Long-term Breastfeeding in the Prevention of Allergic Rhinitis: Allergic Rhinitis Cohort Study for Kids (ARCO-Kids Study).

OBJECTIVES: There is a great deal of interest in the possibility that environmental factors may influence the risk of developing allergic rhinitis (AR) in early life. We investigated the simultaneous effects of mode of delivery and duration of breastfeeding on the development of AR in children. METHODS: Data from 1,374 children participating in the Allergic Rhinitis Cohort Study for kids (ARCO-kids study) was analyzed. All subjects were divided into AR or non-allergic rhinitis (NAR) groups. Data on environmental factors, mode of delivery and duration of breastfeeding were collected using a questionnaire. RESULTS: Compared with short-term breastfeeding (<6 months), long-term breastfeeding (≥12 months) was significantly associated with a lower prevalence of AR (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.34 to 0.88). Children in the AR group also had a higher cesarean delivery rate than those in the NAR group (39.1% vs. 32.8%, P=0.05). Regarding the combined effects of mode of delivery and duration of breastfeeding, long-term breastfeeding with a vaginal delivery strongly suppressed the development of AR, compared to short-term breastfeeding with a cesarean delivery (aOR, 0.47; 95% CI, 0.30 to 0.73). CONCLUSION: Long-term breastfeeding (≥12 months) and a vaginal delivery are associated with a lower risk of developing childhood AR.

Normal Mastoid Air Cell System Geometry: Has Surface Area Been Overestimated?

OBJECTIVES: The aim of this study was to emphasize the necessity of a standard in segmentation threshold and algorithm for measuring volume and surface area of mastoid air cell system (MACS). METHODS: First, we obtained axial computed tomography scans of 54 normal temporal bones from 27 subjects. Then, we manipulated Hounsfield units (HU) image data in DICOM (digital imaging and communications in medicine) files directly using our program. The volume and surface area of MACS were computed and compared at segmentation thresholds (HU) from -700 to 0 at intervals of 50 using 2 algorithms; square pixel based (SP) algorithm and marching square (MS) algorithm. RESULTS: No significant difference was found between the volumes computed by SP and MS algorithms at each segmentation threshold. The surface area computed by SP algorithm, however, was significantly larger than that by MS algorithm. We could minimize this significant difference through a modification of the SP algorithm. As the lower HU threshold value was set, the smaller volume was measured. The surface area showed a plateau at a threshold of approximately -200 HU. The segmentation threshold had greater influence on the measured volume of MACS than the algorithm did. CONCLUSION: A standard method for measuring volume and surface area of MACS is thought to be necessary. We suggest that the MS algorithm and -200 HU of the threshold could be a standard in the measurement of volume and surface area of MACS.

Efficacy and safety of eltrombopag in adult refractory immune thrombocytopenia.

BACKGROUND: Eltrombopag is a thrombopoietin receptor agonist with excellent treatment outcomes in immune thrombocytopenia (ITP). Here, we analyzed the dose of eltrombopag required to achieve and maintain safe platelet counts in Korean ITP patients. METHODS: Adult refractory ITP patients (<30,000 platelets/µL) were enrolled. Eltrombopag doses were increased to achieve a target platelet count (≥50,000 cells/µL). After achieving the target platelet count, the dose of concomitant ITP medications and eltrombopag was reduced to identify the lowest effective dose required to maintain the platelet count. RESULTS: Among 18 patients, 66.7% achieved complete response, 5.6% achieved platelet counts between 50,000 and 100,000 cells/µL, and 27.8% failed to achieve the target platelet count. The median ITP duration was significantly shorter in patients who achieved the target platelet count. The initial dose required to achieve the target platelet count was 25 mg/d. The adjusted maintenance doses were 25 mg twice per week or 25 mg/d. After discontinuation, 83.3% relapsed, and the median relapse-free survival was 15 days. Two relapsed and 1 failed patient switched to romiplostim. The response to romiplostim was similar to eltrombopag. During eltrombopag treatment, 38.9% showed hepatobiliary laboratory anomalies. Among 9 follow-up bone marrow examinations, 1 revealed fibrosis after 1 year of treatment. CONCLUSION: Eltrombopag was well tolerated with excellent treatment outcomes in refractory adult ITP patients. Low-dose eltrombopag effectively maintained the target platelet count. However, some patients required longer or higher-dose treatment to maintain the target platelet count, especially in heavily pretreated or longer ITP cases.

Primary sinonasal tuberculosis confined to the unilateral maxillary sinus.

Extrapulmonary tuberculosis is not rare and occurs mainly in the head and neck region. Cervical tuberculous lymphadenopathy is the most common form of extrapulmonary tuberculosis. Sinonasal tuberculosis is known to occur very rarely due to the protective functions of sinonasal mucosa. Although some signs of sinonasal tuberculosis may be present, such as associated facial abscesses, the symptoms and signs are usually nonspecific. Clinical suspicion is important for timely diagnosis and proper management of sinonasal tuberculosis due to its rarity and nonspecific clinical presentation. We report a case of tuberculosis confined to the unilateral maxillary sinus that was first misdiagnosed as recurrent rhinosinusitis after endoscopic sinus surgery.

