Systematic review of response criteria and endpoints in autoimmune hepatitis by the International Autoimmune Hepatitis Group

BACKGROUND & AIMS

Autoimmune hepatitis (AIH) has been well characterised and codified through the development of diagnostic criteria. These criteria have been adapted and simplified and are widely used in clinical practice. However, there is a need to update and precisely define the criteria for both treatment response and treatment.

METHODS

A systematic review was performed and a modified Delphi consensus process was used to identify and redefine the response criteria in autoimmune hepatitis.

RESULTS

The consensus process initiated by the International Autoimmune Hepatitis Group proposes that the term 'complete biochemical response' defined as 'normalization of serum transaminases and IgG below the upper limit of normal' be adopted to include a time point at 6 months after initiation of treatment. An insufficient response by 6 months was a failure to meet the above definition. Non-response was defined as '<50% decrease of serum transaminases within 4 weeks after initiation of treatment'. Remission is defined as liver histology with a Hepatitis Activity Index <4/18. Intolerance to treatment was agreed to stand for 'any adverse event possibly related to treatment leading to potential drug discontinuation'.

CONCLUSIONS

These definitions provide a simple and reproducible framework to define treatment response and non-response, irrespective of the therapeutic intervention. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable inter-study comparisons. Future prospective database studies are needed to validate these endpoints.

LAY SUMMARY

Consensus among international experts on response criteria and endpoints in autoimmune hepatitis is lacking. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable the comparison of results between clinical trials. Therefore, the International Autoimmune Hepatitis Group (IAIHG) herein presents a statement on 5 agreed response criteria and endpoints: complete biochemical response, insufficient response, non-response, remission, and intolerance to treatment, which can be used to guide future reporting.

Increase of renal resistive index and mineral metabolism disorder in patients with acute coronary syndrome with preserved renal function

OBJECTIVE

Coronary artery disease is one of the first causes of death in the Western world; for this reason, it is essential to identify new, systemic, non-invasive and low-cost cardiovascular risk markers. The acute coronary syndrome includes ST-Elevation Myocardial Infarction (STEMI) and Non-ST-Elevation Myocardial Infarction (NSTEMI), based on ECG findings. We aimed to evaluate Renal Resistive Index (RRI) as a marker of cardiovascular risk and assess the associations with other cardiovascular risk factors (metabolic indexes, mineral metabolism disorders and endothelial dysfunction and atherosclerosis markers) in STEMI and NSTEMI patients.

PATIENTS AND METHODS

Clinical, laboratory and instrumental examinations as metabolic and inflammation indexes, markers of atherosclerosis and endothelial dysfunction (renal function, mineral metabolism disorders, inflammation indexes, Intima Media Thickness (IMT), Ankle Brachial Pressure Index, Left Ventricular Mass Index, Relative Wall Thickness) were performed.

RESULTS

Eighty-one patients with STEMI and NSTEMI were enrolled. We showed a significant positive correlation between RRI and age (p<0.01), intact parathyroid hormone (p<0.01) and IMT (p<0.01), as well as a significant negative correlation between RRI and body surface area (BSA) (p=0.02), estimated Glomerular Filtration Rate (eGFR) (p<0.01), serum calcium (p<0.01) and 25-hydroxy-vitamin D (p=0.03). Moreover, we found a significant correlation between RRI and male patients (p<0.01), coronary artery disease history (CAD) (p=0.049), hypertension (p=0.025) and left ventricular eccentric hypertrophy (LVEH) (p=0.047).

CONCLUSIONS

Our study showed an association between RRI and the main traditional and non-traditional cardiovascular risk factors involved in atherosclerosis pathogenesis, such as age, BSA, hypertension, male sex, CAD history, mineral metabolism disorders and LVEH, in patients with preserved renal function. Moreover, we found a significant correlation between RRI and eGFR, suggesting that RRI could be useful in the evaluation of both renal function and progression of renal damage, even in an early stage with a conserved or only slightly reduced kidney function. We also showed a significant correlation with some markers of systemic atherosclerosis such as IMT and LVEH. For a more precise assessment of prognosis and cardiovascular risk in patients with high cardiovascular mortality, we suggest performing a systematic RRI evaluation, considering the non-invasive nature of the procedure, its reproducibility, easy execution, and low costs.

