An evaluation of the accuracy and safety of prescribing antidepressants and anxiolytics in a paediatric population

Introduction

An NHS Digital survey found that 1 in 8 children aged between 5-19 had at least one mental health disorder in England in 2017.1 Since this survey the prescribing of antidepressants and anxiolytics has increased every year for the past five years in England.2 A GP surgery within East Sussex requested an evaluation of whether prescribing of mental health disorder medication in paediatrics was following legal and clinical guidance. This evaluation reviewed whether the GP practice had followed Summary of Product Characteristics (SPC) prescribing requirements and the East Sussex Healthcare NHS Trust (ESHT) formulary requirements in the use of antidepressants and anxiolytics in the paediatric population.

Aim

To evaluate whether medicines were prescribed in accordance with their SPC, the ESHT Formulary requirements and monitoring requirements. The evaluation also assessed whether patients’ GP records were up to date as per clinic letters and whether patients were receiving cognitive behavioural therapy (CBT) and/or were under the care of appropriate mental health specialists.

Methods

A search was conducted via the EMIS system. Inclusion criteria were that the patient was under the age of eighteen, had an anxiolytic and/or antidepressant prescribed and were registered with the practice between the beginning of March 2022 to the end of April 2022. Data was analysed via excel spreadsheet with patients allocated a random number. Ethics approval was not required as this was a service evaluation.

Results

Eleven patients met the above criteria. Out of these patients 46% were on sertraline, 46% on fluoxetine, 18% on mirtazapine and 9% on citalopram. Audit results demonstrated that 90% of patients were under the supervision of a mental health specialist and/or receiving CBT, 66% of medications were prescribed as per their SPC with 69% prescribed in accordance with the ESHT formulary. Monitoring requirements conducted within the last 12 months was completed for 64% of patients. In addition, 45% of patients had an incorrect medication list when compared to neurology clinic letter with errors ranging from missing medication to incorrect dosing. It was also found that 82% of patients had incorrect coding on their problem lists with errors ranging from missed diagnoses to medication being incorrectly linked to problems.

Discussion/Conclusion

The results show that most prescribing followed formulary and SPC requirements, and that patients had CBT either in place or in the process of being organised. However, more care is needed with monitoring, coding and processing clinic letters within this practice. Clinic letters with new diagnoses and medication changes were not seen by a clinical professional, potentially leading to errors. A small cohort of patients and COVID restrictions with staff and patients were the primary limitations of this study. More research is needed to determine whether other GP surgeries have the same strengths and challenges found within this surgery, and whether lessons can be learnt to standardise practice.

References

1. NHS Digital. Mental health of children and young people in England, 2017. Available from: https://dera.ioe.ac.uk/32622/1/MHCYP%202017%20Summary.pdf

2. NHS Business Services Authority. Medicines Used in Mental Health – England – 2015/16 to 2020/21. Available from: https://www.nhsbsa.nhs.uk/statistical-collections/medicines-used-mental-health-england/medicines-used-mental-health-england-201516-202021

P229 IMPROVED CLINICAL–INSTRUMENTAL OUTCOMES IN PATIENTS WITH CHRONIC DILATED HYPERTENSIVE / ISCHEMIC HEART DISEASE, UNDERGOING CCM, CARRIER OF CRTD WITH PERSISTENT SEVERE LEFT VENTRICULAR DYSFUNCTION

A 62–year–old man repeatedly subjected to PTCA + stent with severe left ventricular dysfunction and estimated FE 15%. After some hospitalizations for heart failure in 2015 he underwent an AICD implant Biventricular. Followed up in our clinics dedicated to heart failure, the patient did not present the characters of the CRT responder presenting a constant high end–systolic volume (224 ml) and none FE improvement of 15%. There was also an asthenia and tendency to inactivity and elevated NT Pro BNP levels despite optimal medical therapy even with entresto 24/26 mg x 2 / day. It has been decided to submit the patient enrolled in the cardiac transplant and / or VAD implantation lists to an implantation procedure of CCM system (cardiac contractility modulation). After two active fixation placement leads on the interventricular septum and connection to the CCM system housed in the subcutaneous pocket right contralateral to the biventricular AICD, the patient was monitored. We have noticed since the first days conditions of hemodynamic stability. Scheduled CCM therapy delivery for 10 hours a day. Following subsequently in the follow up at 3 – 6 – 12 – 18 months the patient showed an improvement of minneshota quality of life questionnaire in heart failure: MLWHFQ (44 at baseline, 17 at two months, 15 to six months, 10 to 12 months and 3 to 18 months), an increase in FE from 15 to 23 up to 26%, a reduction of the NTPROBNP from 13444 to 1178 then climbed back to 5549 and 3712 at 18 months for atrial fibrillation, without any requires re–hospitalization, an increased physical activity of the patient detected by the sensors of the two devices

