The origins of asthma might be traced back to events occurring during fetal life. Reduced lung development has been shown to be a risk factor both for viral induced wheeze and allergic asthma. The evidence for a causal relationship between exposure to environmental tobacco smoke, chemical domestic products for cleaning, outdoor pollutants, and reduction in lung function is quite strong. Reduced maternal intake of vitamin E, vitamin D, and zinc, or increased use of paracetamol during pregnancy is associated with increased wheezing outcomes in children. The odds ratio for asthma onset is also increased in infants born from mothers with oligohydramnios, chorioamnionitis, hypertension, preeclampsia, diabetes and exposed to stressful events. The risk of developing allergic asthma is increased if the child is exposed in the first months of life to synthetic bedding and is enhanced by allergen exposure and an inadequate barrier function of the skin. In conclusion, several lines of evidence support the concept of fetal programming and very early life events in the development of the different phenotypes of asthma. Since some environmental triggers can be easily avoided and some protective factors can be easily implemented all efforts should be made to prevent intrauterine insults and early sensitization.
Background: Bone marrow oedema (BMO) in children/adolescents is a rare clinical condition without an etiologic cause. It is associated with typical increased signal intensity on T2-weighted magnetic resonance images (MRI) and an increase in bone turnover in which vitamin D plays a pivotal role. No treatment guidelines for these young patients are to date available. Methods: We performed a retrospective study in a pediatric setting of 13 patients with diagnosis of primary BMO of the foot on the basis of clinical and radiological findings. Data collection included sex, age, patient history, symptoms at presentation, clinical examination, laboratory bone turnover markers, vitamin D levels, MRI, treatment, and outcome. Results: Vitamin D deficiency or insufficiency was found in 76.9% of cases. All patients were treated with adequate vitamin D daily intake, a short course of analgesic therapy, physical therapy, avoiding detrimental feet and ankle immobilization. All fully recovered in 3-month lag period. Conclusions: Our data highlight that environmental factors, such as underestimated articular or bone microtraumatisms, as well as joint hyper mobility, in a bone turnover milieu of vitamin D deficiency could be the cause of this clinical conditions. Adequate vitamin D supplementation, associated with physical and analgesic therapy, is crucial in the management of BMO.
BackgroundThe prevalence of the temporomandibular joint (TMJ) involvement in patients affected by juvenile idiopathic arthritis (JIA) ranges from 17% to 87% depending on population. TMJ is frequently the first and unique joint involved in the arthritic process. Unfortunately detection of TMJ arthritis in children with JIA is difficult as early signs and symptoms are missing in most patients. Therefore failure to diagnose and treat TMJ arthritis may have severe consequences on masticatory function, like pain at biting, chewing and yawning and moreover mandibular growth can be impaired and facial asymmetries may develop. Although Magnetic Resonance Imaging (MRI) is the gold standard to identify TMJ involvement, it is affected by lack of informations about bone components. Cone beam CT (CBCT), an imagine diagnostic tool with minimal xray exposure, thanks to its 3D studies provides an accurate image of anatomical bone alteration.ObjectivesProvide a screening imaging tool for TMJ involvement in JIA patients so TMJ dysfunction can be detected and managed at an early stage.MethodsEighteen patients affected by JIA from 2 to 16 yeas of age were included in this prospective study (M/F, 3/15); they were all admitted to a Pediatric Rheumathology and Maxillofacial Surgery Integrated out-patient ambulatory, where an experienced surgeon focused on evaluation of TMJs. All symptomatic patients (uni or bilateral TMJ’s pain) performed MRI: anomalous imaging such as increased joint enhancement or intra-articular effusion, was treated with intra-articular corticosteroid injections (IACI). After about two month from intra-articular treatment CBCT was performed in all the enrolled patients (symptomatic and not).ResultsCBCT is a useful tool to improve the diagnostic and therapeutic iter of TMJ involvement in JIA; in fact on one hand it highlights the unsuccessful and palliative role of IACI and on the other hand it can reveal significant impairment of the joint bone components in frequent asymptomatic patients; systemic therapy from the early phase of TMJ involvement could prevents the irreversible modification of the mandibular growth process of undertreated inflammationConclusionCBCT is a useful tool to improve the diagnostic and therapeutic iter of TMJ involvement in JIA; in fact on one hand it highlights the unsuccessful and palliative role of IACI and on the other hand it can reveal significant impairment of the joint bone components in frequent asymptomatic patients; systemic therapy from the early phase of TMJ involvement could prevents the irreversible modification of the mandibular growth process of undertreated inflammation.References[1] Farronato G. et all “Craniofacial Growth in Children Affected by Juvenile Idiopathic Arthritis Involving the Temporomandibular Joint: Functional Therapy Management”. The Journal of Clinical Pediatric Dentistry 33(4):351–358, 200[2] Keller H., et all.” Is early TMJ involvement in children with juvenile idiopathic arthritis clinically detectable? Clinical examination of the TMJ in comparison with...
