Post-operative morbidity in Crohn's disease: what is the impact of patient-, disease- and surgery-related factors?

PURPOSE

Over 50% of patients suffering from Crohn's disease (CD) require surgery in their lifetime. Predictors/risk factors of post-operative morbidity and mortality in CD are poorly investigated. We aimed to assess the risk factors of post-operative morbidity/mortality in CD.

METHODS

We performed a retrospective cohort study in which all CD patients operated and followed up at our tertiary Inflammatory Bowel Disease Centre from 2014 to 2019 were enrolled. For each patient, we evaluated patient-dependent, disease-dependent and surgery-dependent variables. All patients underwent small bowel and/or colic resections.

RESULTS

Of the 165 operated patients, forty-two (25.5%) developed post-operative complications (major complication rate = 9.8%) including wound infection (12.1%), respiratory complications (4.8%), prolonged ileum (4.2%), anastomotic leak (3.6%), urinary infections (3%), abdominal abscess (2.4%), anastomotic bleeding (3.6%), abdominal bleeding (1.2%) and obstruction (0.6%). Two subjects (1.2%) required re-operation within 30 days, and one died. A surgery duration < 141 min was predictive of a better post-operative outcome (sensitivity 80.9%, specificity 43.1%, PPV 32.7%, NPV 86.9%). The multivariable analysis showed stricturing/fistulizing behaviour (OR 3.7, 95% CI 1.6-6.4, p = 0.02), need for total parenteral nutrition (OR 4.1, 95% CI 2.4-9.2, p = 0.01), pre-operative bowel cleansing (OR 0.6, 95% CI 0.41-0.83, p = 0.01) and surgery duration < 141 min (OR 0.2, 95% CI 0.08-0.7, p = 0.03) as the only risk factors associated with post-operative morbidities.

CONCLUSIONS

About 25% of CD patients develop post-operative complications. Several patient-related, disease-related and surgery-related factors should be considered risk factors for post-operative morbidity. The recognition of these factors, as well as a multidisciplinary approach to the pre-operative management of CD, could reduce post-operative complications.

SARS-CoV-2 infection does not induce HIV viral escape in the central nervous system: A case series

We report two cases of HIV positive patients with SARS-CoV-2 infection and a recent diagnosis of opportunistic infections of central nervous system (CNS). We investigated the potential impact of coinfection with SARS-CoV-2 on HIV replication in CNS.

Genetic variability of the measles virus hemagglutinin gene in B3 genotype strains circulating in Northern Italy

Sequencing the whole measles virus hemagglutinin (H) gene, in conjunction with a 450-nucleotide region of the nucleoprotein gene (N-450), is helpful for the identification of new genotypes and as an auxiliary in outbreak characterization. In addition, it is essential to be able to predict the antigenic changes of the H protein to gain a better monitoring of the response to the vaccine. In this study, we obtained the full-length H gene sequences from 19 measles virus (MV) strains belonging to two B3 genotype variants circulating in Lombardy (Northern Italy) between July 2015 and February 2016 and evaluated the variability of the whole MV-H gene. Furthermore, we compared the obtained H amino acid sequences to all MV sequences available in the GenBank database (n = 1152 in total) and analyzed the amino acid substitutions in the H protein within clades where the Italian strains were included. We identified a higher variability in the H gene compared to the N-450 region and our results support previous studies, highlighting that the H gene is more informative for characterizing the MV B3 genotype than the N-450 sequence. Some of the amino acid substitutions were fixed in the viral population and, remarkably, some of the amino acid substitutions were typically present only in the Italian sequences. Accumulating further molecular information about MV-H gene will be necessary to enable in-depth analyses of the variability of this gene in the vaccinated population.