Diagnostic Approach to Acute Liver Failure in Children: A Position Paper by the SIGENP Liver Disease Working Group

Acute liver failure (ALF) is a clinical condition characterized by the abrupt onset of coagulopathy and biochemical evidence of hepatocellular injury, leading to rapid deterioration of liver cell function. In children, ALF has been characterized by raised transaminases, coagulopathy, and no known evidence of pre-existing chronic liver disease; unlike in adults, the presence of hepatic encephalopathy is not required to establish the diagnosis. Although rare, ALF has a high mortality rate without liver transplantation (LT). Etiology of ALF varies with age and geographical location, although it may remain indeterminate in a significant proportion of cases. However, identifying its etiology is crucial to undertake disease-specific management and evaluate indication to LT. In this position statement, the Liver Disease Working Group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) reviewed the most relevant studies on pediatric ALF to provide recommendations on etiology, clinical features and diagnostic work-up of neonates, infants and children presenting with ALF. Recommendations on medical management and transplant candidacy will be discussed in a following consensus conference.

Gastrointestinal symptoms and digestive comorbidities in an Italian cohort of patients with COVID-19

OBJECTIVE

The Coronavirus Disease 2019 (COVID-19) pandemic mainly involves respiratory symptoms, though gastrointestinal (GI) symptoms are increasingly being recognized. In this context, the presence of comorbidities appears to be associated with adverse outcomes. However, the role of digestive manifestations is not yet well defined. The primary aim of this study was to assess the prevalence of GI symptoms and digestive comorbidities in a cohort of patients with COVID-19 compared to controls. The secondary aim was to determine the association of GI-symptoms and digestive comorbidities with clinical outcomes.

PATIENTS AND METHODS

Inpatients with COVID-19 and controls with similar symptoms and/or radiological findings were enrolled. Symptoms at admission and throughout hospitalization were collected as they were comorbidities. The measured clinical outcomes were mortality, intensive care unit admission and cumulative endpoint.

RESULTS

A total of 105 patients were included: 34 with COVID-19 and 71 controls. At admission, the prevalence of GI symptoms among COVID-19 patients was 8.8%. During hospitalization, the frequency of GI symptoms was higher in patients with COVID-19 than in controls (p=0.004). Among patients with COVID-19, the mortality and a cumulative endpoint rates of those with GI symptoms were both lower than for those without GI symptoms (p=0.016 and p=0.000, respectively). Finally, we found digestive comorbidities to be associated with a milder course of COVID-19 (p=0.039 for cumulative endpoint).

CONCLUSIONS

Our results highlighted the non-negligible frequency of GI symptoms in patients with COVID-19, partly attributable to the therapies implemented. In addition, the presence of GI symptoms and digestive comorbidities is associated with better outcomes. Most likely, digestive comorbidities do not hinder the host's immune response against SARS-COV-2, and the occurrence of GI symptoms might be linked to a faster reduction of the viral load via the faecal route.

Oral health conditions in Wilson's disease patients: A clinical diagnostic study

AIM

The aims of this study were: To evaluate oral health conditions, oral health behaviours and eating habits in Wilson's disease (WD) patients; to assess the possible relationship between oral health status and long-term pharmacological therapies undertaken.

METHODS

Sixty WD patients were selected and their data were compared to those of an age-matched control group of 62 subjects. Clinical examinations were carried out and a questionnaire on oral health behaviours and eating habits was submitted to both groups. WD patients were interviewed on long-term pharmacological therapies undertaken. Statistical analysis was performed.

RESULTS

The mean DMFT value was 3.75±4.65 in the WD group and 2.81±4.65 in the control group. The difference in the mean DMFT value between the two groups was not statistically significant. Modified Dental Enamel Defects (DDE) Index showed significantly higher values in WD group than in control group. No statistical differences in Visible Plaque Index (VPI), Gingival Bleeding Index (GBI) and malocclusions were observed between groups. In relation to the questionnaire, the differences between groups were statistically significant for: dental visits in a year; brushing teeth after a snack; drinking soft beverages; using mouthwash. For WD patients no statistical correlation between oral health status and long-term pharmacological therapies undertaken was observed.

