GiovamBattista Rini

Circulating levels of adipose products and differences in fat distribution in the ovulatory and anovulatory phenotypes of polycystic ovary syndrome.

Central fat distribution is increased in anovulatory women with polycystic ovary syndrome (PCOS) compared with ovulatory PCOS and matched controls. Among secreted adipocytokines, this is reflected mainly in lower levels of adiponectin.

Food-additive-induced urticaria : A survey of 838 patients with recurrent chronic idiopathic urticaria

Background: Recurrent chronic idiopathic urticaria (RCIU) is a common skin condition that affects 0.1–3% of the population in the USA and Europe and accounts for nearly 75% of all ‘ordinary’ chronic urticaria (CU) cases. Methods: We studied 838 consecutive patients with RCIU referred to hospital between 1998 and 2003. Patients with known causes of CU were excluded. Clinical history, physical examination, and symptom diaries were evaluated during two periods, a diet-free period (1 week) and a food-additive-free diet (FAFD) period (4 weeks), respectively, and two double-blind placebo-controlled (DBPC) challenges of six food additives were administered. The first DBPC challenge included a mixture of the six food additives (DBPCmixed) given to all patients. The second DBPC challenge comprised the single food additives, administered at increasing doses (DBPCsingle) to patients with a positive DBPCmixed test and 105 patients with a negative DBPCmixed test, as a control. Results: The DBPCmixed challenge was positive in 116 patients. None of the 105 control patients had a positive DBPCsingle test. Only 31 DBPCsingle tests were positive in patients with positive DBPCmixed challenge. Twenty-four of the 116 patients showing a positive DBPCmixed challenge also had a positive DBPCsingle result. Conclusions: Our results confirmed that food additive hypersensitivity reactions occurred in few RCIU patients using DBPCsingle challenge. The combination of the results of FAFD and DBPCmixed challenge seems to be of considerable practical interest for allergists, internists and dermatologists, rather than the data of clinical history and the results of DBPCsingle challenge, in patients with RCIU.

Non-Celiac Wheat Sensitivity Is a More Appropriate Label Than Non-Celiac Gluten Sensitivity

Reply. We thank the authors for their interest in our randomized trial comparing endoscopy and surgery for pseudocyst drainage. All patients screened for participation in our study had a computed tomography (CT) scan that was reviewed by a dedicated expert in body imaging. The study cited by Talukdar and colleagues where CT could detect necrosis in only 23% of patients was actually conducted at our institution in Alabama nearly 16 years ago. Since then, the quality of CT imaging has significantly improved. In the most recent study from South Korea that compared CT and magnetic resonance imaging (MRI), none of the patients diagnosed with necrosis were missed by either modality although MRI correlated better with clinical outcomes. The limitation with CT imaging was that it overestimated the severity grading in almost all cases. The presence of debris within a fluid collection is estimated (rather incorrectly) based on Hounsfield units. In our study, more than 40% of patients were excluded as they had necrosis based on CT imaging. None of these patients at endoscopic ultrasound had necrotic debris. It is possible that some patients in the surgical cohort had liquefied necrosis that was managed by only cystogastrostomy but none required intraoperative debridement. The relevance of minimal debris in the clinical management of pancreatic pseudocysts is unclear. We agree with the comments that the acuteness or chronicity of pancreatitis is more relevant than that of the fluid collection itself. Twenty-nine of40 (72%)patients in this study were recruited from outpatient clinics and others as inpatient admissions or transfers from outside hospitals. While almost all outpatient enrollments had documented, long-standing chronic pancreatitis, with the exception of three cases, we are unsure about disease chronicity in 8 (20%) other patients. The objective of the randomized trial was to compare 2 different standards-of-care techniques, surgery vs endoscopy. None of the patients undergoing surgical cystogastrostomy routinely have preoperative endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography to assess for ductal integrity and is not considered standard-of-care. As surgeons do not request pancreatic duct stent placement prior to cystogastrostomy to manage duct leak, the need for assessment of ductal integrity in uncomplicated pancreatic pseudocysts is unclear. We opine that routine evaluation of the ducts prior to surgery would be an academic exercise with limited practical utility. The single patient who failed treatment in the endoscopy cohort had inadequate drainagewith transmural stenting and not a persistent pancreatic duct leak as this had resolvedwith transpapillary stenting. In the United States, most surgical cystogastrostomy procedures are currently being performed via the open approach and not laparoscopy. We agree that a laparoscopic approach has lower morbidity and possibly expedites hospital stay but would also increase the cost of surgery.