P29 AICD IMPLANTATION IN A PATIENT RESURRECTED FROM CARDIAC ARREST, WITH THE R / T PHENOMENON AT THE HOLTER

A 72–year–old woman with hypertension for thirty years, resuscitated from cardiac arrest during prosthetic surgery of the right knee in January 2020, with external heart massage and orotracheal intubation. On examination Holter performed in February 2021, presence of couples and R / T phenomenon with Lown 1B–3–4A–5 class. The patient is subjected to coronary angiography which showed only mild atheroma without stenosis hemodynamically significant of the arterial districts explored. On the Echocardiogram, FE estimated at 60%. Based on the anamnestic data and the feedback from the fifth class of Lown at the Holter, it was decided to implant a dual chamber defibrillator for secondary prevention. The vulnerable point of refractory ventricular notoriously falls below 300 msec and in the clinical case in question there is a comparison to the holter of fifth class of lown with phenomenon R on T and coupling interval of 276 msec. The precocity of the ventricular ectopias is already in itself a risk factor for MI, reinforced in the case of clincio in question from a history of resuscitated cardiac arrest in a hospital setting. Not indicated to ours opinion of the electrophysiological inducibility study, given the positive clinical history and dynamic ECG according to Holter who examines the arrhythmic phenomenon in its spontaneous and natural way of presenting itself in circadian rhythm. The reproducibility in the laboratory with the SEI, of the electrical vulnerability was in fact in the recent years downsized, due to high specificity but low sensitivity, as there is in the clinical reality of patient neurovegetative and biohumoral fluxuonary factors, which favor the induction of malignant arrhythmias and that escape the predictive laboratory analysis. Making the patient safe with the implant of the bicameral AICD resulted from a clinical – diagnostic – instrumental analysis and after extensive discussion by the heart team in our Operating Unit.

Anatomical and biochemical studies of Spartium junceum infected by Xylella fastidiosa subsp. multiplex ST 87

Spartium junceum L. is a typical species of Mediterranean shrubland areas, also grown in gardens and parks as an ornamental. In recent years in Europe, S. junceum has been recurrently found to be infected by different subspecies and genotypes of the quarantine regulated bacterium Xylella fastidiosa (Xf). This work presents for the first time the anatomy of S. junceum plants that we found, by means of genetic and immunochemistry analysis, to be naturally infected by Xf subsp. multiplex ST87 (XfmST87) in Monte Argentario (Grosseto, Tuscany, Italy), a new outbreak area within the EU. Our anatomical observations showed that bacteria colonized exclusively the xylem conductive elements and moved horizontally to adjacent vessels through pits. Interestingly, a pink/violet matrix was observed with Toluidine blue staining in infected conduits indicating a high content of acidic polysaccharides. In particular, when this pink-staining matrix was observed, bacterial cells were either absent or degenerated, suggesting that the matrix was produced by the host plant as a defense response against bacterial spread. In addition, a blue-staining phenolic material was found in the vessels and, at high concentration, in the pits and inter-vessels. SEM micrographs confirmed that polysaccharide and phenolic components showed different structures, which appear to be related to two different morphologies: fibrillary and granular, respectively. Moreover, our LM observations revealed bacterial infection in xylem conductive elements of green shoots and leaves only, and not in those of other plant organs such as roots and flowers.

Development of Three Molecular Diagnostic Tools for the Identification of the False Codling Moth (Lepidoptera: Tortricidae)

Three molecular protocols using qPCR TaqMan probe, SYBR Green, and loop-mediated isothermal amplification (LAMP) methods were set up for the identification of larvae and adults of an African invasive moth, Thaumatotibia leucotreta (Meyrick, 1913) (Lepidoptera: Tortricidae). The DNA extracts from larval and adult samples of T. leucotreta were perfectly amplified with an average Ct value of 19.47 ± 2.63. All assays were demonstrated to be inclusive for T. leucotreta and exclusive for the nontarget species tested; the absence of false positives for nontarget species showed a 100% of diagnostic specificity and diagnostic sensitivity for all assays. With the SYBR Green protocol, the Cq values were only considered for values less than 22 (cutoff value) to prevent false-positive results caused by the late amplification of nonspecific amplicons. The limit of detection (LoD) for the qPCR probe protocol was equal to 0.02 pg/µl while a value equal to 0.128 pg/µl for the qPCR SYBR Green assay and LAMP method were established, respectively. The intrarun variabilities of reproducibility and repeatability in all the assays evaluated as CV%, ranged between 0.21 and 6.14, and between 0.33 and 9.52, respectively; the LAMP values were slightly higher than other assays, indicating a very low interrun variability. In order for an operator to choose the most desirable method, several parameters were considered and discussed. For future development of these assays, it is possible to hypothesize the setup of a diagnostic kit including all the three methods combined, to empower the test reliability and robustness.