CONCLUSION

WD patients did not show worse oral health conditions than the control group, despite worse oral health behaviours and eating habits. Nerveless, WD patients showed higher presence of dental enamel defects. Finally, for WD group oral health status was not correlated to the long-term pharmacological therapies.

Lateral meniscal cysts: long-term clinical and radiological results of a partial meniscectomy and percutaneous decompressive needling

INTRODUCTION

The aim of this study was to describe clinical and radiological long-term results of an arthroscopic partial meniscectomy associated with an outside-in decompressive needling of the cyst for lateral parameniscal cyst.

METHODS

Eighteen patients with symptomatic parameniscal cysts treated between April 2002 and September 2009 were retrospectively included in the study. All patients underwent arthroscopic partial meniscectomy (preserving peripheral rim) and needling of the cyst using a 20-gauge needle. Pre- and post-operative IKDC, Tegner, and Lysholm scores were used to evaluate clinical results. Radiological results were obtained from pre- and post-operative radiographies and post-operative MRI scans. Both supine and weight bearing MRI examinations were performed. Kellgren-Lawrence and WORMS scales were used to evaluate osteoarthritis development of the knee.

RESULTS

The mean follow-up period was 11.6 ± 2.6 years (range 7-15). Horizontal lesions were found in 56% of patients. All patients fully recovered. Mean Lysholm scores passed from mean pre-operative value 52 ± 16.9 to post-operative 85 ± 11.9 (P < 0.01) and mean IKDC scale score changed from 49.5 ± 14.7 to 67 ± 23.5 (P < 0.01). Mean Tegner scores did not change significantly. Post-operative radiographies showed a Kellgren-Lawrence scale grade 0 in six patients (33%), a grade I in eight (44%), a grade II in three (17%), and a grade III in one patient (6%). No patients were found with a Kellgren-Lawrence scale grade IV. No significant differences with pre-operative radiographies were found (chi-square = 1.867; df = 3; P = 0.60) in osteoarthritis development of the knee. Reported WORMS scores had an average of 12.4 ± 5.1. No recurrence of any cysts was observed.

DISCUSSION

Different treatments for lateral meniscal cysts have been proposed, but proper management of the cyst is still controversial. The results of this study suggest that the outside-in needling of the cyst associated with partial meniscectomy is a highly effective, simple, and repeatable technique. Excellent clinical outcomes were reported at a mean follow-up of 11.6 ± 2.6 years (range 7-15). Imaging evaluation showed no significant evolution to osteoarthritis of the knee.

CONCLUSIONS

Partial arthroscopic meniscectomy associated with percutaneous decompressive needling of the cyst wall under arthroscopic visualization showed positive clinical and radiological long-term results. Neither traditional radiographies nor innovative standing MRIs showed findings of osteoarthritis.

Subgroup comparison according to clinical phenotype and serostatus in autoimmune encephalitis: a multicenter retrospective study

BACKGROUND AND PURPOSE

Autoimmune encephalitides (AE) include a spectrum of neurological disorders whose diagnosis revolves around the detection of neuronal antibodies (Abs). Consensus-based diagnostic criteria (AE-DC) allow clinic-serological subgrouping of AE, with unclear prognostic implications. The impact of AE-DC on patients' management was studied, focusing on the subgroup of Ab-negative-AE.

METHODS

This was a retrospective multicenter study on patients fulfilling AE-DC. All patients underwent Ab testing with commercial cell-based assays (CBAs) and, when available, in-house assays (immunohistochemistry, live/fixed CBAs, neuronal cultures) that contributed to defining final categories. Patients were classified as Ab-positive-AE [N-methyl-d-aspartate-receptor encephalitis (NMDAR-E), Ab-positive limbic encephalitis (LE), definite-AE] or Ab-negative-AE (Ab-negative-LE, probable-AE, possible-AE).

