Fatal Viral and Bacterial Septicemia in a Seventeen-Year-Old Woman with Immunodepressive Influenza A H1N1: An Autopsy Case

Abstract

The Influenza A H1N1 subtype can present with a wide spectrum of severity, from mild symptoms of influenza to severe respiratory distress. The morbidity and mortality connected to influenza are mostly associated with secondary bacterial infections. The influenza syndrome alone can cause a massive release of cytokines with dysregulation of the immune system, and it can act in synergy with other bacteria which can enhance cytokines secretion. This article deals with a case of severe pneumonia of H1N1 in a 17-year-old woman with bacterial superinfection with Staphylococcus aureus characterized by a high level of interleukine-6 (105900 pg/mL) and the appearance of severe leukopenia with immuno-suppression, such that HIV infection and hematological diseases were included in the initial differential diagnosis. After death, the autopsy confirmed the presence of severe pneumonia, in addition to an hepatic steatosis in absence of other risk factors. This case reports the rapid and lethal course of influenza A /H1N1 in a young and healthy subject without comorbidities, in an age group in which mortality is about 0.3 deaths per 100,000. The case underlines the importance of quickly diagnosis of viral infections and the differential diagnoses with other immunosuppressive diseases, which can be fatal even in adolescent and healthy subjects.

Prolonged iatrogenic thoracic duct chylous fistula in Neck Surgery: conservative management or surgery? A Literature review

BACKGROUND

Thoracic duct chylous fistula is a rare complication following neck surgery, especially for malignant disease. Despite its low incidence, it can be a life-threatening postoperative complication increasing the risk of infection, bleeding, hypovolemia, electrolyte imbalance, and malnutrition. Currently, the management of thoracic duct fistula is not standardized yet. It can range from conservative to surgical approaches, and even when surgery indication occurs, there is no unanimous agreement on timing and operative steps, so the surgical approach still remains mostly subjective, in accordance with clinical conditions of the patients and with surgeon's experience.

AIMS

The aim of the study was to search into Literature a common accepted behaviour in thoracic duct chylous fistula occurring.

METHODS

A literature review was carried out. Conservative treatments include fasting associated with total parental nutrition or low-fat diet, compressive dressings, and octreotide administration. If conservative treatment fails, in order to avoid dangerous consequences, functional repair of the thoracic duct injury with lymphovenous microanastomosis should be the preferred solution, rather than an approach that obliterates the thoracic duct or lymphatic-chylous pathways, such as thoracic duct embolization, therapeutic lymphangiography, and thoracic duct ligation.

CONCLUSIONS

In our experience, patients undergone thyroidectomy and neck dissection for thyroid-differentiated cancer, who report an unrecognized thoracic duct chylous fistula after surgery, must be treated via integrated conservative and surgical treatment. A literature review about thoracic duct chylous fistula following neck surgery, focusing on the current management and therapeutic approach, was furthermore carried out, in order to delineate the actual therapeutic options in case of thoracic duct chylous fistula occurrence.

A Literature Systematic Review with Meta-Analysis of Symptoms Prevalence in Covid-19: the Relevance of Olfactory Symptoms in Infection Not Requiring Hospitalization

PURPOSE OF REVIEW

To investigate the association between the olfactory dysfunction and the more typical symptoms (fever, cough, dyspnoea) within the Sars-CoV-2 infection (COVID-19) in hospitalized and non-hospitalized patients.

RECENT FINDINGS

PubMed, Scopus and Web of Science databases were reviewed from May 5, 2020, to June 1, 2020. Inclusion criteria included English, French, German, Spanish or Italian language studies containing original data related to COVID19, anosmia, fever, cough, and dyspnoea, in both hospital and non-hospital settings. Two investigators independently reviewed all manuscripts and performed quality assessment and quantitative meta-analysis using validated tools. A third author arbitrated full-text disagreements. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 11 of 135 studies fulfilled eligibility. Anosmia was estimated less prevalent than fever and cough (respectively rate difference = - 0.316, 95% CI: - 0.574 to - 0.058, Z = - 2.404, p < 0.016, k = 11 and rate difference = - 0.249, 95% CI: - 0.402 to - 0.096, Z = - 3.185, p < 0.001, k = 11); the analysis between anosmia and dyspnoea was not significant (rate difference = - 0.008, 95% CI: - 0.166 to 0.150, Z = - 0.099, p < 0.921, k = 8). The typical symptoms were significantly more frequent than anosmia in hospitalized more critical patients than in non-hospitalized ones (respectively [Q(1) = 50.638 p < 0.000, Q(1) = 52.520 p < 0.000, Q(1) = 100.734 p < 0.000).

SUMMARY

Patient with new onset olfactory dysfunction should be investigated for COVID-19. Anosmia is more frequent in non-hospitalized COVID-19 patients than in hospitalized ones.

Clinical risk management in High-Security Forensic Psychiatry Residences. Protecting patients and health professionals: perspectives and critical issues of the Law 81/2014

The Italian Law n. 9/2012 provided the Italian Regions with a new decisional role by demanding the management/rehabilitation of prisoners judged as partially/fully mentally ill to care and protection delivered by the psychiatric services of the Regional Health Service. Healthcare has to be guaranteed by the so-called High-Security Forensic Psychiatry Residences (Italian: Residenze per l'Esecuzione delle Misure di Sicurezza: REMS) and by community mental health centres. Ensuring patients' and professionals' health and safety is a complex issue which requires effective strategies to cope with several structural, technological, and organisational problems. The present paper summarises the historical evolution of the Italian laws towards the development of the High-Security Forensic Psychiatry Residences in Italy, focusing specifically on the Tuscany Region situation. The paper also presents the key issues emerging after the implementation of the Law 81/2014 which complemented the Law 9/2012. Since these reforms included the need for assessing to what extent the patient may be considered as a danger to society and for ensuring the safety of National Health Service (NHS) professionals, they underscored the importance of a preventive use of specific clinical governance tools aimed to reduce risk of adverse events. The present work has the strength of proposing a new, evidence-based scientific approach to the implementation of assessment and care pathways in High-Security Forensic Psychiatry Residences.