Supporting the Regional Network for Children with Burn Injuries in a Pediatric Referral Hospital for COVID-19

Considerable reorganization of the regional network for pediatric burn treatment during the pandemic was required to cope with severe burn injuries in small children. In support of the emergency network for burns during the COVID-19 pandemic, we referred to regional indications for centralization in our hospital for all children aged less than 5 years who presented with severe burns, >15% of total body surface area (TBSA), or who necessitated admittance to the pediatric intensive care unit (PICU). A new service with a dedicated management protocol was set up to treat pediatric burns in our SARS-CoV-2 pediatric hospital during the lockdown period. A multidisciplinary burn treatment team was set up to offer compassionate and comprehensive burn care. Patient's clinical data, burn features, treatment and follow up were recorded. A higher number of admissions was recorded from February to December 2020 compared with the same period in 2019 (52 vs. 32 admissions). Eighteen patients were admitted to the COVID-19 Service (10 M/8 F; 3.10 ± 2.6 yrs); ten children (55.5%) were hospitalized in the ward and eight in the ICU (44.5%). Fifty percent of the cases presented with lesions extending over >15% TBSA; in one case, TBSA was 35%. All patients suffered 2nd-degree burns; while five patients also had 3rd degree lesions covering more than 15% TBSA. All of the injuries occurred at home. No major secondary infections were recorded. Successful treatment was achieved in 94.4% of cases. The average length of stay was 15.2 ± 12.6 days. A proactive, carefully planned service, involving a multidisciplinary team, was created to ensure appropriate care in a pediatric hospital during the COVID-19 period, despite the effective pandemic associated challenges. Better health promotion in pediatric burn cases should also include dedicated TBSA assessment and a database of children's burn characteristics.

Serum biomarkers for sepsis in children with febrile neutropenia and cancer

The National Institute for Health and Care Excellence (NICE) defines febrile neutropenia or "neutropenic sepsis" as a patient with an absolute neutrophil count (ANC) less than 0.5 x 109/L and temperature >38°C or signs and symptoms of sepsis.

Molecular Typing of Bois Noir Phytoplasma Strains in the Chianti Classico Area (Tuscany, Central Italy) and Their Association with Symptom Severity in Vitis vinifera 'Sangiovese'

Bois noir (BN) is the most widespread disease of the grapevine yellows complex in the Euro-Mediterranean area. BN is caused by 'Candidatus Phytoplasma solani' (BNp), transmitted from herbaceous plants to grapevine by polyphagous insect vectors. In this study, genetic diversity among BNp strains and their prevalence and possible association with grapevine symptom severity were investigated in a Sangiovese clone organic vineyard in the Chianti Classico area (Tuscany). Field surveys over 2 years revealed a range of symptom severity on grapevine and an increase of BN incidence. A TaqMan allelic discrimination assay detected only tufB type b among BNp strains, suggesting the prevalence of the bindweed-related ecology. Nucleotide sequence analyses of vmp1 and stamp genes identified 12 vmp1 and 16 stamp sequence variants, showing an overall positive selection for such genes. The prevalent genotype was Vm43/St10, reported for the first time in this study and closely related to strains identified only in the French Eastern Pyrenees. BNp strains identified in the examined vineyard and mostly grouped in separate bindweed-related phylogenetic clusters showed statistically significant differences in their distribution in grapevines exhibiting distinct symptom severity. These results suggest the possible occurrence of a range of virulence within BNp strain populations in the Chianti Classico area.

Influence of TNF-α inhibition on oxidative stress of rheumatoid arthritis patients

The aim of this study was to assess circulating levels of reactive oxygen metabolites (ROMs) as a marker of oxidative stress in rheumatoid arthritis (RA) patients during an anti-tumor necrosis factor alpha (TNF-α) treatment. We enrolled 40 patients with RA (36 females; age 53 ± 13 yrs) treated with different subcutaneously administered TNF-α inhibitors. The oxidative status was determined on the basis of plasma samples taken before, at 24 and 52 weeks of the anti-TNF-α treatment. Hydroperoxide levels were measured using the d-ROMs test, a useful clinically proven oxidative stress marker. During the anti-TNF-α therapy, we observed a significant reduction in serum ROMs levels in RA patients from 33.2 ± 10 mg H2O2/L at baseline to 29.5 ± 7 and 29.3 ± 9 mg H2O2/L, at 24 and 52 weeks, respectively (p<0.05). We also identified a significant correlation between the oxidative stress status and the disease activity score on 28 joints/C-reactive protein and health assessment questionnaire disability index. The results of our study demonstrate that a good control of the disease with anti-TNF-α agents can reduce oxidative stress in RA patients. However, further studies of larger patient cohorts are needed to confirm these preliminary data.