RESULTS

Commercial CBAs detected neuronal Abs in 70/118 (59.3%) patients. Testing 37/48 Ab-negative cases, in-house assays identified Abs in 11 patients (29.7%). A hundred and eighteen patients fulfilled the AE-DC, 81 (68.6%) with Ab-positive-AE (Ab-positive-LE, 40; NMDAR-E, 32; definite-AE, nine) and 37 (31.4%) with Ab-negative-AE (Ab-negative-LE, 17; probable/possible-AE, 20). Clinical phenotypes were similar in Ab-positive-LE versus Ab-negative-LE. Twenty-four/118 (20.3%) patients had tumors, and 19/118 (16.1%) relapsed, regardless of being Ab-positive or Ab-negative. Ab-positive-AE patients were treated earlier than Ab-negative-AE patients (P = 0.045), responded more frequently to treatments (92.3% vs. 65.6%, P < 0.001) and received second-line therapies more often (33.3% vs. 10.8%, P = 0.01). Delays in first-line therapy initiation were associated with poor response (P = 0.022; odds ratio 1.02; confidence interval 1.00-1.04).

CONCLUSIONS

In-house diagnostics improved Ab detection allowing better patient management but was available in a patient subgroup only, implying possible Ab-positive-AE underestimation. Notwithstanding this limitation, our findings suggest that Ab-negative-AE and Ab-positive-AE patients share similar oncological profiles, warranting appropriate tumor screening. Ab-negative-AE patients risk worse responses due to delayed and less aggressive treatments.

Re-revision total hip arthroplasty: Epidemiology and factors associated with outcomes

INTRODUCTION

The epidemiology of re-revision total hip arthroplasty (THA) is not yet well-understood. We aim to investigate the epidemiology and risk-factors that are associated with re-revision THA.

METHODS

288 revision THA were analyzed between 1/2012 and 12/2013. Patients who underwent two or greater revision THA were included. Hips with first-revision due to periprosthetic joint infection (PJI) were excluded. Failure was defined as reoperation.

RESULTS

51 re-revision patients were available. Mean age was 59.6 (±14.2 years), 32 (67%) females, average BMI of 28.8 (±5.4), and median ASA 2 (23; 55%). The most common re-revision indications were acetabular component loosening (15; 29%), PJI (13; 25%) and instability (9; 18%). The most common indications for first revision in the re-revision population were acetabular component loosening (11; 27%), polyethylene wear (8; 19%) and instability (8; 19%). There was an increased risk of re-revision failure if the re-revision involved exchanging only the head and polyethylene liner (RR = 1.792; p = 0.017), instability was the first-revision indication (RR = 3.000; p < 0.001), and instability was the re-revision indication (RR = 1.867; p = 0.038). If isolated femoral component revision was indicated during the re-revision, there was a decreased risk of failure (RR = 0.268, p = 0.046). 1-year re-revision survival was 54% (23/43).

DISCUSSION

Acetabular component loosening, instability, and PJI were the most common indications for re-revision. Revision due to instability is a recurrent problem that leads to re-revision failure. There was a higher infection rate in the re-revision population compared to published revision PJI. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

2019 Frank Stinchfield Award: A comparison of prosthetic joint infection rates between direct anterior and non-anterior approach total hip arthroplasty

AIMS

We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution.

PATIENTS AND METHODS

A total of 6086 consecutive patients undergoing primary total hip arthroplasty (THA) at a single institution between 2013 and 2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. There were 3053 male patients (50.1%) and 3033 female patients (49.9%). The mean age and BMI of the entire cohort was 62.7 years (18 to 102, sd 12.3) and 28.8 kg/m² (13.3 to 57.6, sd 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols.

RESULTS

There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period.

CONCLUSION

We found a higher rate of PJI in DA versus NA approaches. Infection prevention protocols such as use of aspirin, dilute povidone-iodine lavage, vancomycin powder, and Gram-negative coverage may have been positively associated with diminished PJI rates observed for all approaches over time. Cite this article: Bone Joint J 2019;101-B(6 Supple B):2-8.

Surgical approach significantly affects the complication rates associated with total hip arthroplasty

AIMS

A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications.

PATIENTS AND METHODS

The electronic medical records of all patients who underwent primary elective THA at a single large-volume arthroplasty centre, between 2011 and 2016, with at least two years of follow-up, were reviewed. After exclusion, 3574 consecutive patients were included in the study. There were 1571 men (44.0%) and 2003 women (56.0%). Their mean age and body mass index (BMI) was 63.0 years (sd 11.8) and 29.1 kg/m² (sd 6.1), respectively. Data gathered included the age of the patient, BMI, the American Society of Anesthesiologists (ASA) score, estimated blood loss (EBL), length of stay (LOS), operating time, the presence of intra- or postoperative complications, type of complication, and the surgical approach. The approaches used during the study were posterior, anterior, direct lateral, anterolateral, and the northern approach. The complications that were recorded included prolonged wound drainage without infection, superficial infection, deep infection, dislocation, aseptic loosening, and periprosthetic fracture. Finally, the need for re-operation was recorded. Means were compared using analysis of variance (ANOVA) and Student's t-tests where appropriate and proportions were compared using the chi-squared test.