Correlation of pre-operative planning to surgical correction of opening wedge HTO: a radiographic study utilizing a manual measurement method

High tibial osteotomy (HTO) utilizing a medial opening wedge has become a common and effective surgical technique for treatment of isolated medial compartment knee osteoarthritis secondary to varus malalignment. To reduce the risk of under- or overcorrection, accurate preoperative planning is important. This is a radiographic study to evaluate the reliability of preoperative measurement on full-length weight-bearing X-rays (FLWBXr) compared to post-operative X-rays after healing. In addition, we calculated if the intraoperative opening wedge performed was consistent with the preoperative calculation and the postoperative correction. Three independent observers measured preoperative and postoperative FLWBXr at three different times. The angle of varus deformity; the angle to correct and the wedge needed to achieve desired alignment: the angle achieved postoperatively, and the postoperative mechanical axis deviation were measured. Intra- and inter-rater reliability showed high values for all the investigated parameters. The discrepancy between the calculated wedge and the wedge actually used in surgery ranged from 1 mm of over-correction to 3 mm of undercorrection, averaging -1.3 mm. The mechanical axis crossed the tibial plateau an average of 53% ±12.7. Clustering the data by the plate type statistically significant differences were found for preoperative varus alignment, advocated correction, intraoperative correction and post-op alignment. The Dugdale method can be considered highly reliable. Possible factors affecting the final correction are: surgeon's desire not to overcorrect in young patients and minimal osteoarthritis; measurement errors; variability in the method the FLWBXr is performed. In addition, the under correction could be the result of some collapse with time or the correction could be affected by the fixation system. Further investigation should include complete post-operative evaluation of outcomes and assess the role of these potential factors and their relationship to correction. Level of Evidence: Level III, Retrospective study.

Talar exostosis (epiphyseal dysplasia): case report of posterior arthroscopic excision

Posterior ankle impingement is a syndrome characterized by discomfort or pain at the hind foot during plantarflexion. The etiology can be divided into three main categories: overuse, trauma and anatomic abnormalities. Regarding overuse, usually patients that complain of posterior ankle pain are ballet dancers, downhill runners, field athletes and soccer players secondary to flexor hallucis tendinitis.

KOOS pain as a marker for significant knee pain two and six years after primary ACL reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort study

OBJECTIVE

The prevalence of radiographic osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) approaches 50%, yet the prevalence of significant knee pain is unknown. We applied three different models of Knee injury and Osteoarthritis Outcome Score (KOOS) thresholds for significant knee pain to an ACLR cohort to identify prevalence and risk factors.

DESIGN

Multicenter Orthopaedic Outcomes Network (MOON) prospective cohort patients with a unilateral primary ACLR and normal contralateral knee were assessed at 2 and 6 years. Independent variables included patient demographics, validated Patient Reported Outcomes (PRO; Marx activity score, KOOS), and surgical characteristics. Models included: (1) KOOS criteria for a painful knee = quality of life subscale <87.5 and ≥2 of: KOOSpain <86.1, KOOSsymptoms <85.7, KOOSADL <86.8, or KOOSsports/rec <85.0; (2) KOOSpain subscale score ≤72 (≥2 standard deviations below population mean); (3) 10-point KOOSpain drop from 2 to 6 years. Proportional odds models (alpha ≤ 0.05) were used.

RESULTS

1761 patients of median age 23 years, median body mass index (BMI) 24.8 kg/m(2) and 56% male met inclusion, with 87% (1530/1761) and 86% (1506/1761) follow-up at 2 and 6 years, respectively. At 6 years, n = 592 (39%), n = 131 (9%) and n = 169 (12%) met criteria for models #1 through #3, respectively. The most consistent and strongest independent risk factor at both time-points was subsequent ipsilateral knee surgery. Low 2-year Marx activity score increased the odds of a painful knee at 6 years.

CONCLUSIONS

Significant knee pain is prevalent after ACLR; with those who undergo subsequent ipsilateral surgery at greatest risk. The relationship between pain and structural OA warrants further study.

Bone marrow CD34+ progenitor cells may harbour HIV-DNA even in successfully treated patients

The issue about bone marrow hematopoietic progenitor cells harbouring HIV-DNA in infected patients is still under scrutiny. We studied nine HIV-infected individuals undergoing bone marrow aspiration for diagnostic purposes. In all patients, even in those receiving successful antiretroviral therapy for several years, HIV-DNA was detected in purified CD34+ lineage-bone marrow progenitor cells. This finding, although not conclusive due to the low number of patients examined, adds further evidence that current treatment strategies may be insufficient to resolve latent infection in bone marrow CD34+ hematopoietic progenitor cells.

