in Italy and in countries with similar climatic and environmental situations, standardized Alternaria extract should be included in the panel commonly used in investigating the allergen responsible in patients suffering from respiratory allergy.

Treatment of allergic diseases during pregnancy.

Pregnancy may variously modify the natural history of allergic disorders through occurring endocrinologic, functional and immunological changes. A pharmacologic treatment of allergic diseases (mainly asthma) is often necessary during pregnancy. On the other hand, a drug should be not potentially teratogenic and should not have serious side effects, both for the mother and the fetus. This paper reviews current knowledge about allergic diseases during pregnancy, considering the points of view of the different specialists involved in their management. Topical mucosal agents seem to be the safest, due to their minimal or absent absorption which should reflect reduced side effects. Preferred agents should be topical antihistamines (for rhinitis and conjunctivitis), and cromones and topical steroids (for asthma), as they are both safe and effective.

Oral antihistamine/decongestant treatment compared with intranasal corticosteroids in seasonal allergic rhinitis.

This international, multicentre, randomized, double-blind, double-dummy, parallel-group trial was undertaken to compare the efficacy and tolerability of once-daily astemizole-D (10 mg astemizole plus 240 mg pseudoephedrine) with beclomethasone nasal spray (0.05 mg/ml) two puffs/nostril administered twice daily in a total of 204 patients with seasonal allergic rhinitis. Treatment duration was 4 weeks. Although investigator assessments of symptom severity were generally comparable in the two treatment groups throughout the trial, statistically significant differences in favour of astemizole-D for sneezing and ocular symptoms were apparent at the end of the 4-week treatment period (P < 0.05). Patient diary data support these findings, with significant differences in favour of the antihistamine/decongestant combination reported for ocular symptoms after 2 weeks of treatment (P < 0.05) and non-significant trends for sneezing after 2 weeks and ocular symptoms over the entire treatment period (P = 0.07). Use of rescue medication for ocular symptoms was also significantly lower in the astemizole-D treatment group (P < 0.05). A wide range of adverse experiences were reported, however, there were no statistically significant differences in the type or incidence of those between the two treatment groups. In conclusion, astemizole-D appears to be at least as effective and well tolerated as intranasal beclomethasone in the treatment of seasonal allergic rhinitis, providing at least comparable relief from all nasal symptoms including congestion and significantly greater relief from ocular symptoms than the topical steroid.

Sublingual immunotherapy in Parietaria pollen-induced rhinitis: a double-blind study.

A double-blind, placebo-controlled study of immunotherapy was conducted in 31 patients with allergic rhinitis due to Parietaria pollen to evaluate the efficacy and safety of high doses of allergen via the sublingual route. The patients were assessed before and after a 10-month period of treatment by clinical (symptom-medication scores and specific nasal reactivity) and immunological (total IgE, specific IgE, IgG and IgG4 antibodies) parameters. High doses of Parietaria extract corresponding to a cumulative dose of 105 BU for each patient were administered with negligible side effects. The actively treated patients had significantly lower medication scores than those on placebo (p < 0.05) when the maximum pollen count was recorded, and at the end of the trial they showed a significant decrease in nasal reactivity (p < 0.02) and a significant increase in serum specific IgG4 (p = 0.02). No differences were detected in any of these parameters in the placebo group. Possible explanations for the mechanisms of sublingual immunotherapy are proposed.

Tacalcitol in psoriasis: a video-microscopy study.

Video-microscopy is a video-imaging system which permits direct visualization of the skin surface and capillaries, by using a microscope attached to a camera, a video-recorder and a printer. This technique provides information on the morphology of capillaries in vivo and has been used both for research into normal skin microcirculation and as a clinical method to detect capillary changes in psoriasis and other skin diseases. The aim of this study was to evaluate the morphology of capillaries in psoriatic plaques before and after treatment with tacalcitol, a new topical vitamin D3 analogue. Clinical evaluation was made after 3 and 6 weeks of therapy. After 3 weeks a reduction in erythema and scaling was noted; and areas in which capillaries were less tortuous became evident. After 6 weeks, capillaries were less dilated and tortuous in the whole plaque and had lost the large and tortuous appearance of active psoriasis.