RESULTS

A total of 248 patients had 263 complications related to the surgery, with an incidence of 6.94%. The anterior approach had the highest incidence of complications (8.5% (113/1329)) and the posterior approach had the lowest, at 5.85% (97/1657; p = 0.006). Most complications were due to deep infection (22.8%), periprosthetic fracture (22.4%), and prolonged wound drainage (21.3%). The rate of dislocation was 0.84% (14/1657) with the posterior approach and 1.28% (17/1329) with the anterior approach (p = 0.32).

CONCLUSION

Overall, THA has a relatively low complication rate. However, the surgical approach plays a role in the incidence of complications. We found that the posterior approach had a significantly lower overall complication rate compared with the anterior approach, with an equal dislocation rate. Periprosthetic fracture and surgical site infection contributed most to the early complication rates. Cite this article: Bone Joint J 2019;101-B:646-651.

Cost-effective peri-operative pain management: assuring a happy patient after total knee arthroplasty

Aims

The aim of this study was to determine the optimal regimen for the management of pain following total knee arthroplasty (TKA) by comparing the outcomes and cost-effectiveness of different protocols implemented at a large, urban, academic medical centre.

Patients and Methods

Between September 2013 and September 2015, we used a series of modifications to our standard regimen for the management of pain after TKA. In May 2014, there was a department-wide transition from protocols focused on femoral nerve blocks (FNB) to periarticular injections of liposomal bupivacaine. In February 2015, patient-controlled analgesia (PCA) was removed from the protocol while continuing liposomal bupivacaine injections. Quality measures and hospital costs were compared between the three protocols.

Results

The cohort being treated with PCA-less liposomal bupivacaine injections had a significantly higher percentage of patients who were discharged to their home (p = 0.010) and a significantly shorter length of stay (p < 0.001). Patient-reported Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores relating to pain being “well-controlled” and “overall pain management” also favoured this cohort (p = 0.214 and p = 0.463, respectively), in which cost was significantly lower compared with the other two cohorts (p = 0.005).

Conclusion

The replacement of FNBs injections and the removal of PCAs, both of which are known to be associated with high rates of adverse outcomes, and the addition of liposomal bupivacaine periarticular injections to a multimodal pain regimen, led to improvements in many quality measures, HCAHPS pain scores, and cost-effectiveness.

Cite this article: Bone Joint J 2018;100-B(1 Supple A):55–61.

Nanohydroxyapatite promotes the healing process in open-wedge high tibial osteotomy: A CT study

BACKGROUND

The aim of this prospective and randomized study was to evaluate the effectiveness of adding nanohydroxyapatite (NHA) to heterologous bone graft in open wedge high tibial osteotomy (OWHTO) by measuring the bone density of the tibial osteotomy gap.

METHODS

Twenty-seven patients (26 knees) were operated by OWHTO and randomly divided into two groups: pure graft group, in which the osteotomy gap was filled with only heterologous bone graft; nanohydroxyapatite group, in which the osteotomy gap was filled with heterologous bone graft and NHA. All patients underwent computed tomography (CT) examination within one week after operation (Time 0), and after two months (Time 1) and 12months (Time 2). CT volume acquired Hounsfield Units (HU) were calculated and the mean value of bone density on three planes was measured.

RESULTS

At Time 0, the mineral density of the nanohydroxyapatite group appeared significantly higher compared with the pure graft group, due to the presence of NHA. At Time 1, the mineral density of the nanohydroxyapatite group had decreased relative to Time 0, while in the pure graft group it remained unchanged. At Time 2, the mineral density in the nanohydroxyapatite group had further decreased, reaching values close to the mineral density of normal bone. In contrast, in the pure graft group the mineral density had increased, probably due to the lack of reabsorption of the graft and the development of sclerosis in the osteotomy borders.