Safety and efficacy of turoctocog alfa (NovoEight®) during surgery in patients with haemophilia A: results from the multinational guardian™ clinical trials

Recombinant factor VIII (rFVIII) products provide a safe and efficacious replacement therapy for prevention and treatment of bleeding episodes in patients with haemophilia A. The present investigations from the multinational, open-label guardian™ clinical trials assessed the haemostatic response of turoctocog alfa (NovoEight®), a rFVIII product, in patients with severe haemophilia A (FVIII ≤ 1%) undergoing surgery. All patients had a minimum of 50 exposure days to any FVIII product prior to surgery and no history of inhibitors. A total of 41 procedures (13 orthopaedic, 19 dental and 9 general) were performed in 33 patients aged 4–59 years. Of the 41 procedures, 15 were major surgeries in 13 patients and 26 were minor surgeries in 21 patients. The success rate for haemostatic response was 100% (success was defined as ‘excellent’ or ‘good’ haemostatic outcome). Turoctocog alfa consumption on the day of surgery ranged from 27 to 153 IU kg⁻¹. The mean daily dose declined over time, while retaining adequate FVIII coverage as measured by trough levels. Overall, no safety issues were identified. No thrombotic events were observed and none of the patients developed FVIII inhibitors. In conclusion, the present results show that turoctocog alfa was effective in controlling blood loss by obtaining a sufficient haemostatic response in patients with severe haemophilia A undergoing surgery.

Patient characteristics as predictors of clinical outcome of distraction in treatment of severe ankle osteoarthritis

Osteoarthritis (OA) is a slowly progressive joint disease. Joint distraction can be a treatment of choice in case of severe OA. Prediction of failure will facilitate implementation of joint distraction in clinical practice. Patients with severe ankle OA, who underwent joint distraction were included. Survival analysis was performed over 12 years (n = 25 after 12 years). Regression analyses were used to predict failures and clinical benefit at 2 years after joint distraction (n = 111). Survival analysis showed that 44% of the patients failed, 17% within 2 years and 37% within 5 years after joint distraction (n = 48 after 5 years). Survival analysis in subgroups showed that the percentage failure was only different in women (30% after 2 years) versus men (after 11 years still no 30% failure). In the multivariate analyses female gender was predictive for failure 2 years after joint distraction. Gender and functional disability at baseline predicted more pain. Functional disability and pain at baseline were associated with more functional disability. Joint distraction shows a long-term clinical beneficial outcome. However, failure rate is considerable over the years. Female patients have a higher chance of failure during follow-up. Unfortunately, not all potential predictors could be investigated and other clinically significant predictors were not found.

Long-lasting immunogenicity and safety of a 2009 pandemic influenza A(H1N1) MF59-adjuvanted vaccine when co-administered with a 2009-2010 seasonal influenza vaccine in young patients with type 1 diabetes mellitus

AIMS

To evaluate the long-lasting immunogenicity and safety of a pandemic vaccine co-administered with a seasonal influenza vaccine in young subjects with Type 1 diabetes.

METHODS

Eighty patients (mean age: 16.7 ± 5.5 years, disease duration: 10.2 ± 4.7 years) were randomly assigned to receive a single or a double dose (1 month apart) of MF59-adjuvanted influenza A(H1N1) vaccine, simultaneously with a single dose of a virosome-adjuvanted trivalent influenza vaccine for the 2009-2010 season.

RESULTS

One month after immunization, the rate of seroconversion to 2009 pandemic A(H1N1) was 92.5% with an overall 100% proportion of vaccinees with protective antibody titres (≥ 1:40). No significant differences were observed between vaccinees who received the one-dose or the two-dose schedule. Seasonal vaccine induced a significant increase of both seroprotection rates and antibody levels. Local adverse events at the injection site of pandemic and seasonal vaccines were reported by 66.3% and 50% of subjects, respectively. Solicited systemic adverse events, mainly mild in intensity, were reported by 26.7% of vaccinees. No subjects had an influenza-like illness during the 6-month follow-up.

CONCLUSIONS

One injection of 2009 pandemic influenza A(H1N1) MF59-adjuvanted vaccine is immunogenic and safe in young patients with Type 1 diabetes who are at increased risk of influenza morbidities. Pandemic vaccine can be safely co-administered with seasonal influenza vaccine.