Immunotherapy for respiratory allergic diseases: indications, efficacy and monitoring.

The author reports a detailed analysis of the indications for Specific Immuno-Therapy (SIT) in allergic rhinitis and asthma. After pointing out the requirements for a correct clinical trial, the efficacy of SIT towards various allergenic agents is examined (pollen, mites, cat and dog danders, moulds). Clinical monitoring--by means of clinical diaries, symptom score, drug consumption, skin tests, challenge tests--and immunological monitoring--by means of measuring of IgE and IgG serum antibodies, mediator and cytokine release, lymphocyte study, etc.--are then discussed. Immunological and clinical parameters to evaluate the efficacy of SIT are compared: clinical parameters being the most effective means of evaluation of clinical improvement.

Extensive deletion of immunoglobulin heavy chain constant region genes in the absence of recurrent infections: when is IgG subclass deficiency clinically relevant?

This report describes two children with undetectable serum levels of IgA1, IgG2, IgG4, and IgE due to a homozygous deletion encompassing the A1-E genes. The father is a heterozygous carrier of the same deletion and the mother a heterozygous compound carrying the deletion on one chromosome and duplication on the other. In both children, serum IgG, IgG1, and IgG3 were higher than in normal children and IgG antibody response to tetanus toxoid and polysaccharide antigens was normal with increased IgG1 and IgG3 response compared to controls. The latter can be interpreted as a compensatory mechanism for the subclass deficit and may explain the lack of significant infections in both children. The importance of distinguishing IgG subclass deficiency due to gene deletion from that due to immunoregulatory dysfunction is discussed.

Is the allergen-inhalation challenge predictive of the severity of seasonal asthmatic exacerbations?

Fifteen asthmatic patients sensitized to Parietaria pollen were studied. Before the pollen season they underwent an allergen-inhalation challenge which was preceded and followed by a methacholine-inhalation challenge. Pollen count, symptom score, and drug consumption were monitored daily throughout the study. A severity score was obtained by adding symptom score and drug consumption. Patients underwent a third methacholine challenge during the pollen season, after they had been exposed to a high atmospheric concentration of pollen. The severity score during the first period of the pollen season was significantly correlated with both the early and the late asthmatic responses to the allergen observed before the season (r2 = 0.50; P < 0.005). Bronchial sensitivity to methacholine was significantly increased both after allergen challenge and after seasonal exposure, but these increases correlated neither with each other nor with the severity score. We conclude that bronchial responses to experimental exposure to allergens, but not the changes in nonspecific airway responsiveness, can, in part, predict the severity of asthma exacerbation during the pollen season.

Intravenous immunoglobulin in two children with Guillain-Barré syndrome.

Two children with Guillain-Barrè syndrome were successfully treated with high-dose intravenous immunoglobulin (IVIG) and no relapses occurred over a 1 year follow up. No side-effects were observed. These data provide further evidence that IVIG may be safely and effectively employed in children with Guillain-Barrè syndrome.

Nedocromil sodium and astemizole, alone or combined, in the treatment of seasonal allergic conjunctivitis. A multicentre double blind clinical trial.

Two hundred and seven patients with active symptoms of allergic conjunctivitis were studied in a four-week multicentre double blind, double dummy, clinical trial comparing efficacy and safety of nedocromil sodium eye drops with oral astemizole, placebo, and the combined active treatments. Clinical signs were evaluated by clinicians after 1, 2 and 4 weeks, while symptoms were recorded by patients on daily diary cards. Overall opinions were recorded at the end of treatment. Nedocromil sodium eye drops and astemizole, alone or combined, significantly reduced ocular symptoms when compared to placebo (diary card total symptom score and patients' opinion). In the clinicians' opinion nedocromil sodium alone or combined (but not astemizole alone) significantly decreased ocular symptoms when compared to placebo. All treatments were safe and well tolerated, drowsiness being the most frequent side effect observed in patients treated with astemizole. These results indicate the effectiveness of nedocromil sodium eye drops in the treatment of seasonal allergic conjunctivitis.