CONCLUSIONS

The results of the present study show better osseointegration of the heterologous graft when nanohydroxyapatite is added.

Dark-induced senescence of barley leaves involves activation of plastid transglutaminases

Transglutaminases (E.C. 2.3.2.13) catalyze the post-translational modification of proteins by establishing ε-(γ-glutamyl) lysine isopeptide bonds and by the covalent conjugation of polyamines to endo-glutamyl residues of proteins. In light of the confirmed role of transglutaminases in animal cell apoptosis and only limited information on the role of these enzymes in plant senescence, we decided to investigate the activity of chloroplast transglutaminases (ChlTGases) and the fate of chloroplast-associated polyamines in Hordeum vulgare L. 'Nagrad' leaves, where the senescence process was induced by darkness (day 0) and continued until chloroplast degradation (day 12). Using an anti-TGase antibody, we detected on a subcellular level, the ChlTGases that were associated with destacked/degraded thylakoid membranes, and beginning on day 5, were also found in the stroma. Colorimetric and radiometric assays revealed during senescence an increase in ChlTGases enzymatic activity. The MS/MS identification of plastid proteins conjugated with exogenous polyamines had shown that the ChlTGases are engaged in the post-translational modification of proteins involved in photosystem organization, stress response, and oxidation processes. We also computationally identified the cDNA of Hv-Png1-like, a barley homologue of the Arabidopsis AtPng1 gene. Its mRNA level was raised from days 3 to 10, indicating that transcriptional regulation controls the activity of barley ChlTGases. Together, the presented results deepen our knowledge of the mechanisms of the events happened in dark-induced senescence of barley leaves that might be activation of plastid transglutaminases.

Treatment of chronic hepatitis C in children with pegylated interferon and ribavirin: the impact of dose

INTRODUCTION

In the last years children with chronic hepatitis C (CHC) have been treated with Pegylated Interferon α (PEG-IFNα) and ribavirin (RBV). Treatment can cause several side effects that require reduction or interruption of therapy. The relationship between dose of PEG-IFNα and response to therapy has not been clearly evaluated. Aim of this study was to evaluate the impact of the dose of PEG-IFNα2b and RBV on the efficacy of therapy.

PATIENTS AND METHODS

All children with CHC treated with PEG-IFNα2b and RBV, observed at the Paediatric Liver Unit of University Federico II of Naples from 1996 to 2006 were evaluated.

RESULTS

Sixteen children with CHC treated with combined therapy were enrolled. Seven out of 16 patients (43.7%) achieved rapid virological response; 13/16 patients (81.2%) achieved early virological response; 5/16 patients (31.25%) relapsed; 1 patient resulted non responder. According to percentage of expected dose, our patients were divided into two groups: the first group included 7 patients that performed an overall dosage of PEG-IFNα2b ≥ 75% of the scheduled full dose; the second group included 9 patients that performedm PEG-IFNα2b dose < 75% of scheduled full dose. No difference was noted in terms of sustained virological response.

CONCLUSIONS

Modifications of therapy due to PEG-IFNα-related adverse events are frequent in children with CHC, but dose adjustments do not seem to impair efficacy of therapy.

Oral health status in liver transplant Italian children

AIM

The aim of this study was to assess the oral health status in children submitted to liver transplantation in order to evaluate the need to promote suitable dental caries prevention programmes.

MATERIALS AND METHODS

Thirty-eight children submitted to liver transplantation (4-5 years) were selected and their data were compared to those of an age-matched control healthy group of 78 children. Clinical examinations were carried out and X-ray bitewings were taken, in order to record caries prevalence, caries experience, periodontal health and dental enamel defects. A questionnaire investigating demographic and oral health behaviour data was completed by parents.

RESULTS

Caries prevalence was 78.9% in the liver transplantation group and 39.7% in the healthy control group. The dmft mean value was 2.26±2.25 in the liver transplantation group and 0.69±1.51 in the healthy group. The difference in the mean dmft between the two groups was statistically significant (p<0.0001). From the elaboration of the data on periodontal health it resulted that 23.7% of the liver transplantation subjects and 48.7% of controls had a healthy periodontal status, respectively; 39.5% of the liver transplantation children and 23.6% of the controls had plaque and calculus. In addition, 44.7% of the liver transplantation patients and 28.2%% of the control subjects showed bleeding on probing. In the liver transplantation subjects there was a higher prevalence (65.8%) of dental enamel defects with respect to the healthy group (21.8%).