Various tumors in the nasal vestibule.

Various types of diseases can involve the nasal vestibule. Diagnosis and treatment of a nasal vestibular mass is often challenging due to the anatomical features of the nasal vestibule. Here, we present four cases with nasal vestibular masses. Two cases were diagnosed as squamous papillomas. The others were a trichofolliculoma and pseudoepitheliomatous hyperplasia with hyperkeratosis. Our aim was to discuss the characteristics of each disease and the considerations thought to be necessary for diagnosis and treatment of nasal vestibular tumors from these cases and the related literature.

Seasonal variation in skin sensitivity to aeroallergens.

PURPOSE: We previously demonstrated seasonal variation in sensitization to aeroallergens in a small group of patients with exercise-induced asthma. This study was performed to confirm the relationship in a much larger population. METHODS: The charts of 1,891 patients who received allergy skin prick tests were reviewed retrospectively. The test results from subjects aged ≤60 years were compared between the groups classified according to the season when the patients received the tests (spring: March-May, summer: June-August, fall: September-November, winter: December-February). The data from 25 respiratory allergy patients who received the tests two or more times and showed a positive response at least once were analyzed longitudinally. RESULTS: The most prevalent among 29 tested aeroallergens were house dust mites (HDMs) Dermatophagoides pteronyssinus and D. farinae. The skin sensitization rates to D. pteronyssinus (23.2% vs. 32.1%, P=0.004) and D. farinae (22.2% vs. 30.2%, P=0.009) were significantly lower in the summer and higher in the fall (38.3% vs. 26.6% and 35.6% vs. 25.3%; P=0.001 respectively) than those in other seasons in patients with a respiratory allergy (n=1,102). The sensitization rates to weed pollens in the fall (13.9% vs. 8.3%, P=0.006) and to Aspergillus fumigatus in the winter (2.9% vs. 0.7%, P=0.005) were significantly higher. In patients with non-respiratory allergy such as urticaria/anaphylaxis (n=340), the D. farinae sensitization rate was significantly lower in the summer also but higher in the spring. The trend of the HDM sensitization rate being lower in the summer and higher in the fall was observed in the longitudinal study. CONCLUSIONS: Skin sensitivity to aeroallergens such as HDMs, pollens, and molds demonstrates seasonal variation in respiratory allergy patients. Non-respiratory allergy patients also showed seasonal variation in sensitivity to aeroallergens, which might be related to the "priming" effect of allergens.

Fibrous dysplasia of the inferior turbinate.

Fibrous dysplasia (FD) is a benign skeletal disorder in which abnormally overgrowing bony lesion replaces normal bone. FD can affect one bone (monostotic form) or multiple bones (polyostotic form). The craniofacial bones are involved in about 10% of subjects with monostotic FD. However, its occurrence in the sinonasal tract is very rare. We report a case of monostotic FD developed only in the inferior turbinate in a 29-year-old woman. To the best of our knowledge, it is the second report of monostotic FD involving the inferior turbinate in the medical literature. We, therefore, report this rare case with a review of literature.

The role of mucosal immunity in fungus ball of the paranasal sinuses.

CONCLUSION: Increased levels of immunoglobulin (Ig)A, plasma cells, and lymphocytes without infiltration of other inflammatory cells suggest that mucosal immunity may play an important role in paranasal fungus ball. OBJECTIVES: This study aimed to examine the nasal mucosal immune responses to fungi to understand the pathogenesis of fungus ball. METHODS: Five patients with fungus ball of the maxillary sinus were enrolled. Lavage samples were collected from both nasal cavities and the maxillary sinus of the affected side. Mucosal samples were taken from both inferior turbinates and the maxillary sinus of the affected side. Interleukin (IL)-4, interferon (IFN)-γ, and IgA levels in the lavage samples were measured. Cells were counted on the lamina propria of mucosa under an electron microscope. RESULTS: No significant differences in levels of IL-4 and IFN-γ were observed between the three groups of lavage samples. However, a significant rise in IgA levels was observed in the lavage samples from the nasal cavity and maxillary sinus of the affected side compared with that of the contralateral nasal cavity. Infiltration of plasma cells and lymphocytes in mucosal samples from the inferior turbinate and maxillary sinus of the affected side was significantly increased compared with that from the contralateral inferior turbinate, but other inflammatory cells were few and showed no difference.

A schwannoma in the nasal septum.

Schwannomas of the sinonasal tract are very rare neoplasms. We present the case of a schwannoma developing in the nasal septum. The patient was a 51-year-old woman with the complaint of unilateral nasal obstruction. We completely removed this tumor by an endoscopic approach. We discuss the clinical presentation, differential diagnosis, and treatment of this rarely encountered neoplasm.