Revision ACL reconstruction outcomes: MOON cohort

Many clinicians believe that the results of revision anterior cruciate ligament (ACL) reconstruction compare unfavorably with primary ACL reconstruction. However, few prospective studies have evaluated revision ACL reconstruction using validated patient-based metrics. This study was performed to evaluate and compare the results of revision ACL reconstruction and primary ACL reconstruction. The Multicenter Orthopaedic Outcomes Network consortium is an NIH-funded, hypothesis-driven, multicenter prospective cohort study of patients undergoing ACL reconstruction. All patients preoperatively complete a series of validated patient-oriented questionnaires. At scheduled 2-year follow-up all patients are given the same series of questionnaires to complete. The study evaluated the results of 2-year follow-up of revision ACL reconstruction performed in 2001. Parameters evaluated included Marx activity level, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) scores. For this study 446 subjects met inclusion criteria; 2-year follow-up was obtained on 393 (88%). The study group consisted of 55% males with median age of 22 years. There were 33 revision ACL reconstruction cases, for which follow-up was available for 29 (88%). Median baseline Marx (interquartile range) was 12 (8 to 16) and 12 (6 to 16) for the primary ACL reconstruction and revision ACL reconstruction groups, respectively (p= 0.81). At 2 years, median Marx was 9 (4 to 13) and 5 (0 to 10) for the primary ACL reconstruction and revision ACL reconstruction groups, respectively (p= 0.03). Median 2-year IKDC was 75.9 (revision) versus 83.9 (primary) (p=0.003). Median KOOS subscale Knee Related Quality of Life (KRQOL) at 2 years was 62.5 (revision) versus 75 (primary) (p < 0.001), subscale Sports and Recreation was 75 (revision) and 85 (primary) (p = 0.005), subscale Pain was 83.3 (revision) and 91.7 (primary) (p= 0.002). Marx activity score declined at 2-year follow-up in revision ACL reconstruction compared with primary ACL reconstruction. IKDC and KRQOL were significantly decreased in revision ACL reconstruction compared with primary ACL reconstruction at 2-year followup. Revision ACL reconstruction resulted in a significantly worse outcome as measured by these patient-based measures at 2 years.

Is avian influenza virus A(H5N1) a real threat to human health?

The A(H5N1) influenza remains a disease of birds with a significant species barrier: in the presence of some tens million cases of infection in poultry--with a wide geographical spread--, only a few hundreds cases have occurred in humans. To date, human cases have been reported in 15 countries--mainly in Asia--and all were related to the onset of outbreaks in poultry. A peak of H5N1 human cases was recorded in 2006, then decreasing in subsequent years. Despite this trend, the H5N1 virus still represents a possible threat to human health, considering that more than half of human cases of H5N1 have been fatal. Moreover, despite the drop in the number of cases, the risk of a novel pandemic cannot be excluded, since H5N1 continues to circulate in poultry in countries with elevated human population density and where monitoring systems are not fully appropriate. In addition, there is a major global concern about the potential occurrence of a reassortment between the 2009 pandemic H1N1 and the highly pathogenic H5N1 influenza viruses following a co-infection in a susceptible host. Therefore, the implementation of appropriate surveillance and containment measures is crucial in order to minimize such risk. In conclusion, H5N1 avian influenza is still a rare disease in humans but its clinical severe outcome requires a careful monitoring of the virus's ability to evolve and to trigger a new pandemic.

Postural stability effects of random vibration at the feet of construction workers in simulated elevation

The risk of falls from height on a construction site increases under conditions which degrade workers' postural control. At elevation, workers depend heavily on sensory information from their feet to maintain balance. The study tested two hypotheses: "sensory enhancement"--sub-sensory (undetectable) random mechanical vibrations at the plantar surface of the feet can improve worker's balance at elevation; and "sensory suppression"--supra-sensory (detectable) random mechanical vibrations can have a degrading effect on balance in the same experimental settings. Six young (age 20-35) and six aging (age 45-60) construction workers were tested while standing in standard and semi-tandem postures on instrumented gel insoles. The insoles applied sub- or supra-sensory levels of random mechanical vibrations to the feet. The tests were conducted in a surround-screen virtual reality system, which simulated a narrow plank at elevation on a construction site. Upper body kinematics was assessed with a motion-measurement system. Postural stability effects were evaluated by conventional and statistical mechanics sway measures, as well as trunk angular displacement parameters. Analysis of variance did not confirm the "sensory enhancement" hypothesis, but provided evidence for the "sensory suppression" hypothesis. The supra-sensory vibration had a destabilizing effect, which was considerably stronger in the semi-tandem posture and affected most of the sway variables. Sensory suppression associated with elevated vibration levels on a construction site may increase the danger of losing balance. Construction workers at elevation, e.g., on a beam or narrow plank might be at increased risk of fall if they can detect vibrations under their feet. To reduce the possibility of losing balance, mechanical vibration to supporting structures used as walking/working surfaces should be minimized when performing construction tasks at elevation.