IgM peak independently predicts treatment-free survival in chronic lymphocytic leukemia and correlates with accumulation of adverse oncogenetic events

We examined the significance of IgM peaks in chronic lymphocytic leukemia (CLL), including its association with newly reported MYD88, BIRC3, NOTCH1 and SF3B1 mutations. A total of 27, 25, 41 and 57 patients with monoclonal IgM or IgG peaks (IgM and IgG groups), hypogammaglobulinemia (Hypo-γ group) and normal immunoglobulin serum levels (normal-γ group) were, respectively, included. IgM peaks were mainly associated with Binet stage C and the del(17p). Biased usage of IGHV3-48 was shared by both IgM and IgG groups. IGHV3-74 and IGHV4-39 gene rearrangements were specific for IgM and IgG peaks, respectively. SF3B1, NOTCH1, MYD88 and BIRC3 mutation frequencies were 12%, 4%, 2% and 2%, respectively, being over-represented in IgM, IgG and Hypo-γ groups for SF3B1, and being equal between normal-γ and IgM groups for MYD88. Overall, 76%, 87%, 49% and 42% of cases from IgM, IgG, Hypo-γ and normal-γ groups had at least one intermediate or poor prognosis genetic marker, respectively. By multivariate analysis, IgM peaks were associated with shorter treatment-free survival independently from any other univariate poor prognosis biological parameters, including IgG peaks, Hypo-γ, IGHV status, SF3B1 mutations, cytogenetics and lymphocytosis. Therefore, as with IgG peaks, IgM peaks aggravated the natural course of CLL, with increased accumulation of adverse genetic events.

First Report of Knot Disease Caused by Pseudomonas savastanoi on Sweet Olive in Central Italy

In April 2012 the presence of hyperplastic outgrowths on trunks, branches, and twigs of sweet olive plants, Osmanthus fragrans Lour (Fam. Oleaceae), was recorded in two ornamental hedges made up of five and four plants, respectively, in the city center of Montecatini (Pistoia-Italy). All sweet olive plants were seriously affected by the disease with outgrowths appearing either singly or close together, often forming a single mass that could extend up to 20 cm along the stems, occasionally surrounding the entire circumference. The symptoms observed on O. fragrans closely resembled those induced by the bacterium Pseudomonas savastanoi on Olea europea (common olive) and other plant species. Suspecting a bacterial origin of the disorder, young knots were collected from four diseased plants and used for bacterial isolation with standard techniques on nutrient sucrose agar medium (1). After 3 days of incubation at 26°C, non-levan forming colonies about 3 mm in diameter that were circular, convex, smooth, and cream colored with entire margins appeared on the surface of the agar medium. Purified isolates were gram negative, levan negative, oxidase negative, potato rot negative, arginine dihydrolase negative, showed a tobacco hypersensitive reaction, and tested positive to PCR screening for the presence of the iaaM (tryptophan-2-monooxygenase), iaaH (indoleacetamide hydrolase), ptz (isopentenyl transferase) (1) and iaaL (IAA-lysine synthethase) (3) genes. Three isolates were selected arbitrarily and further characterized by sequencing a fragment of the housekeeping genes rpoD (sigma factor 70) and pgi (phosphoglucose isomerase) (2). All sequenced gene fragments, of 620 bp and 552 bp for the rpoD and pgi genes, respectively, were identical to those of P. savastanoi pv. savastanoi strain NCPPB3335. The pathogenicity of the three isolates was verified on three O. fragrans plants and three Olea europea (cv. Frantoio) plants. Per each isolate, three 1-cm wounds were made on the branches of each plant using a sterile scalpel dipped in a bacterial suspension (1 × 10⁸ CFU/ml). P. savastanoi pv. savastanoi PVFi-t2b isolated from olive was also inoculated as reference strain. After 30 days, all isolates including the reference strain induced typical knots on both plant species while no symptoms were observed on wounds inoculated with sterile water. Bacteria were reisolated from induced knots and Koch's postulates were confirmed. On the basis of biochemical tests, PCR screening, pathogenicity testing, and sequence analyses, the causal agent of knot disease on O. fragrans was identified as P. savastanoi. The potential susceptibility of O. aquifolium Sieb. to the causal agent of olive knot disease has been demonstrated in the past by means of artificial inoculations but interestingly, in the same trials, O. fragrans had tested negative (4). To the best of our knowledge, this is the world's first report of O. fragrans as natural host of P. savastanoi, which extends the growing list of cultivated and ornamental plant species affected by this phytopathogenic bacterium. References: (1) G. Marchi et al. Eur J. Plant Pathol. 112:101, 2005. (2) N. Parkinson et al. Plant Pathol. 60:338, 2011. (3) R. Penyalver et al. Appl. Environ. Microbiol. 66:2673, 2000. (4) C. O. Smith. Phytopathology 12:271, 1922.