Effects of dexamethasone on the expression of transforming growth factor-beta in the mouse model of allergic rhinitis.

OBJECTIVES/HYPOTHESIS: This study aimed to evaluate the effect of dexamethasone on the expression of transforming growth factor (TGF)-beta in the mouse model of allergic rhinitis. STUDY DESIGN: Female BALB/c mice were randomly assigned to four groups, including two control groups and two treatment groups. METHODS: General sensitization and local challenge were performed with ovalbumin (OVA). In the treatment groups, dexamethasone was injected intraperitoneally 3 hours before general sensitization or local challenge. Symptom score, eosinophil infiltration, and immunostaining for TGF-beta1 and CD4 in nasal mucosa, and TGF-beta1 and OVA-specific immunoglobulin E (IgE) in sera were analyzed. RESULTS: Dexamethasone administration before general sensitization reduced the symptom score, OVA-specific IgE, and eosinophil infiltration and increased the serum level of TGF-beta1 significantly. Dexamethasone administration before local challenge reduced only the eosinophil infiltration significantly. Immunoreactivity of TGF-beta1 and CD4 was lower in both treatment groups. CONCLUSION: These results suggest that dexamethasone may play an important role in the regulation of allergic reactions by at least two mechanisms; one by suppressing allergic sensitization through decrease of CD4+ T cells and increase of TGF-beta, and the other by suppressing late allergic reactions through the inhibition of proliferation and chemotaxis of inflammatory cells such as eosinophils.

Suppression of allergic response by CpG motif oligodeoxynucleotide-house-dust mite conjugate in animal model of allergic rhinitis.

BACKGROUND: Although there have been many therapeutic options for allergic disease, the true allergen desensitization remains a challenging goal. The classic immunotherapy has a limited efficacy, is inconvenient, and has a risk of anaphylaxis. Recent reports revealed that immunostimulatory DNA sequences (ISS-oligdeoxynucleotide [ODN], CpG motif) act as a strong Th1 response-inducing adjuvants and that DNA-based vaccination might be an effective therapeutic option. In this study, we investigate whether ISS-ODN/Dermatophagoides farinae (Der f) conjugate has antiallergic effects in the allergic rhinitis mouse model, sensitive to house-dust mites. Der f is the most common allergen-inducing allergic rhinitis in Korea. METHODS: C57BL/6 mice were sensitized with crude extract of Der f. After injection of ISS-ODN or ISS-ODN/Der f conjugate, several parameters of allergic response were evaluated. RESULTS: Scratching and sneezing symptoms and eosinophilic infiltration into nasal mucosa were suppressed by injection with ISS-ODN only and ISS-ODN/Der f conjugate. Interleukin-5 level was decreased and interferon gamma level was increased in nasal lavage fluid by injection of ISS-ODN/Der f conjugate. Der f-specific immunoglobulin E was decreased by injection of ISS-ODN or Der f /ISS-ODN conjugate; however, these were not statistically significant. Transforming growth factor beta1 secreted by cultured splenocyte was increased significantly in ISS-ODN/Der f conjugate group. CONCLUSION: These results suggest ISS-ODN/Der f conjugate induces an antiallergic effect and induces an increase in transforming growth factor beta1 level in the allergic rhinitis model using Der f allergen. Allergic response developed by Der f allergen could be more effectively reduced by injection with ISS-ODN/Der f conjugate than by injection with ISS-ODN only.

Comparison of ciliary wave disorders measured by image analysis and electron microscopy.

CONCLUSION: We have developed a simple, reliable method for the simultaneous determination of the ciliary wave disorder (CWD) and ciliary beat frequency (CBF) of actively beating cilia. OBJECTIVE: The CBF and the directions of beating cilia are two important components of mucociliary transport. Although lots of studies have been performed on the measurement of the CBF, there have been few studies on the direction of cilia, with the exception of those using electron microscopy (EM). EM takes too long to determine the directions of cilia, and it cannot determine the direction of actively beating cilia. The aim of this study was to develop an image analysis (IA) system to conveniently determine the wave directions of multiple actively beating cilia as well as the CBF. MATERIAL AND METHODS: Sphenoid sinus mucosae obtained from 10 patients undergoing pituitary tumor removal via a trans-septal trans-sphenoidal approach were divided into two 4 x 4 mm2-sized pieces. One piece was studied using IA, the other with EM. Using IA, ciliary wave directions were determined from 5 20 x 20 microm2 regions of interest and the mean of 5 consecutive values was regarded as the CWD of each sample. The CBF was also measured. CWD was also measured using EM. RESULTS: The average number of cilia analyzed by EM was 102.50 (range 48-136). The mean CWDs determined using IA and EM were 28.25+/-4.84 degrees and 23.59+/-8.16 degrees, respectively. There was a significant correlation between the CWDs determined using these two methods (Spearman's correlation coefficient =0.648; p =0.043). The mean CBF of sphenoid mucosa was 10.50+/-2.20 Hz.