Subchondral bone remodeling is related to clinical improvement after joint distraction in the treatment of ankle osteoarthritis

OBJECTIVE

In osteoarthritis (OA), subchondral bone changes alter the joint's mechanical environment and potentially influence progression of cartilage degeneration. Joint distraction as a treatment for OA has been shown to provide pain relief and functional improvement through mechanisms that are not well understood. This study evaluated whether subchondral bone remodeling was associated with clinical improvement in OA patients treated with joint distraction.

METHOD

Twenty-six patients with advanced post-traumatic ankle OA were treated with joint distraction for 3 months using an Ilizarov frame in a referral center. Primary outcome measure was bone density change analyzed on computed tomography (CT) scans. Longitudinal, manually segmented CT datasets for a given patient were brought into a common spatial alignment. Changes in bone density (Hounsfield Units (HU), relative to baseline) were calculated at the weight-bearing region, extending subchondrally to a depth of 8mm. Clinical outcome was assessed using the ankle OA scale.

RESULTS

Baseline scans demonstrated subchondral sclerosis with local cysts. At 1 and 2 years of follow-up, an overall decrease in bone density (-23% and -21%, respectively) was observed. Interestingly, density in originally low-density (cystic) areas increased. Joint distraction resulted in a decrease in pain (from 60 to 35, scale of 100) and functional deficit (from 67 to 36). Improvements in clinical outcomes were best correlated with disappearance of low-density (cystic) areas (r=0.69).

CONCLUSIONS

Treatment of advanced post-traumatic ankle OA with 3 months of joint distraction resulted in bone density normalization that was associated with clinical improvement.

Early co-circulation of different clades of influenza A/H1N1v pandemic virus in northern Italy

INTRODUCTION

The spatial diffusion over time of pandemic influenza A/HINI virus (A/HIN1v) was surveyed in Northern Italy (nearly 10 million inhabitants)from April to December 2009, and the molecular characteristics of circulating viruses were analyzed to identify the appearance of drift variants. About 45% of analyzed samples were laboratory-confirmed cases of A/HINlv. Sporadic cases occurred until the middle of June 2009, then, case numbers began to increase delineating distinct epidemiological phases of viral circulation.

METHODS

RNA was extracted using RNeasy Mini kit (QIAGEN GmbH, Germany). Virological diagnosis of A/HINlv infection was carried out by real-time RT-PCR assay. Sequence analysis of hemagglutinin (HA) gene was performed through a RT-PCR assay specific for a 995 bp fragment (nt. 64-1,058) in the HAl domain. The nucleotide sequences were obtained by automated DNA sequencing. The HAl sequences were aligned with other sequences collected from GenBank database by ClustalX software. The multiple sequence alignment was used to perform a basic phylogenetic analysis and a phylogenetic tree from HA sequences was constructed.

RESULTS

The HA gene sequences ofA/HINlv analyzed segregated into three genetically distinct clades and were characterized by the appearance of amino acid variations that were progressively fixed in the field viral population under scrutiny.

CONCLUSIONS

These data suggest an early co-circulation of genetically distinct A/HNINv variants and emphasize the importance of a close molecular surveillance to detect rapidly the spread of new viral variants and to define their epidemiological impact.