Occurrence of Lily mottle virus on Lilium in Italy

Lily mottle virus (LMoV), a member of the genus Potyvirus, is one of the main viruses infecting lily. Symptoms on lily differ according to the susceptibility and sensitivity of different cultivars and hybrids. They range from leaf mottle or mosaic, vein clearing, chlorotic and yellow streaking, leaf curling, and necrotic spots, to milder forms of leaf symptoms. Plants may even be symptomless at some stages of growth. A varietal collection of Lilium from the early 1990s is held in Pistoia Province (Tuscany, Italy) and is composed of Asian hybrids obtained from intraspecific breeding of commercial cultivars. During a survey conducted from May to June 2010, several plants showing vein clearing, leaf mottle, leaf mosaic, and reddish brownish necrotic spots were observed. Leaf samples from 60 symptomatic or symptomless lily plants, belonging to 20 cultivars, were collected and tested for the presence of LMoV. Samples were assayed by double-antibody sandwich (DAS)-ELISA and eight of them, belonging to four different cultivars, tested positive. Total RNA was extracted from 2 g of leaf tissue of every collected sample according to the protocol described earlier (3) and cDNA synthesis was performed with an iScript cDNA Synthesis Kit (Bio-Rad, Hercules, CA). Samples were tested by reverse transcription (RT)-PCR and real-time PCR assays using primers LMoV1 (5'-GCAAATGAGACACTCAATGCTG-3') and LMoV2 (5'-CGTGCGTGAAGTAACTTCATAG-3') designed to amplify 651 bp of the coat protein (CP) gene of LMoV (1). Results obtained with RT-PCR and real-time PCR exactly matched those achieved with ELISA assay, and the eight positive samples showed amplicons of the expected size. PCR products from five infected samples were directly sequenced from both directions and submitted in GenBank (Accessions Nos. JQ655106 to JQ655110). Our isolates share more than 99% nucleotide identity among each other. Comparison with other LMoV-CP gene sequences present in GenBank showed nucleotide identities ranging from 93 to 94% with LMoV isolates from South Korea (GenBank Accession Nos. GQ150683 to GQ150686), China (GenBank Accession Nos. EU348826, AJ748256, AJ564636, and AJ564637), Australia (GenBank Accession No. JN127341), and Japan (GenBank Accession No. AB570195). To our knowledge, this is the first report of LMoV on Lilium in Italy where this virus was already reported to infect escarole (2). Considering the economic importance of Lilium production as a flowering plant in Pistoia Province, and in several other areas of Italy, the report of LMoV present on lilies suggests the use of healthy propagation material and the adoption of preventive measures to avoid its diffusion. References: (1) J.-H. Lim et al. Korean J. Microbiol. 45:251, 2009. (2) V. Lisa et al. Plant Dis. 86:329, 2002. (3) D. J. MacKenzie et al. Plant Dis. 81:222, 1997.

Predicting the human in vivo performance of different oral capsule shell types using a novel in vitro dynamic gastric model

The disintegration of a capsule shell may determine the onset of drug dissolution from capsule formulations. In this study, the release of a rapidly dissolving model drug (paracetamol), from two hydroxypropyl methylcellulose capsules containing either carageenan (HPMC-C) or gellan gum (HPMC-G) and one hard gelatin (HG) capsule, were investigated using a conventional in vitro model, the USP dissolution apparatus I, and a novel in vitro model of the human gastric compartment, the dynamic gastric model (DGM). The results obtained in vitro were compared with in vivo gamma scintigraphy human data and in vivo gastric emptying profiles available in the literature. The drug release from HPMC-G capsules, observed with the USP dissolution apparatus I, was delayed with respect to the other two capsules, while the results obtained from the DGM in the fasted state were closer together, which was in agreement with data from the in vivo studies. In the fasted state, the capsule rupture times obtained from the DGM were similar to those observed by gamma scintigraphy in vivo studies. In the fed state, the 'apparent' rupture times observed with the DGM were delayed compared to fasted, and were even longer than those observed by scintigraphy in vivo for HPMC-G and HG capsules. However, these discrepancies can reasonably be explained by considering the impact of food upon dispersion of the capsule contents and the sampling from the DGM, when compared to the human scintigraphy experiments.