Enhancing adherence to antipsychotic treatment for bipolar disorders. Comparison of mobile app-based psychoeducation, group psychoeducation, and the combination of both: protocol of a three-arm single-blinded parallel-group multi-centre randomised trial

Group Psychoeducation (PE) is an effective strategy to enhance adherence to antipsychotic treatment in Bipolar Disorders (BD). However, it requires attendance to weekly sessions during a period of about 6 months. This may impede its application for those patients living far from mental health centres, resulting inequality in access to evidence-based care. Therefore, there is an increasing need to find new efficient strategies to deliver and extend PE programs to a wider population of BD patients. Mobile apps are a cost-effective way to deliver PE. In the Italian healthcare context, no evidence about the use of apps is available. The current paper presents the protocol about the development of a smartphone app to deliver PE for BD and the protocol for a trial assessing its effectiveness. In euthymic BD patients, the study will compare the adherence rates to antipsychotics between PE delivered through Bipolar mobile Application (Bip.App), group PE and a combination of both, will investigate demographic, socio-cultural and clinical predictors of lower adherence in the arms, and will investigate whether PE combined with Bip.App is associated with lower risk of recurrence of (hypo)manic and depressive episodes than group PE alone, and assess the feasibility and satisfaction for Bip.App. Participants will be recruited from mental health centres and included if they are 18-65 year-old, have primary BD in the euthymic phase, they have been prescribed a second-generation oral antipsychotic as a maintenance/prophylactic therapy for at least 1 year, they have not undergone a structured protocol of PE for BD, they have access to a smartphone and sufficient competence in using it. Participants will be excluded if they have neurological disease, mental retardation or learning disability, psychosis, limited fluency in Italian. Adherence will be assessed through count pills, blood levels, and self-reported adherence. A single-blinded parallel-group superiority multi-centre randomised controlled trial design will be used.

Overview on surgical management of papillary thyroid microcarcinoma

Particular interest is now being given to the best treatment of papillary thyroid microcarcinoma (PTMC) due to its significantly increased incidence. PTMC typically shows indolent organic behavior but, in a low percentage of cases, it can express a relative aggressive behavior. Several risk factors have been shown to negatively influence the rate of regional recurrences and metastases such as tumor diameter, Romaage, sex, multifocality, capsular invasion, extracellular diffusion, lymph node metastases, histological variants, mutated Braf and incidentality. The identification of patients with aggressive PTMCs among the majority with low risk lesions is very important to plan an adequate clinical management, thus the most appropriate surgical treatment. The latter includes thyroid lobectomy and total thyroidectomy with central compartment lymphadenectomy, though several studies did not show statistically significant differences in terms of recurrence and mortality rates between the two techniques. At last, it seems crucial to better define those biological features able to improve selection making process of patients with PTMCs aiming to reserve more radical surgery to those patients carrying more aggressive clinicopathologic features and worse prognosis.

Papillary thyroid microcarcinoma in super obese patient

Papillary thyroid microcarcinoma (PTMC) typically has an indolent behavior with a good prognosis but it is not always completely harmless. Surgical treatment varies from thyroid lobectomy to total thyroidectomy eventually associated with lymph node dissection and radioiodotherapy. The ability to identify patients with aggressive PTMCs from the majority of low risk patients is critical to planning proper clinical management. Several studies don't report any statistically significant differences about recurrence and mortality among patients undergone lobectomy and patients undergone total thyroidectomy. Recently, higher body mass index (BMI) has been associated with aggressive pathologic features of papillary thyroid carcinoma. For differentiated thyroid cancers, an elevated BMI has been linked to a higher incidence of thyroid cancer in some cohorts. The risk factors for a more aggressiveness of PTMC don't yet clearly defined such as their biological features enable to condition the surgical treatment. In order to elucidate the precise mechanism contributing to the relationship between obesity and thyroid cancer aggressiveness, future studies must be performed.

Workers safety in public psychiatric services: problems, laws and protections

The dramatic case of murder of a psychiatrist during her service in her public office (Centro di Salute Mentale of Bari-Libertà) has led the authors to reflect on the safety of workplaces, in detail of public psychiatric services. It is in the light of current legislation, represented by the Legislative Decree of April 9th, 2008 no. 81, which states the implementing rules of Law 123/2007. In particular, the Authors analyzed the criticalities of the application of this Law, with the aim of safeguarding the health and safety of the workers in all psychiatric services (nursing departments, outpatient clinics, community centers, day care centers, etc.). The Authors suggest the need to set up an articulated specific organizational system of risk assessment of psychiatric services, that can prevent and protect the workers from identified risks, and finally to ensure their active participation in prevention and protection activities, in absence of which specific profiles of responsibility would be opened up to the employers.