Background:Acute Rheumatic Fever (ARF) is an immunomediated multisystem disease that occurs about 2-5 weeks after Group A Streptococcus Pyogenes beta-hemolytic (GAS) pharyngitis. After a negative peak in the 1980s, following the introduction of antibiotic prophylaxis, the disease is currently recovering. Rheumatic carditis is one of the most worrying aspects as it is still one of the major causes of cardiovascular death in the young-adult population. However, if diagnosed early and treated, sequelae with aortic and mitral valve involvement can be prevented.Objectives:The aim of our study is a description of Acute Rheumatic Fever in all its manifestations in a cohort of pediatric patients belonging to the Azienda Ospedaliera Universitaria Integrata of Verona.Methods:A retrospective analysis was conducted collecting all the cases of ARF, diagnosed by Jones’s criteria, related to Pediatric Rheumatology and Pediatric Cardiology of Verona from January 2005 to December 2019. Demographic and clinical data were collected for all patients such as clinical presentation, disease evolution and cardiac involvement.Results:73 patients were analyzed, of whom 53 had an acute onset of ARF and 20 received a diagnosis of previous ARF due to indolent carditis. The prevalent age at the time of diagnosis in both groups was between 5 and 14 years of age. Among patients with acute onset, carditis was the most frequent major manifestation (94.3%), followed by polyarthritis (41.5%), chorea (24.5%) and erythema marginatum (7.5%). Only in one patient we could observe subcutaneous nodules (1.8%). Regarding the minor manifestations, the increase in inflammation markers was present in 83% of cases and fever was present in 75.5%, followed by arthralgia (58.4%) and prolonged of PR interval to ECG (9.4%). Carditis was also present in all 13 patients who presented chorea. Clinically, previously unknown heart murmur occurred in 28 patients. Therefore, the mismatch between cardiac objectivity and carditis finding is clear: infact, compared to an important finding of carditis (50 patients) only slightly more than half of the patients (28 patients) showed an evident clinic finding. Finally, no correlation was found between the levels of the antistreptolysin O titer and the severity of heart damage. Patients with early diagnosis of carditis were treated at onset with corticosteroid therapy according to the American Heart Association scheme and did not show valvular cardiac outcomes. A patient who received a late diagnosis of carditis currently presents a significant and permanent cardiac damage despite adequate steroid treatment undertaken at the time of diagnosis.Conclusion:The description of this cohort of pediatric patients shows that the ARF has not disappeared in industrialized countries. Treatment of streptococcal infection (primary prophylaxis) plays a key role in preventing ARF. Of great impact is the prevalence of carditis which is present in 94.3% of patients. Early diagnosis is therefore of primary importance and the subsequent follow-up path, consisting of periodic therapy with penicillin (secondary prophylaxis) and periodic cardiological checks, greatly affects children’s quality of life. Chorea, unlike what has been described in the literature, occurred simultaneously with the cardiac process, while the cutaneous manifestations (subcutaneous nodules and erythema marginatum), once pathognomonic of the rheumatic disease, are today of rare observation.References:[1]Carapetis, Beaton, Cunningham et al. Acute rheumatic fever and rheumatic heart disease. Nature Reviews Disease Primers. 2016;2:15084.Disclosure of Interests:None declared
BackgroundBone marrow oedema (BMO) in children is a rare clinical condition characterized by joint and bone extremity pain, out of proportion to the clinical findings, exacerbated by weight bearing, in the absence of a known etiologic cause. It is associated with typical increased signal intensity on T2-weighted MRI. Management is still under debate. Treatment has mostly been reported in adult case series encompassing analgesic drugs, a variety of pharmacological treatments (corticosteroids, bisphosphonates, vasodilators), physiotherapy, reduction of weight-bearing, or core decompression. No treatment guidelines for children are to date available.ObjectivesRecently it has become evident that BMO is associated by an increase in bone turnover, in which vitamin D plays a pivotal role. In literature association between hypovitaminosis D and BMO of the foot and ankle in adult patients is reported. No data are reported in cohorts of children. The purpose of this study is to investigate the incidence of hypovitaminosis D in a paediatric population with primary bone BMO of the feet and the role of a vitamin D supplementation therapy.MethodsA retrospective study involving 12 paediatric patients (range age 8-14 years) referred to our Rheumatologic Paediatric Clinic of Verona University in the period 2015-2018 with persistent foot pain and MRI compatible with BMO of the foot has been performed. They had all been misdiagnosed in other institutions as affected by algodystrophy or complex regional pain syndrome. Data collection included sex, age, medical and surgical history, recent or remote trauma history, symptoms at presentation, clinical examination, laboratory bone turnover markers, vitamin D levels, MRI, treatment and outcome.Results2/12 patients are male and 10/12 female (male to female ratio: 1:5). 2/12 had a previous diagnosis of juvenile idiopathic arthritis ANA + with the disease in remission at the moment of evaluation. 10/12 were previously healthy.In all cases history of minor ankle strain or recurrent microtraumas of feet prior to symptom onset had been reported. Joint hypermobility was observed in 75% of cases. One child had been previously treated with bisphosphonates and 5 with limb immobilization, without any improvement. Physical examination revealed weight bearing pain of foot or ankle in all patients. No other sensory, vasomotor, trophic ore neurological signs and symptoms were detected. Vitamin D deficiency was found in all cases (range 10 to 22 ng/ml). All patients were thus treated with adequate vitamin D daily intake. Pain relief was achieved with paracetamol, low dose ibuprofen, or a short course of oral prednisone. Rest from intense physical activity and physical therapy, avoiding detrimental feet and ankle immobilization were recommended. All children (100%) fully recovered in 3-month lag period.ConclusionBMO in children is a cause of disability and it is often misdiagnosed and incorrectly treated. Environmental factors, such as underestimated articular or bone microtraumatisms, as well as joint hy...
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