Acute respiratory distress following fine needle aspiration of thyroid nodule: case report and review of the literature

BACKGROUND

Fine needle aspiration (FNA) is a widely used practice to assess thyroid lesions, with a low morbidity rate. Although neck hematomas following this procedure are quite common, only three cases of massive hemorrhage causing acute airways obstruction have been previously described.

CASE REPORT

We report the case of a 74 years old female with acute respiratory distress following ultrasound-guided FNA for a right paraisthmic thyroid nodule. The patient was admitted to the Emergency Room (ER) 6 hours after the procedure with a large neck hematoma compressing the cervical trachea and requiring surgical decompression. Patient underwent endotracheal intubation followed by isthmectomy and evacuation of the hematoma. Extubation was made 24 hours later in the Intensive Care Unit and the patient was discharged after 48 hours uneventfully.

CONCLUSIONS

Acute thyroid hemorrhage following FNA is very rare but still possible. Prompt intervention is mandatory for patients with rapidly evolving symptoms.

A large population of galaxies 9 to 12 billion years back in the history of the Universe

To understand the evolution of galaxies, we need to know as accurately as possible how many galaxies were present in the Universe at different epochs. Galaxies in the young Universe have hitherto mainly been identified using their expected optical colours, but this leaves open the possibility that a significant population remains undetected because their colours are the result of a complex mix of stars, gas, dust or active galactic nuclei. Here we report the results of a flux-limited I-band survey of galaxies at look-back times of 9 to 12 billion years. We find 970 galaxies with spectroscopic redshifts between 1.4 and 5. This population is 1.6 to 6.2 times larger than previous estimates, with the difference increasing towards brighter magnitudes. Strong ultraviolet continua (in the rest frame of the galaxies) indicate vigorous star formation rates of more than 10-100 solar masses per year. As a consequence, the cosmic star formation rate representing the volume-averaged production of stars is higher than previously measured at redshifts of 3 to 4.

Matriz óssea homóloga desmineralizada associada à medula óssea autógena fresca na artrodese vertebral dorsolateral lombar em coelhos

Foi avaliada a matriz óssea homóloga desmineralizada (MOD), associada à medula óssea autógena fresca (MO), na artrodese vertebral dorsolateral lombar em 24 coelhos (grupo 1), depositada sobre os processos transversos de L5-L6 previamente descorticados. Em outros nove coelhos (grupo-controle), foi realizada apenas a descorticação dos processos transversos e nas diferentes avaliações, foi observada insignificante reação periosteal local, sem união óssea. No grupo 1, às cinco semanas de pós-operatório, 87,5% dos animais apresentaram união (artrodese) à palpação, seguido por 75 e 100% às sete e nove semanas, respectivamente. Os índices de artrodese aos RX foram de 50%, 62% e 75%, no mesmo período de avaliação. Histologicamente, às cinco semanas havia características de osteointegração da MOD com os processos transversos descorticados, de onde partiram os vasos sangüíneos que penetraram a matriz, e presença de ilhas de cartilagem no centro do enxerto. Nas semanas seguintes, a ossificação endocondral evoluiu e a MOD foi quase totalmente substituída por tecido ósseo trabecular, formando uma ponte de osso maduro entre e sobre os processos transversos adjacentes, propiciando ao segmento operado maior resistência mecânica em comparação aos segmentos adjacentes. A associação da MOD com a MO mostrou-se uma opção exeqüível e de baixo custo na artrodese vertebral dorsolateral lombar em coelhos.

Study of hardness and roughness modification in explanted joint components

The significant wear of the UHMWPE bearings of explanted knee prostheses is produced mainly by micrometric debris ("third-body" wear) that diffuse toward the mobile metal-polymer interface. Here debris is crushed during the movement producing scratches in the metal and in the polymeric surfaces. Mechanical stress and the biological effects change the physical polymeric properties. In order to evaluate the area of UHMWE bearings submitted to high load stresses, in this work physical investigations are performed on the explanted knee prosthesis. Particularly, the roughness profile analysis (RPA) and the micro-hardness measurements (MHM) resulted suitable for the localisation of the mechanical and biological wear area. In the stressed zone, surface treatments could be applied in order to improve the mechanical resistance of the polymeric material. Particularly, the ion implantation with heavy ions is proposed to enhance the polymeric wear resistance. The Scanning Electron Microscopy (SEM), Energy Dispersive X-ray Spectrometry (EDX) and Infrared absorption spectroscopy (FTIR) techniques were also applied and results discussed.