Autologous chondrocytes implantation: indications and results in the treatment of articular cartilage lesions of the knee

Articular cartilage lesions of the knee constitute a frequent event and one that is difficult to treat. In time, different surgical methods have been used with results that are often contradictory. The authors report the indications and results of different methods used in the treatment of cartilage lesions: in particular, the experience initiated in 1997 with autologous chondrocytes implantation is discussed. Between 1997 and 2000, a total of 40 patients were submitted to autologous chondrocytes implantation injected in suspension under a periosteal flap. This method includes wide exposure of the joint lesion by arthrotomy. Between 1999 and 2001, a total of 30 patients were submitted to autologous chondrocytes implantation using a tridimensional matrix. The availability of biomaterial simplified the implant method and made arthroscopy possible. All of the patients were submitted to serial clinical follow-ups. MRI was also conducted for a second arthroscopic look. The results obtained in both series after a mean follow-up of 4 years (range 2 to 6 years) are good, and confirm the effectiveness of the method that allows for complete morphological and structural repair of lesions of the joint cartilage.

Hip prosthesis revisions with LS stem: indications and results

The authors present a study that includes 350 patients affected with loosening of hip arthroplasty and submitted to revision with a Wagner LS stem at the 4th Division of the Rizzoli Orthopaedic Institute. Several different types of cotyle (Fitek, Wagner, Standard Cup, cemented cotyle with support ring, Octopus system) were used depending on the anatomopathologic findings, combined with autoplastic grafts. Staging and grading of loosening were based on the four G.I.R. grades. A clinical evaluation of results was based on the Merle D'Aubigné parameters modified by Charnley. For radiographic evaluation the De Lee Charnley areas were studied for cotyle, the Gruen areas for the femoral stem. Overall, good results were obtained in 175 patients, fair in 137, poor in 38.

Microsynteny between the Medicago truncatula SYM2-orthologous genomic region and another region located on the same chromosome arm

A synteny based positional cloning approach was started to clone the pea SYM2 gene by using locally conserved genome structure with the model plant Medicago truncatula. We reported that a pea marker tightly linked to SYM2 was used to screen a M. truncatula BAC library, and two contigs named C1/C2 and C3 were constructed that are both located on the long arm of M. truncatula chromosome 5 and separated by 9 cM. C1/C2 is highly microsyntenic to the pea SYM2 genomic region and corresponds to the M. truncatula SYM2-orthologous region, which is delimitated to 350 kbp. In this manuscript we analyze the distribution in the three contigs of 22 sequences and their homologues, including eight C1/C2 and two pea RFLP markers linked to SYM2. Among the analyzed sequences are several different (receptor) kinase-like gene sequences and two classes of LRR-containing resistance protein-like sequences. From all the studied sequences only four detected homologous sequences in C3, and their distribution is comparable in C1/C2 and C3, suggesting that a 70-kbp and a 120-kbp segments of these two contigs, respectively, arose through a duplication. The implications of these findings for the cloning of SYM2 are discussed.

The results of the surgical treatment of 64 patients with thoracic and lumbar fracture

A total of 64 patients surgically treated for vertebral fractures were evaluated clinically and radiographically after a mean time of 49.55 months (from 1 to 124). There were 50 males and 14 females. Mean age at the time of surgery was 40.67 years (from 17 to 71). Fractures were divided based on the Denis classification system: comminuted fractures: 45; fractures caused by flexion-distraction: 2; fracture-dislocation: 17; 31 of the fractures were localized at the lumbar level, 30 in the dorsal region, 3 at the dorsolumbar passage. Neurologic evaluation was carried out on admission and at follow-up using the Frankel classification system: type A: 22; type B: 13; type C: 7; type D: 6; type E: 16. 56.25% of the patients (36 cases) were classified as having multiple trauma. Of the 64 patients, 38 had reduction and stabilization within 6 hours of trauma, 26 were treated after a mean time of 2.7 days (from 1 to 6). Harrington-Luque stabilization was carried out in 5 patients, using the Hartshill rectangle in 59. The mean time for hospitalization was 27.68 days (from 9 to 91). Follow-up showed neurologic recovery in all of the patients operated on, with the exclusion of those classified as Frankel A, without sacral sparing. Despite the residual kyphosis and the final anatomic findings which were not always satisfactory, the methods used allowed us to obtain results that could be compared to those obtained by other means of fixation and more complex techniques.

Hip arthroplasty in coxarthrosis secondary to Paget's disease

A total of 5 hip arthroplasties implanted between 1997 and 2000 in 5 patients affected with coxarthrosis secondary to Paget's disease were reviewed. The quality of the pagetic bone (sclerotic and very vascularized) resulted in a slightly longer amount of time required for surgery because of the difficulty preparing prosthetic placement and intra- and postoperative blood loss exceeding the norm. Complications were not observed. Clinical results were good in 100% of cases. Radiographically, 2 stems were assembled in varus.

Comparison of a new bisphenol-a-glycidyl dimethacrylate-based cortical bone void filler with polymethyl methacrylate

A newly formulated and reinforced bisphenol-a-glycidyl dimethacrylate (bis-GMA) resin (Cortoss/Orthovita, Malvern, Pa.) was compared with Simplex P polymethyl methacrylate (Stryker Howmedica Osteonics, East Rutherford, N.J.) in rabbits for up to 52 weeks and in sheep for up to 78 weeks. As seen in scanning electron microscopy and histology examinations, both implant materials were surrounded by bone at late time periods, with fibrous layers of connective tissue seen in half the Simplex P specimens. No clinically significant safety differences between implant materials were apparent. Interfacial bond strengths between the implant and bone generally increased with time, but were 4.5-fold greater with Cortoss than Simplex P at 24 weeks, and 100-fold greater at 52 weeks. Forces required to displace 316SS rods held in place with Cortoss were consistently greater than forces to displace rods held in place with Simplex P. No statistically significant differences in displacement forces were found between rods held in place with Cortoss polymerized in situ and rods held with prepolymerized Cortoss. Interfacial bond strengths were greater for Simplex P that was polymerized in situ than for prepolymerized polymethyl methacrylate specimens. Cortoss synthetic cortical bone void filler is a good candidate material to fix implants in bone. It has characteristics consistent with long-term safety and has a better ability to bond to bone than Simplex P.