Serum transforming growth factor β1 during diabetes development in non-obese diabetic mice and humans

Recent data show that regulatory cells with transforming growth factor (TGF)-β1-dependent activity are able to restore self-tolerance in overtly diabetic non-obese diabetic (NOD) mice. Thus, TGF-β1 seems to have a relevant role in protection from autoimmune diabetes. Our aim was to investigate the possible significance of serum TGF-β1 measurement in the natural history of diabetes in NOD mice, as well as in children positive for at least one islet-related antibody. Serum TGF-β1 (both total and active) was measured by enzyme-linked immunosorbent assay at monthly intervals in 26 NOD mice during the spontaneous development of diabetes and, on a yearly basis, in nine siblings of patients with type 1 diabetes (T1D) with a follow-up of 4 years. Diabetes appeared between the 12th week of age and the end of the study period (36 weeks) in 17 mice. TGF-β1 serum level variations occurred in the prediabetic period in both NOD mice and humans and diabetes diagnosis followed a continuing reduction of active TGF-β1 (aTGF-β1) serum levels. In mice, aTGF-β1 serum levels measured at 4 weeks of age correlated positively with severity of insulitis, and negatively with percentage of insulin-positive cells. Our findings suggest that in NOD mice serum TGF-β1 levels during the natural history of the diabetes reflect the course of islet inflammation. The measurement of aTGF-β1 in islet-related antibody-positive subjects may provide insights into the natural history of prediabetic phase of T1D.

53BP1 represses mitotic catastrophe in syncytia elicited by the HIV-1 envelope

p53 binding protein-1 (53BP1) participates in checkpoint signaling during the DNA damage response (DDR) and during mitosis. In this study we report that 53BP1 aggregates in nuclear foci within syncytia elicited by the human immunodeficiency virus (HIV)-1 envelope. 53BP1 aggregation occurs as a consequence of nuclear fusion (karyogamy (KG)). It colocalizes partially with the promyelomonocytic leukemia protein (PML), and the ataxia telangiectasia mutated kinase (ATM), the two components of the DDR that mediate apoptosis induced by the HIV-1 envelope. ATM-dependent phosphorylation of 53BP1 on serines 25 and 1778 (53BP1S25P and 53BP1S1778P) occurs at these DNA damage foci. 53BP1S25P was also detected in syncytia present in the lymph nodes or frontal brain sections from HIV-1-infected carriers, as well as in peripheral blood mononucleated cells from HIV-1-infected individuals, correlating with viral load. Knockdown of 53BP1 caused HIV-1 envelope-induced syncytia to enter abnormal mitoses, leading to their selective destruction through mitochondrion-dependent and caspase-dependent pathways. In conclusion, depletion of 53BP1 triggers the demise of HIV-1-elicited syncytia through mitotic catastrophe.

Molecular characterization and phylogenetic analysis of human influenza A viruses in three consecutive seasons with different epidemiological profiles

INTRODUCTION

Influenza activity and influenza virus circulation were observed in Lombardy (northern Italy) during three consecutive seasons and the molecular characteristics of circulating viruses analysed to control for introduction of new variants.

METHODS

The molecular characterization of 38 isolates, namely 20 A/H3N2 and 18 A/H1N1 influenza strains from the 2005/06, 2006/07 and 2007/08 seasons, was performed by sequence analysis of the globular head region of the HA protein (HA1 subunit), specific for influenza virus A/H3 and A/H1.

RESULTS AND DISCUSSION

The last three influenza seasons in the study region were characterized by medium-low activity. A typical co-circulation of several variants was shown for A/H3 viruses for approximately two years and were subsequently almost entirely substituted by new emerging variants. Vice versa, A/H1 viruses had a more homogeneous circulation with a single lineage clearly dominating each season. The HA sequences of the A/H3 and the A/H1 viruses isolated in the last three seasons fell into 4 and 3 principal phylogenetic groups, respectively. No evidence of positive or negative selection in the sequence alignments was observed.

CONCLUSIONS

Molecular characterization of the influenza viruses in three consecutive seasons highlighted considerable heterogeneity in their HA sequences. A careful surveillance of genetic changes in the HA1 domain during seasonal influenza epidemics may reveal immune escape and provide early information on newly emerging strains with epidemiologic inference.