Leukotriene receptor antagonists in monotherapy or in combination with antihistamines in the treatment of chronic urticaria: a systematic review

In vitro and in vivo clinical and experimental data have suggested that leukotrienes play a key role in inflammatory reactions of the skin. Antileukotriene drugs, ie, leukotriene receptor antagonists and synthesis inhibitors, are a class of anti-inflammatory drugs that have shown clinical efficacy in the management of asthma and in rhinitis with asthma. We searched MEDLINE database and carried out a manual search on journals specializing in allergy and dermatology for the use of antileukotriene drugs in urticaria. Montelukast might be effective in chronic urticaria associated with aspirin (ASA) or food additive hypersensitivity or with autoreactivity to intradermal serum injection (ASST) when taken with an antihistamine but not in mild or moderate chronic idiopathic urticaria [urticaria without any possible secondary causes (ie, food additive or ASA and other NSAID hypersensitivity, or ASST)]. Evidence for the effectiveness of zafirlukast and the 5-lipoxygenase inhibitor, zileuton, in chronic urticaria is mainly anecdotal. In addition, there is anecdotal evidence of effectiveness of antileukotrienes in primary cold urticaria, delayed pressure urticaria and dermographism. No evidence exists for other physical urticarias, including cholinergic, solar and aquagenic urticarias, vibratory angioedema, and exercise-induced anaphylaxis.

Relationship Between Human Leucocyte Antigen Class I and Class II and Chronic Idiopathic Urticaria Associated With Aspirin and/or NSAIDs Hypersensitivity

Background. HLA genes play a role in the predisposition of several diseases. The aim was to analyze the prevalence of HLA class I phenotypes and HLA-DRB1* genotype in patients with CIU associated with ASA and NSAIDs hypersensitivity (AICU). Methods. 69 patients with AICU, and 200 healthy subjects. Results. Subjects with HLA-B44 and HLA-Cw5 antigens were more represented in patients with AICU than in control group. Subjects with HLA-A11, HLA-B13, HLACw4, and HLA-Cw7 antigen were more represented in control group than in patients with AICU. Multiple logistic regression demonstrated an association of HLA-Cw4 and HLA-Cw7 with a lower risk of AICU, whereas carriers of HLA-B44 phenotype had a higher risk of AICU. No differences were found between patients and controls as regards to HLA-DRB1* genotype. Conclusions. We observed an association between some HLA class-I antigens and AICU. To the best of our knowledge this is the first description of such association.

Influence of sociocultural factors on the ovulatory status of polycystic ovary syndrome

OBJECTIVE To evaluate the role of social and cultural differences inside the same ethnic group on the ovulatory status of women with polycystic ovary syndrome (PCOS). DESIGN To correlate social and cultural status with the phenotypic expression (body weight and ovulation) and with androgen and insulin levels of PCOS. SETTING University department of medicine. PATIENT(S) Two hundred and forty-four consecutive PCOS women. INTERVENTION(S) All studied patients completed a simple questionnaire to indicate their mean family income and their school education. MAIN OUTCOME MEASURE(S) Ovulation was assessed by measurement of serum progesterone on day 22 of a spontaneous or induced menstrual cycle. Levels of blood testosterone, sex hormone-binding globulin, insulin, and blood glucose were evaluated. RESULT(S) In the low to medium income group, 21% of patients had ovulatory PCOS, but the prevalence of the same PCOS phenotype was 43% in patients with high income. In patients with low education, only 12% presented with ovulatory PCOS compared with 47% of the patients with high education status. Mean family income negatively correlated with body mass index, waist circumference, insulin, and insulin resistance. Serum progesterone correlated negatively with insulin and insulin resistance. CONCLUSION(S) In an ethnically homogeneous PCOS population, high socioeconomic status was associated with a higher prevalence of the ovulatory phenotype. Differences in ovulatory status between the social classes seem to be related to differences in insulin levels and fat quantity and distribution.