Effects of temporins on molecular dynamics and membrane permeabilization in lipid vesicles

Temporins are a novel family of small (10-13 residues) cationic antimicrobial peptides recently isolated from the skin of the European red frog Rana temporaria. Although recently acquired evidence shows that temporins have the potential to kill bacteria by permeabilizing the cytoplasmic membrane, the molecular mechanisms of membrane selectivity and permeabilization are largely unknown. In this study, it was found that temporins cause the release of fluorescent markers entrapped in phosphatidylcholine liposomes in a manner that depends significantly on the size of the solute. Temporins were also shown to lack a detergent-like effect on lipid vesicles, indicating that marker leakage caused by these peptides is not due to total membrane disruption but to perturbation of bilayer organization on a local scale. Binding of temporins to liposomes did lead to a small increase in lipid hydrocarbon chain mobility, as revealed by EPR spectroscopy of nitroxide-labeled fatty acids incorporated in the bilayer. Reference experiments were conducted using the bee venom peptide melittin, whose properties and behavior in natural and model membrane systems are well known. Our findings for temporins are discussed in relation to the models proposed to date to account for the action of antimicrobial peptides on membranes.

The Chernobyl accident: EPR dosimetry on dental enamel of children

The radiation dose on tooth enamel of children living close to Chernobyl has been evaluated by EPR. The sample preparation was reduced to a minimum of mechanical steps to remove a piece of enamel. A standard X-ray tube at low energy was used for additive irradiation. The filtration effect of facial soft tissue was taken into account. The radiation dose for a group of teeth slightly exceeds the annual dose, whereas for another group the dose very much exceeds the annual dose. Since the higher dose is found in teeth whose enamel have much lower EPR sensitivity to the radiation, it can be suggested that for these teeth the native signal could alter the evaluation of the smaller radiation signal.

Integration of the FISH pachytene and genetic maps of Medicago truncatula

A molecular cytogenetic map of Medicago truncatula (2n = 2x = 16) was constructed on the basis of a pachytene DAPI karyogram. Chromosomes at this meiotic prophase stage are 20 times longer than at mitotic metaphase, and display a well differentiated pattern of brightly fluorescing heterochromatin segments. We describe here a pachytene karyogram in which all chromosomes can be identified based on chromosome length, centromere position, heterochromatin patterns, and the positions of three repetitive sequences (5S rDNA, 45S rDNA and the MtR1 tandem repeat), visualized by fluorescence in situ hybridization (FISH). We determined the correlation between genetic linkage groups and chromosomes by FISH mapping of bacterial artificial chromosome (BAC) clones, with two to five BACs per linkage group. In the cytogenetic map, chromosomes were numbered according to their corresponding linkage groups. We determined the relative positions of the 20 BACs and three repetitive sequences on the pachytene chromosomes, and compared the genetic and cytological distances between markers. The mapping resolution was determined in a euchromatic part of chromosome 5 by comparing the cytological distances between FISH signals of clones of a BAC contig with their corresponding physical distance, and showed that resolution in this region is about 60 kb. The establishment of this FISH pachytene karyotype, with a far better mapping resolution and detection sensitivity compared to those in the highly condensed mitotic metaphase complements, has created the basis for the integration of molecular, genetic and cytogenetic maps in M. truncatula.

Interlaboratory reproducibility of standard accelerated aging methods for oxidation of UHMWPE

During accelerating aging, experimental uncertainty may arise due to variability in the oxidation process, or due to limitations in the technique that is ultimately used to measure oxidation. The purpose of the present interlaboratory study was to quantify the repeatability and reproducibility of standard accelerated aging methods for ultra-high molecular weight polyethylene (UHMWPE). Sections (200 microm thick) were microtomed from the center of an extruded rod of GUR 4150 HP, gamma irradiated in air or nitrogen, and circulated to 12 institutions in the United States and Europe for characterization of oxidation before and after accelerated aging. Specimens were aged for 3 weeks at 80 degrees C in an air circulating oven or for 2 weeks at 70 degrees C in an oxygen bomb (maintained at 503 kPa (5 atm.) of O2) in accordance with the two standard protocols described in ASTM F 2003-00. FTIR spectra were collected from each specimen within 24 h of the start and finish of accelerated aging, and oxidation indices were calculated by normalizing the peak area of the carbonyl region by the reference peak areas at 1370 or 2022 cm(-1). The mean relative interlaboratory uncertainty of the oxidation data was 78.5% after oven aging and 129.1% after bomb aging. The oxidation index measurement technique was not found to be a significant factor in the reproducibility. Comparable relative intrainstitutional uncertainty was observed after oven aging and bomb aging. For both aging methods, institutions successfully discriminated between air-irradiated and control specimens. However, the large interinstitutional variation suggests that absolute performance standards for the oxidation index of UHMWPE after accelerated aging may not be practical at the present time.