Analysis of risk factors for the development of GVHD after T cell-depleted allogeneic BMT: effect of HLA disparity, ABO incompatibility, and method of T-cell depletion

Multivariate analysis was performed to determine the independent factors affecting the risk of acute GVHD (aGVHD) grades II to IV and extensive chronic GVHD (cGVHD) and the rate of survival in 481 recipients of T cell-depleted (TCD) marrow allografts who received transplants at a single center between 1991 and 2000. All patients received grafts partially depleted of CD3+ T cells by complement-mediated lysis using 2 narrow-specificity monoclonal antibodies (MoAbs), T10B9.1A-31 (n = 400) or Muromonab-Orthoclone OKT3 (n = 81). Factors considered in the analysis included patient/donor sex, age, cytomegalovirus (CMV) status, and ABO blood group along with T-cell dose, disease, and disease status, donor relationship, HLA antigen (Ag)mismatch (MM), growth-factor use, anti-thymocyte globulin use, year of transplantation, and the MoAb used for TCD. The results showed an association of HLA with an increased relative risk (RR) of aGVHD for recipients of grafts from relateddonors that were > or =2 Ag MM (n = 73, RR = 2.09, P = .005), matched unrelated (UR) donors (n = 130, RR = 1.98, P = .004), and > or =2 Ag MM UR donors (n = 34, RR = 2.68, P = .003) compared with the baseline matched-sibling group (n = 121). No increased risk of aGVHD was seen for 0 to 1 Ag MM family donors (n = 24) or 1 Ag MM UR donors (n = 99). aGVHD risk was increased with minor, but not major or major-minor, ABO disparity (RR = 2.0, P = .003) compared with that of ABO-identical pairs. We found less effective TCD and resultant higher T-cell dose for recipients of grafts that were T cell depleted using OKT3. However, the use of OKT3 and not the T-cell dose was associated with increased aGVH-D risk (RR of 1.84, P = .001). Increased risk of extensive cGVHD was associated with patient age of >20 years (RR = 2.2, P < .0001) and with CMV status (positive patient/negative donor, RR = 1.9, P = .002). Decreased survival was associated with older age (>20 years), a > or =2 Ag MM related donor, a 1 or > or =2 Ag MM UR donor, risk group, and a CMV-positive patient/-negative donor pair. There was no difference in survival for 0 to 1 Ag MM related or matched UR donors compared with the baseline group. These data indicate that there are quantitative as well as potential qualitative differences in outcome depending on the TCD method. Expected and unexpected risk factors for GVHD and survival were associated with partial TCD. Our data support the consideration of ABO match in donor selection, the preferential selection of CMV-positive donors for CMV-positive recipients, and the acceptance of 1 but not > or =2 Ag HLA MM donors.

Novel use of bovine zeta-crystallin as a conformational DNA probe to characterize a phase transition zone and terminally differentiating fiber cells in the adult canine ocular lens

Using a novel immunocytochemical staining method, we aimed to characterize the phase transition zone (PTZ) (approximatly 100 microm) in adult ocular lenses and the process of terminal differentiation (denucleation) within normal fiber cells. The binding to DNA of zeta-(zeta) crystallin (Z-DNA-binding protein) and anti-double-stranded (ds-)-B-DNA antibody probes was found to decline gradually throughout denucleating fibers, with a precipitous decrease occurring at about 100 microm (PTZ). Nuclei of superficial fiber cells (in front of the PTZ) showed the highest DNA probe-binding values, followed by middle fibers (MF) and deep fibers (DF). With the use of zeta-crystallin, anti-ds-B-DNA antibody, and anti-single stranded (ss-) DNA antibody probes, it was possible to reveal a loss of reactivity of fiber cell ds-DNA. Ss-DNA antibody binding was seen initially in the MF and reached its highest intensity level in the DF. The pattern of zeta-crystallin probe-DNA reactivity correlates with the loss of anti-B-DNA antibody staining and decreased eosin-protein staining. These data suggest that a reorganization of DNA and intracellular protein supramolecular order in normal adult lenses occurs at a depth of about 100 microm (PTZ).

[Peristomal laparocele: particular indications for the use of prosthetic materials]

The authors report the case of a female patient suffering from colic neoplasm and a vast peristomal laparocele, the long-term outcome of a rectal amputation that the patient underwent at a young age. After colic resection, a vast area of surgical mesh in dacron was modelled and positioned in a retromuscular scat, thus allowing the hernia pathology to be resolved relatively simply, owing to its particular location-in correspondence with a preternatural anus-until not long ago this would have represented an absolute contraindication to the use of prosthetic materials. A precise surgical approach, marked by a scrupulous respect for aseptic conditions, is essential in these circumstances owing to the persistent risk of septic complications.