Engineering and public health at CDC

Engineering is the application of scientific and technical knowledge to solve human problems. Using imagination, judgment, and reasoning to apply science, technology, mathematics, and practical experience, engineers develop the design, production, and operation of useful objects or processes. During the 1940s, engineers dominated the ranks of CDC scientists. In fact, the first CDC director, Assistant Surgeon General Mark Hollis, was an engineer. CDC engineers were involved in malaria control through the elimination of standing water. Eventually the CDC mission expanded to include prevention and control of dengue, typhus, and other communicable diseases. The development of chlorination, water filtration, and sewage treatment were crucial to preventing waterborne illness. Beginning in the 1950s, CDC engineers began their work to improve public health while developing the fields of environmental health, industrial hygiene, and control of air pollution. Engineering disciplines represented at CDC today include biomedical, civil, chemical, electrical, industrial, mechanical, mining, and safety engineering. Most CDC engineers are located in the National Institute for Occupational Safety and Health (NIOSH) and the Agency for Toxic Substances and Disease Registry (ATSDR). Engineering research at CDC has a broad stakeholder base. With the cooperation of industry, labor, trade associations, and other stakeholders and partners, current work includes studies of air contaminants, mining, safety, physical agents, ergonomics, and environmental hazards. Engineering solutions remain a cornerstone of the traditional "hierarchy of controls" approach to reducing public health hazards.

Lack of 'tissue' transglutaminase protein cross-linking leads to leakage of macromolecules from dying cells: relationship to development of autoimmunity in MRLIpr/Ipr mice

Genetic defects of the CD95 (Fas/Apo-1) receptor/ligand system, has recently been involved in the development of human and murine autoimmunity. We investigated whether a deregulation of the ;tissue' transglutaminase (tTG), a multifunctional enzyme which is part of the molecular program of apoptosis, may act as a cofactor in the development of autoimmunity. We found that MRLlpr/lpr, which are characterized by a defect in the CD95 receptor and suffer of a severe systemic lupus erythematosus-like disease, produce large amounts of circulating tTG autoantibodies. This phenomenon is paralleled by an abnormal accumulation of an inactive enzyme protein in the accessory cells of lymphoid organs. To investigate the molecular mechanisms by which tTG inhibition may contribute to the development of autoimmunity we generated a cell culture model system consisting of L929 cells stably transfected with a full length tTG cDNA. When L929 cells were killed by Tumor Necrosis Factor alpha (TNFalpha) a pronounced release of DNA and Lactate Dehydrogenase (LDH) was observed. Overexpression of tTG in these cells largely prevented the leakage of macromolecules determined by TNFalpha treatment, an effect which is abolished by inactivating the enzyme cross-linking activity by a synthetic inhibitor. These in vitro observations provided the basis to explain the increased levels of plasmatic LDH we detected in MRLlpr/lpr mice. These data suggest that lack of an active tTG may represent a cofactor in the development of autoimmunity.

Expression of Werner and Bloom syndrome genes is differentially regulated by in vitro HIV-1 infection of peripheral blood mononuclear cells

In HIV infection, continuous immune activation leads to accelerated ageing of the adaptive immune system, similar to that observed in elderly people. We investigated the expression of WRN and BLM (genes involved in disorders characterized by premature ageing, genomic instability and cancer predisposition) in peripheral blood mononuclear cells (PBMC) activated in vitro with phytohaemagglutinin (PHA) and infected with different HIV-1 strains. The steady state levels of mRNA were analysed by reverse transcription-polymerase chain reaction (RT-PCR), and protein expression was assayed using immunocytochemistry and Western blot techniques. In uninfected PBMC, PHA stimulation induced an increase in BLM mRNA and protein expression, while WRN expression remained virtually unchanged. When PBMC were infected in vitro with a lymphotropic HIV-1 strain, the level of BLM mRNA showed a peak at 24 h of infection, followed by a decline to uninfected culture levels. A similar result failed to be seen using an R5-tropic HIV-1 strain. In accordance with mRNA expression, in HIV-infected cultures PBMC were stained more frequently and more intensely by a BLM-specific antibody as compared to uninfected cultures, staining peaking at 24. Conversely, WRN expression was not modulated by HIV-1. The proportion of cells showing BLM up-regulation, established by immunocytochemical staining, was much greater than the proportion of productively infected PBMC, as established by proviral DNA measurement. This result indicates that BLM up-regulation is probably a result of an indirect bystander cell effect. Activation of the BLM gene in infected PBMC suggests that premature ageing could be a further immunopathogenetic mechanism involved in HIV-induced immunodeficiency, and points to a possible new candidate target for innovative therapeutic intervention.