Evaluation of the effects of extremely low frequency electromagnetic fields on mammalian follicle development

The aim of this study was to evaluate the effects of pulsed, extremely low-frequency electromagnetic fields (ELF-EMF) on in-vitro mouse pre-antral follicle development. Pre-antral follicles were cultured for 5 days and exposed to ELF-EMF at the frequencies of 33 or 50 Hz. ELF-EMF application did not affect follicular growth over a 3 day culture period, but on day 5 the growth of 33 Hz-exposed follicles was significantly reduced when compared with controls, while the 50 Hz-exposed follicles were not significantly affected. However, ELF-EMF severely impaired antrum formation at both frequencies, as 79 +/- 3% of control follicles developed antral cavities compared with 30 +/- 6% and 51.6 +/- 4% of 33 or 50 Hz-exposed follicles respectively. The follicles with failed antrum formation showed lower oestradiol release and granulosa cell DNA synthesis, but these effects were not related to granulosa cell apoptosis. Furthermore, a high percentage of the in-vitro grown oocytes obtained from exposed follicles had a reduced ability to resume meiotic maturation when compared with controls. These results suggest that ELF-EMF exposure might impair mammalian female reproductive potentiality by reducing the capacity of the follicles to reach a developmental stage that is an essential pre-requisite for reproductive success.

EPR imaging from projections: errors due to misalignment of projection centres and their rectification by a novel acquisition modality

Continuous wave and pulsed wave electron paramagnetic resonance imaging (EPRI) makes use of classical methods of acquisition of projections. Acquisition/reconstruction techniques, such as spin-echo, gradient-echo, etc, cannot be applied to EPRI because they would require very short switching times for the gradient coils. Due to the use of the polar acquisition technique, it is necessary to define a centre of rotation about which the measured projections are rotated during the reconstruction process. This centre represents the point at which the field gradient coils must produce zero magnetic field. Due to the presence of a magnetic field control system that serves to compensate for field variations, principally due to heating, some interference can occur in the control system between the main magnetic field and the magnetic field produced by the gradient coils. The effect changes as the orientation changes. This results in a shift of the centres of the projections as a function of the variation of magnetic field produced by the gradient coils on the control Hall probe. If this condition is present, some artefacts can appear on the reconstructed image. This effect is irrelevant when EPR is used for imaging of paramagnetic probes whose linewidths are of the order of 10(-4) T, while it can be significant in the case of linewidths of the order of 10(-5) T or lower or when EPR is used in microimaging applications (i.e. for high values of magnetic field gradient). We describe the effects that misalignments of the projections have on the reconstructed images. We present a useful method for estimating the real position of the centre and correcting the measured projections before the application of the reconstruction algorithm. Moreover, we demonstrate the functioning of our technique by presenting some examples of EPR reconstruction collected by an X-band EPR imaging apparatus.

Sister chromatid exchange in patients with joint prostheses

The evaluation of sister chromatid exchanges (SCE) is used to establish the cytogenic damage in subjects exposed to toxic substances. The test is considered to be 1 of the most sensitive and accurate indicators of damage and responds to toxic chemicals at low doses. We evaluated the incidence of SCE in peripheral lymphocytes of patients with articular prostheses. Subjects with prostheses made of titanium-aluminium-vanadium alloys presented a significantly higher SCE number than the control population (6.3+/-2.3 vs 4.4+/-1.3; P = .0128), whereas subjects with prostheses made of chrome-cobalt alloy or mixed prostheses presented a higher SCE value than the controls but not significantly different. The presence of high-frequency cells was alarming only in 5 patients, 4 of whom had titanium alloy prostheses, whereas none belonged to the control group. The number of SCE was not affected by the presence of bone-cement used in prosthesis fixation or by the implant duration. The indication of possible cytogenic damage in patients with titanium alloy prostheses that emerged from this study should be considered carefully, even though the sample population was small.

Osteoblasts and stromal cells isolated from femora in rheumatoid arthritis (RA) and osteoarthritis (OA) patients express IL-11, leukaemia inhibitory factor and oncostatin M

We investigated both in vitro and ex vivo the role of mature osteoblasts (OB) and bone marrow stromal cells (BMSC) in RA and OA by analysing the expression of the following IL-6-type cytokines: IL-11, leukaemia inhibitory factor (LIF), oncostatin M (OSM) and IL-6. OB and BMSC were isolated from femora of RA, OA and post-traumatic (PT) patients, cultured in vitro in the presence or absence of IL-1beta and tumour necrosis factor-alpha (TNF-alpha), and assessed for the production and mRNA expression of IL-6-type cytokines. Trabecular bone biopsies were obtained from the inner portions of femoral heads and used for cytokine in situ immunostaining. Cultured OB and BMSC from different patients constitutively secreted IL-11 and IL-6 but not OSM. LIF was secreted only by BMSC, at very low levels. Interestingly, IL-11 basal production was significantly higher in BMSC than in OB in all three groups tested. IL-1beta and TNF-alpha strongly stimulated IL-6-type cytokine release (except for OSM) by both OB and BMSC. OSM was expressed only at mRNA levels in all groups studied. Cytokine immunostaining on bone biopsies confirmed the data obtained on cultured cells: IL-11, IL-6 and LIF proteins were detected both in mesenchymal (BMSC and OB) and mononuclear cells; OSM was found only in mononuclear cells. These data demonstrate that IL-6-type cytokines are constitutively expressed in the bone compartment in RA, OA and PT patients and can be secreted by bone cells at different stages of differentiation (BMSC and OB). This suggests that these cytokines may be involved in the mechanisms of bone remodelling in OA and RA.