Oligo-Antigenic Diet in the Treatment of Chronic Anal Fissures. Evidence for a Relationship Between Food Hypersensitivity and Anal Fissures

OBJECTIVES:Patients with chronic constipation due to food hypersensitivity (FH) had an elevated anal sphincter resting pressure. No studies have investigated a possible role of FH in anal fissures (AFs). We aimed to evaluate (1) the effectiveness of diet in curing AFs and to evaluate (2) the clinical effects of a double-blind placebo-controlled (DBPC) challenge, using cows milk protein or wheat.METHODS:One hundred and sixty-one patients with AFs were randomized to receive a “true-elimination diet” or a “sham-elimination diet” for 8 weeks; both groups also received topical nifedipine and lidocaine. Sixty patients who were cured with the “true-elimination diet” underwent DBPC challenge in which cows milk and wheat were used.RESULTS:At the end of the study, 69% of the “true-diet group” and 45% of the “sham-diet group” showed complete healing of AFs (P<0.0002). Thirteen of the 60 patients had AF recurrence during the 2-week cows milk DBPC challenge and 7 patients had AF recurrence on wheat challenge. At the end of the challenge, anal sphincter resting pressure significantly increased in the patients who showed AF reappearance (P<0.0001), compared with the baseline values. The patients who reacted to the challenges had a significantly higher number of eosinophils in the lamina propria and intraepithelial lymphocytes than those who did not react to the challenges.CONCLUSIONS:An oligo-antigenic diet combined with medical treatment improved the rate of chronic AF healing. In more than 20% of the patients receiving medical and dietary treatment, AFs recurred on DBPC food challenge.

PREVALENCE OF ANTIBODIES ANTI-BARTONELLA HENSELAE IN WESTERN SICILY: CHILDREN, BLOOD DONORS, AND CATS

To evaluate seroprevalence of B. henselae infection both in Sicilian children and healthy blood donors. Furthermore, circulation of Bartonella in the natural reservoir was also studied. Two hundred forty-three children, living in Sicily (Palermo), affected by various diseases, without clinical features suggesting B. henselae infection, together with 122 healthy blood donors were serologically investigated for IgG and IgM antibodies by indirect fluorescent antibody test (IFAT). One hundred twenty stray and 62 pet cats were also analyzed only for IgG. Among children 25.1% had IgG antibodies to B. henselae; 18.5% showed a titer 1:64, 2.4% 1:128, 2.4% 1:256, 0.8% 1:512, 0.4% 1:1024, and 0.4% 1:5120. Among healthy blood donors 11.4% had IgG class antibodies to B. henselae; 9.8% showed a titer 1:64 and 1.6% 1:128. All the human serum samples did not show positive results for B. henselae IgM class antibodies. Stray cats (68.3%) and pet cats (35.4%) also had IgG class antibodies to B. henselae. We demonstrated high frequency of serologic evidence of past B. henselae infection, in young Italian children, affected by various diseases, apparently free of any clinical features suggesting B. henselae infection. This observation is supported by high circulation of Bartonella in cats.

Correlation between different degree and duration of metabolic control and thyroid hormone levels in type 1 and type 2 diabetics

SummaryThyroxine (T4), triiodothyronine (T3), reverse T3 (rT3) and HbA1c were assayed in 21 insulin-dependent (type 1) diabetics and in 45 non-insulin-dependent (type 2) diabetics with normal thyroid function and different levels of control, and were compared to values found in apparently healthy controls. rT3 and rT3/T3 ratio were significantly increased both in type 1 and type 2 diabetics. T3 and T4 were significantly lower in type 2 diabetics than in the controls. Significant positive correlations of HbA1c to rT3 (r=0.63) and to rT3/T3 ratio (r=0.53) were found in type 1, and in type 2 diabetics (HbA1c, rT3−r=0.50), (HbA1c, rT3/T3−r=0.37). There was no correlation between glycemia (BG), relative body weight (RBW) and thyroid hormones. These data suggest that the alterations of thyroid hormones in type 1 and type 2 diabetes mellitus reflect the degree of control better than the hyperglycemia and the duration of metabolic unbalance.