Electroporation of antibodies, DNA, and other macromolecules into cells: a highly efficient method

While antibodies are a major extracellular tool of the highest specificity to answer important biomedical questions, the improvements in electroporation discussed below may make it feasible to also use antibodies as an intracellular deletion tool to study (a) viruses inside the cell, (b) cancer cells, (c) signal transduction, (d) genetics, (e) metabolism, and (f) other structures and mechanisms. Already, others have succeeded in depositing macromolecules, including antibodies (Abs), and nucleic acids inside cells, using many techniques, including electroporation (EP). However, EP has limitations that have precluded its widespread use, particularly its high kill rate for cells and the low percentage of cells that are able to incorporate macromolecules. If these limitations could be overcome for Abs and nucleic acids, then it would be practical to use them as highly specific probes for intracellular molecules. In our experiments using EP, we were able to largely prevent lethality for cells during EP by employing a commercially available cold-storage solution for organ transplants containing high K(+) and Mg(++) (ViaSpan, Belzer UW cold-storage solution, DuPont Pharmaceuticals). This solution decreased cell death after standard EP by an average of 50% for a number of cell lines. Viability of WISH cells after EP approached 100%. In transfection studies, ViaSpan medium strongly increased both P3HR1 cell survival as well as the total number of cells transfected with DNA for green fluorescent protein (GFP). In additional experiments with Abs, we were able to strongly increase the percent of cells that incorporated Ab by using two serial EPs. This enhanced the intracellular protection by Abs against viruses in Vero cells from 64% to a maximum of 98%. We were able to further simplify the EP technique by using unpurified antiserum in place of purified IgG. Thus, this EP technique offers multiple advantages: simplicity, high cell viability, high effectiveness, high specificity, rapid action, usefulness with adherent or non-adherent cells, and no requirement for purification of antibodies from antiserum.

The residues between the two transformation effector sites of Epstein-Barr virus latent membrane protein 1 are not critical for B-lymphocyte growth transformation

Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) is essential for EBV-mediated transformation of primary B lymphocytes. LMP1 spontaneously aggregates in the plasma membrane and enables two transformation effector sites (TES1 and TES2) within the 200-amino-acid cytoplasmic carboxyl terminus to constitutively engage the tumor necrosis factor receptor (TNFR)-associated factors TRAF1, TRAF2, TRAF3, and TRAF5 and the TNFR-associated death domain proteins TRADD and RIP, thereby activating NF-kappaB and c-Jun N-terminal kinase (JNK). To investigate the importance of the 60% of the LMP1 carboxyl terminus that lies between the TES1-TRAF and TES2-TRADD and -RIP binding sites, an EBV recombinant was made that contains a specific deletion of LMP1 codons 232 to 351. Surprisingly, the deletion mutant was similar to wild-type (wt) LMP1 EBV recombinants in its efficiency in transforming primary B lymphocytes into lymphoblastoid cell lines (LCLs). Mutant and wt EBV-transformed LCLs were similarly efficient in long-term outgrowth and in regrowth after endpoint dilution. Mutant and wt LMP1 proteins were also similar in their constitutive association with TRAF1, TRAF2, TRAF3, TRADD, and RIP. Mutant and wt EBV-transformed LCLs were similar in steady-state levels of Bcl2, JNK, and activated JNK proteins. The wt phenotype of recombinants with LMP1 codons 232 to 351 deleted further demarcates TES1 and TES2, underscores their central importance in B-lymphocyte growth transformation, and provides a new perspective on LMP1 sequence variation between TES1 and TES2.

[Sciatic, femoral and cutaneous nerve block for arthroscopic meniscectomy in a patient with Eisenmerger's syndrome. Case report]

The principal complication to prevent in Eisenmerger disease with left-right shunt during surgery decreasing of systemic pressure with reduction of pulmonary perfusion and break-down of central oxigenation. A 32 ys old male patient (ASA risk 3) to undergo an extirpation of meniscus by arthroscopic surgery, suffering from Eisenmerger's syndrome with left-type only ventricle, diagnosed when he was 3 ys old and but no repaired by any operation. We performed a sciatic, femoral and lateral cutaneous of thigh nerves block with ropivacaine, that consents a prolonged antalgic effect in postoperative period with minimizing of systemic and pulmonary hypotension risk compared to general, epidural or spinal anaesthesia. Basing on our experience and literature references we think that the anaesthesiological technique with the lowest risk for lower limb surgery in Eisenmerger's syndrome is truncular block.