The evolution of nodulation

In this review we will first describe the different steps leading to nodule formation, and these will be compared with processes of non-symbiotic plant development and growth. In general, aspects of both actinorhizal as well as rhizobial symbiosis are described, but in several cases, the emphasis will be on the Rhizobium-legume symbiosis because more knowledge of this system is available. Subsequently, the phylogeny of nodulating plants is described and a comparison is made between several aspects of legume and actinorhizal nodulation. At the end of this paper the relationship between nodule symbiosis and endomycorrhizal symbiosis is described, and it is discussed to what extent the development of root nodules involves unique properties, or whether processes and genes have been recruited from common plant development and the endomycorrhizal symbiosis.

Chemokine production by human chondrocytes

OBJECTIVE

To evaluate the role of chondrocytes in producing CXC chemokines [interleukin 8 (IL-8), growth related gene product (GRO-alpha)] and CC chemokines [monocyte chemoattractant protein (MCP-1), macrophage inflammatory protein (MIP-1alpha), RANTES] in patients with rheumatoid arthritis (RA) and osteoarthritis (OA) and subjects after traumatic injury (PT).

METHODS

Articular cartilage specimens were obtained from 38 patients with OA and 18 with RA undergoing joint replacement surgery. Healthy human cartilage was obtained from femoral condyles removed after trauma in 11 subjects with no history of joint pathology (PT cases). Chondrocytes were isolated from articular cartilage by sequential enzymatic digestion and cultured in vitro. Chemokine production was investigated in unstimulated condition and after 72 h incubation with proinflammatory [IL-1beta, tumor necrosis factor-alpha (TNF-alpha)] and antiinflammatory [transforming growth factor-beta1 (TGF-beta1), IL-10] mediators. Chemokine concentrations in cell supernatants were evaluated by ELISA.

RESULTS

Chondrocytes produce all these chemokines to a different extent. IL-1beta was a more potent stimulus than TNF-alpha in inducing production of all chemokines except MCP-1. We found no statistical differences among chondrocytes isolated from OA, RA, and PT for chemokine production in either basal conditions or after cytokine stimulation. IL-1beta induced chemokine production can be modulated by TGF-beta1 in different ways according to the various chemokines, while IL-10 does not affect IL-1beta induced chemokine production.

CONCLUSION

Chondrocytes produce IL-8, GRO-alpha, MCP-1, MIP-1alpha, and RANTES. Proinflammatory factors (IL-1beta, TNF-alpha) effectively upregulate chemokine production, but production is scarcely modulated by the antiinflammatory mediators TGF-beta and IL-10. Chondrocyte derived chemokines may play a role in triggering the mechanisms involved in pathogenesis and persistence of joint diseases.

Geometry of proximal femur in the prediction of hip fracture in osteoporotic women

111 White post-menopausal women with hip fracture and 329 healthy controls were studied in order to determine whether proximal femur geometry predicts hip fracture and improves the discriminant ability of femoral neck bone mineral density (BMD) in elderly women. All subjects underwent dual X-ray photon absorptiometry (DXA) of the hip from which the femoral neck BMD, hip axis length, femoral neck width and femoral neck-shaft angle were measured. Fractured subjects had a lower femoral neck BMD, a longer hip axis length and a more valgus neck-shaft angle. The hip axis length correlated significantly with neck-shaft angle, femoral neck width and age. No significant correlation was found between neck-shaft angle and age. On standardized logistic regression, the hip axis length and the neck-shaft angle predicted fracture independently of BMD after correction for age, weight and femoral neck BMD. The femoral neck BMD significantly discriminated fractured subjects after correction for all potential confounders. The logistic models containing simultaneously one femoral geometric parameter and the neck BMD discriminated significantly better than those containing the same variables as single predictor. Our data suggest that hip axis length may play a role in fracture risk and supports a similar role for neck-shaft angle. Combining proximal femur geometric measurements and femoral neck BMD improved the discriminant ability of each measurement.

Preliminary results in 167 bioceramic cemented arthroplasties with five-year follow-up in patients aged 60 years or over

A total of 167 ceramic-ceramic cemented arthroplasties with a mean follow-up of 62.5 months were evaluated. There were no signs of loosening in the femoral components. Loosening of the acetabulum was observed in 5 patients. A statistical study conducted on the two groups (the first aged under 70 years, the second aged 70 or over) did not reveal any relationship between failure of the acetabular component and the age of the patient. An evaluation of bone density based on the DXA system in 5 cases of loosening revealed its diminution in relation to follow-up parameters. Based on our experience, implantation of the ceramic-ceramic cemented prosthesis is a reliable choice in patients with good bone trophism, in those where there is a significant reduction in bone density; it is best to use polyethylene-ceramic implants.

[Use of Electronic Spin Resonance in the study of dental enamel caries. Preliminary results]

BACKGROUND

By means of the Electron Spin Resonance technique (EPR) it is possible to detect carbonate-related paramagnetic centers in human tooth enamel. Several arguments indicate that the radicals formed after X-ray irradiation (CO2- and CO3(3-)) are ascribed to carbonate which is the most important constituent of hydroxyapatite. There is experimental evidence that the distribution of the orientation of these centers is related to microcrystal alignment in dental enamel, which might be responsible for caries susceptibility. The results reported in the literature, however, should be interpreted very carefully.

METHODS

In our own preliminary research we studied twenty-seven samples of dental enamel taken from the buccal face of upper molars. Fifteen were carious and the other ones were sound. We used the R-parameter and the S-parameter to convert our experimental results into numerical values. The R-parameters, as introduced by Cevc et al. (1976-1980) is the ratio of the amplitude for the high field and the low component of the EPR signal. The S-parameter is the ratio of the amplitude of the A2 component and the low one.