[Risks and benefits of influenza and pneumococcal immunization in HIV-1 infected individuals]

Influenza and Streptococcus pneumoniae diseases can cause severe complications in HIV-1 infected individuals leading to increases in hospital admission and even death. Both vaccinations are recommended for such individuals, but some studies reported that such immunizations may stimulate an increase of HIV-1 viral load and decrease of CD4+ cells count. A review of published studies, including our studies carried out in HIV-1 infected former drugs addicts, indicates that influenza and pneumococcal vaccinations are well tolerated in individuals with HIV-1, and do not induce deterioration of the course of HIV-1 infection, even though the immune response to vaccination is lower than that one observed in immunocompetent individuals. Therefore the lack of significant changes of virological and immunological parameters indicates that such immunizations can be safely administrated to HIV-1 infected individuals.

The effect of fixation technique on graft position in anterior cruciate ligament reconstruction

The purpose of this paper was to determine the extent to which the technique used in ACL reconstruction and fixation influences graft placement. This is a Comparative Radiographic cohort study. Precise graft placement is one of the most crucial components of a successful anterior cruciate ligament (ACL) reconstruction. Two commonly used techniques of ACL reconstruction are arthroscopic bone-patellar tendon-bone (B-PT-B) autograft with interference screw fixation and semi-tendinosus and gracilis (ST + G) tendon autograft with endobutton femoral and multiple staple belt buckle tibial fixation. Using radiographic measurements of bone tunnel position following ACL reconstruction this study quantified the extent to which these techniques influenced graft placement. Femoral and tibial tunnel position in ACL reconstruction was determined using the post-operative radiographs of 40 male patients who had undergone ACL reconstruction (20 B-PT-B and 20 ST + G). The primary outcome measure was location of bone tunnel position following ACL reconstruction. Measurements were based on the guidelines of Amis et al. Femoral tunnel position of B-PT-B grafts was an average of 9.36% more anterior in the sagittal plane than with ST + G grafts. The mean position of B-PT-B grafts was at 31.11% (SD = 5.45%). The mean position of the ST + G grafts was 21.76% (SD = 6.62%). This difference between the two was found to be significant (p < .001). As demonstrated by this study, placement and orientation may vary to accommodate technique and fixation. Clinical outcomes measured were similar in both groups.

Safety and immunogenicity of 23-valent pneumococcal polysaccharide vaccine in HIV-1 infected former drug users

The immunogenicity of 23-valent pneumococcal polysaccharide vaccine was assessed in 57 HIV-1 infected former intravenous drug users and in 20 HIV-1 negative controls. The effect of vaccination on HIV-1 infection was studied in a subgroup of 38 patients, 60% of whom under highly active antiretroviral therapy (HAART). Antibody to capsular polysaccharides from Streptococcus pneumoniae serotypes 3, 4, 6B, 19F, 23 F, and changes in CD4+ count, HIV-1 RNA, proviral DNA and HIV-1 phenotype were measured in pre- and post-vaccination samples. Vaccinations were well-tolerated. The rate of responders was higher (P<0.05) in HIV-1 negative than in HIV-1 infected individuals. No difference in antibody response was found within HIV-1 infected patients stratified according to CD4+ counts. Post-vaccination antibody geometric mean concentrations (GMCs) to the five antigens were higher (P<0.05) than baseline in HIV-1 negative subjects, but not in HIV-1 positive individuals. Those with CD4+ >500 cells/mm(3) showed a significant increase of antibody against type 3 only. Immunisation caused no significant changes in CD4+ counts and in either plasma HIV-1 RNA nor proviral DNA levels. Pneumococcal vaccination does not induce virological or immunological deterioration in HIV infected patients, but the antibody response to a single dose of vaccine is poor.

[Extracorporeal shockwave therapy in symptomatic heel spurs. An overview]

Extracorporeal shock wave application (ESWA) has been successfully used for years in routine clinical management of plantar fasciitis. So far no clinical trails have shown the efficiency in placebo-controlled protocols. This paper presents an overview of conservative and operative treatment modalities with respect to their efficacy. Results of a prospective randomized placebo-controlled double-blind multicenter trial to show efficiency and safety of ESWT are presented. In patients treated conservatively without success, a single shock wave application can improve the condition significantly compared with placebo treatment (p = 0.0149). The Roles and Maudsley score also showed a significant improvement between the groups, with 61.6% good or excellent results in the verum group and 39.7% in the placebo group (p = 0.0128). Therapy-related side effects (local swelling, petechia) are rare. The data presented in this study led to FDA approval in January 2002 of the shock wave device used.