RESULTS

No significant difference was found between the R and S-value of carious and sound dental enamel samples. The degree of microcrystal alignment in enamel of clinically sound upper molar from their buccal site is very high. However, this result is not sufficient to evaluate the caries susceptibility or the caries resistance of tooth enamel.

CONCLUSIONS

Therefore, we can conclude that it is not sufficient to ascribe the caries susceptibility to the R-value, because other factors (such as etiological factors and the structure of the teeth) should be considered.

Anterior uveitis associated with Mycoplasma pneumoniae pneumonia: a case report

The authors report a case of bilateral uveitis following Mycoplasma pneumoniae pneumonia verified by IgM and rising IgG antibodies against the organism. Uveitis is a rare manifestation of Mycoplasma pneumoniae pneumonia and since it is a common pathogen, it should be considered in the differential diagnosis, even in the absence of respiratory symptoms or neurological findings. Immunobiological hypotheses are briefly discussed.

Chemokine expression by subchondral bone marrow stromal cells isolated from osteoarthritis (OA) and rheumatoid arthritis (RA) patients

We analysed the spontaneous and cytokine-stimulated production and expression in vitro of IL-8, GROalpha, MCP-1, RANTES, MIP-1alpha, MIP-1beta, by subchondral bone marrow stromal cells (BMSC) isolated from RA, OA, post-traumatic (PT) patients and normal donors (ND). BMSC were cultured in vitro in the presence or absence of IL-1beta and tumour necrosis factor-alpha (TNF-alpha), and assessed for chemokine production, expression and immunolocalization. BMSC from different sources constitutively released MCP-1, GROalpha and IL-8, but not MIP-1alpha or MIP-1beta, while BMSC from ND constitutively released only IL-8 and MCP-1. IL-8, GROalpha and RANTES production in basal conditions was significantly higher in RA patients than in ND. RANTES production was also higher in OA and RA than in PT patients. The combination of TNF-alpha and IL-1beta synergistically increased the production of all chemokines tested except for RANTES. Reverse transcriptase-polymerase chain reaction (RT-PCR) demonstrated that all chemokines not detectable in the supernatants were expressed at the mRNA level. Chemokine immunostaining was localized around the nuclei. This work demonstrates that BMSC from subchondral bone produce chemokines and indicates that these cells could actively participate in the mechanisms directly or indirectly causing cartilage destruction and bone remodelling.

Proinflammatory cytokines and chemokine production and expression by human osteoblasts isolated from patients with rheumatoid arthritis and osteoarthritis

OBJECTIVE

To evaluate whether subchondral osteoblasts (OB) are involved in the production of cytokines and chemokines in rheumatic diseases.

METHODS

OB were isolated from subchondral bone of rheumatoid arthritis (RA), osteoarthritis (OA) and post-traumatic (PT) patients, cultured in vitro in the presence or absence of interleukin 1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha), and assessed for the production, immunolocalization, and mRNA expression of proinflammatory cytokines (IL-1alpha, IL-1beta, TNF-alpha) and alpha and beta chemokines [IL-8, growth related gene product (GRO-alpha), monocyte chemoattractant protein 1 (MCP-1), RANTES, and macrophage inflammatory proteins MIP-1alpha, MIP-1beta].

RESULTS

Cultured OB from different patients did not release IL-1alpha, IL-1beta, or TNF-alpha, and constitutively secreted IL-8, GRO-alpha, and MCP-1, while RANTES, MIP-1alpha, MIP-1beta were undetectable or near the lower level of sensitivity of the immunoenzymatic assay. GRO-alpha was significantly higher in RA than in OA and PT patients. IL-1beta and TNF-alpha alone or in combination strongly stimulated chemokine release by OB. Only RANTES production was not increased by the combination of the 2 cytokines. IL-1alpha, IL-1beta, and TNF-alpha were expressed as cytoplasmic proteins and were not secreted by OB even after stimulation.

CONCLUSION

OB from subchondral bone release chemokines that could be involved in the mechanisms that directly or indirectly cause bone remodelling and cartilage destruction.

Ilizarov external fixation in the treatment of comminuted leg fractures

Fifty consecutive comminuted leg fractures were treated by Ilizarov external fixation. Eleven were closed fractures, 37 were Grade II, and 2 were Grade III open fractures. Forty-five fractures healed within 6 months. In 5 fractures the Ilizarov device was removed and healing occurred by intramedullary nailing (2 cases) and decortication (3 cases). The causes of failure were: rapid peroneal union or bone fragment necrosis. Subjective tolerance and fracture stability are limited by septic loosening of the wires requiring frame removal after 6 to 8 months. Excellent results may be obtained (no leg length discrepancy, no angulation, no rotation, no joint stiffness), but the time required for union is long and additional surgery is required.

Loss of bone mass after total hip replacement: preliminary data

In a total of 37 females with cemented total hip replacement for monolateral coxarthrosis, of which 13 with prosthetic stem loosening, and 11 with monolateral coxarthrosis that is not prosthetized, bone mineral density (BMD) is determined by dual ray photonic absorbimetry selecting regions of interest (ROI) on the cortex of the femurs 4 cm under the lesser trochanter and on the ischium bilaterally. In females that are not prosthetized there are differences in bone mass between the two femurs and the ischium on both sides. In prosthetized patients BMD of the femur and of the ischium on the side operated on is significantly less than on the contralateral one (Student's "t" test: p < 0.001). In patients with stable prostheses, BMD of the femur operated on is greater than that in females with prosthetic stem loosening (Student's "t" test: p < 0.000). Based on a comparison between these two groups we did not observe any other significant differences in BMD among the ROI analyzed. BMD was correlated with the amount of time since surgery only in the ROIs in prosthetized femurs. The study confirms the significant bone resorption of the cortex in prosthetized femurs and documents analogously significant reduction in BMD in the ischium on the side operated on. Finally, it indicates that prosthetic stem loosening may be associated with loss of BMD in the femoral cortex which is significantly greater than that observed, during analogous periods of time in stable implants.

Simultaneous densitometry and quantitative bone sonography in the estimation of osteoporotic fracture risk

759 post-menopausal women (41-80 years old), 175 with and 584 without vertebral fracture, were studied by quantitative bone sonography and densitometry of the distal radius in order to evaluate the ability of ultrasound transmission velocity (UTV) to separate fractured from healthy women independently of bone mineral density (BMD) and to test the possibility of improving the discriminant ability of BMD by the simultaneous use of UTV. A second BMD measurement was made at the mid radial shaft. Both BMD and UTV were higher in healthy subjects than in fractured women; the latter being older, shorter and having a longer postmenopausal status. On logistic regression, standardized for 1 SD from the mean value of healthy women, UTV differentiated between healthy and fractured subjects after correction for BMD. UTV was also a significant predictor of fracture in a selected subgroup of healthy and fractured women paired for BMD (144 pairs). In this same subgroup, the difference in UTV between fractured and healthy women regression lines was related to elasticity (E) variation between pairs. Simultaneously evaluating BMD and UTV as fracture predictors, logistic regression showed an odds ratio that was twice that of each predictor alone and 1.2 times higher than that derived from the simultaneous evaluation of two different BMD predictors. These data confirmed that UTV differentiates between healthy and fractured women both as well as and independent of BMD. In addition, UTV separated fractured from healthy BMD matched women by measuring non mass related differences. The simultaneous use of BMD and UTV improved the discriminant ability of each of them alone and of two simultaneous measurements of BMD detected at different skeletal sites.

Structural characterization of human glyoxalase II as probed by limited proteolysis

Human glyoxalase II is partially proteolyzed by trypsin, under non denaturing conditions, only at the level of the C-terminal region. The proteolytic cleavage resulted in an inactivation of the enzyme without loss of the secondary structure. Sodium dodecyl sulphate polyacrylamide gel-electrophoresis and microsequence analysis showed that the glyoxalase II is proteolyzed at the level of Arg 184 and Lys 230 and undergoes a third cleavage in a region located at the beginning of the supposed C-terminal domain. The proteolysis occurs either in the presence or in the absence of specific inhibitors. Our limited proteolysis experiments and secondary structure prediction give evidence for the presence of two domains characterized by different pattern of secondary structure.

The efficacy of noninvasive mechanical ventilation on nocturnal hypoxaemia in Duchenne's muscular dystrophy

The aim of this 2 yr follow-up study was to evaluate the efficacy of nocturnal noninvasive mechanical ventilation in a group of 10 Duchenne's muscular dystrophy (DMD) patients who desaturated during the night but had normal daytime blood gases: mean (range) age 18.3 (15-22) yrs; mean (SD) vital capacity (VC) 752.5 (460-1,308) mL; mean time in bed (TIB) with arterial oxygen saturation (Sa,O2) < 90% 22.8% of total TIB (range: 16.6-32.0); mean arterial oxygen tension (Pa,O2) 10.3 (9.3-11.7) kPa (78 (70.0-87.8) mmHg); mean arterial carbon dioxide tension (Pa,CO2) 5.9 (4.8-6.5) kPa (44.3 (36.3-48.5) mmHg). All the patients were noninvasively ventilated during the night with a bilevel positive pressure ventilation (BiPAP) devise in spontaneous mode in order to correct the episodes of nocturnal desaturation. Nocturnal Sa,O2 values normalized during nocturnal noninvasive mechanical ventilation, and daytime sleep-disordered breathing disappeared, for the entire study period. No statistically significant differences were observed between baseline and follow-up daytime blood gas values, although a slight increase in Pa,O2 was found. During the follow-up, VC declined at a rate of 79.1 +/- 25 mL.yr-1, less than that generally reported in the past in untreated patients in the same age range. In conclusion, our data suggest that patients with advanced Duchenne's muscular dystrophy with pronounced nocturnal desaturation, not fulfilling criteria for imperative ventilation, could be successfully treated with "elective" nocturnal ventilation with immediate benefits consequent to the correction of the nocturnal blood gas anomalies and with long-term benefits related to the preservation of residual respiratory function, delay of development of chronic hypercapnia and thus the requirement for imperative mechanical ventilation.

Knee prosthesis in rheumatoid patients

Total knee arthroplasty is a reliable means to improve the quality of life not only in osteoarthritis, but also in rheumatoid patients. Specific aspects, like the low mechanical quality of bone tissue, the contemporary damage of several joints and the higher risk of complications, have to be taken into account in rheumatoid arthritis. The experience with 24 prostheses in 21 rheumatoid patients is reported and confirms the efficacy of this operation. Among the technical details discussed, stress is placed on the conservation of the posterior cruciate ligament, the use of cement, the procedure of patelloplasty instead of prosthetic replacement. Careful preoperative planning is required and resections, especially in the tibia, should be economical. The evaluation of the results according to the protocol of the America Knee Society shows a satisfactory increase both of the articular score (average from 36 to 88) and the functional score (average from 34 to 68).