CONCLUSION

The high prevalence of caries and gingival diseases showed the need to promote specific dental caries prevention programmes in liver transplant children.

ACL reconstruction with hamstrings: how different technique and fixation devices influence bone tunnel enlargement

BACKGROUND

Bone tunnel enlargement after anterior cruciate ligament (ACL) reconstruction is well documented in the literature. The cause of this tunnel enlargement is unclear, but is thought to be multifactorial, with mechanical and biological factors playing a role.

AIM

The aim of this prospective study was to evaluate how the different techniques may affect the bone tunnel enlargement and clinical outcome.

PATIENTS AND METHODS

Forty-five consecutive patients undergoing ACL reconstruction with autologous doubled semitendinosus and gracilis tendons entered this study. They were randomly assigned to enter group A (In-Out technique, with cortical fixation and Interference screw) and group B (Out-In technique, metal cortical fixation on the femour and tibia). At a mean follow-up of 10 months, all the patients underwent CT scan exam to evaluate the post-operative diameters of both femoral and they underwent tibial tunnels clinical examination after 24 months.

RESULTS

The mean femoral tunnel diameter increased significantly from 9.05±0.3 mm to 10.01±2.3 mm in group A and from 9.04±0.8 mm to 9.3±1.12 mm in group B. The mean increase in femoral tunnel diameters observed in group A was significantly higher than that observed in group B (p < 0.05) The mean tibial tunnel diameter increased significantly from 9.03±0.04 mm to 10.68±2.5 mm in group A and from 9.04±0.03 mm to 10.±0.78 mm in group B. The mean increase in tibial tunnel diameters observed in group A was significantly higher than that observed in group B (p < 0.05). No clinical differences were found between two groups and no correlations between clinical and radiological results were found in any patients of both groups.

CONCLUSIONS

Results of the study suggest that different mechanical fixation devices could influence tunnel widening. The lower stiffness of the fixation devices is probably responsible of the tunnel widening through the fixation devices's micromotions in the femoral and tibial tunnels.

Ultrasound scanning in infants with biliary atresia: the different implications of biliary tract features and liver echostructure

OBJECTIVE

To evaluate ultrasonographic features of the liver and biliary tree, including the presence of the triangular cord, in infants with biliary atresia and to analyze the correspondence between hepatic echostructure and histological aspects of the liver.

MATERIALS AND METHODS

35 consecutive infants (19 males) with documented diagnosis of biliary atresia were included. Ultrasonography evaluation, performed at a mean age of 63.1 ± 34.9 days, was focused on the extrahepatic bile ducts, characteristics of the gallbladder and liver, and the presence of the triangular cord. Liver biopsies were examined with particular regard to the presence and severity of fibrosis.

RESULTS

On ultrasound, the gallbladder was not seen in 11 (31 %) cases, while in the remaining 24 patients the gallbladder was regular in 6 patients and irregular in 18 cases. The triangular cord was identified in 9 (26 %) of 35 patients. In 21 patients the liver echostructure appeared normal, while in 14 infants the liver parenchyma was more echogenic and coarse than normal. Liver biopsy showed signs of cirrhosis or fibrosis in all cases, including patients with a normal hepatic echostructure.

CONCLUSION

Although the triangular cord was visualized in one-fourth of the infants with biliary atresia, abnormalities of the gallbladder on ultrasound (absence or abnormalities of length/shape) were detected in 83 % of the patients. Therefore, ultrasound evaluation of the liver and biliary tree plays an important role in suspecting biliary atresia. On the other hand, a low correspondence between liver echostructure aspects and the presence and severity of fibrosis at liver biopsy was identified. Therefore, severe liver disease in infants with biliary atresia cannot be excluded only on the basis of ultrasound findings.

Computer-assisted surgery: a teacher of TKAs

INTRODUCTION

The hypothesis of this study is that computer-aided navigation experience could improve the ability to better place components in the coronal plane and to improve visual/spatial awareness based on the ability of navigation to provide instant feedback. The purpose of this study is to demonstrate the educational role of the navigation system to obtain a better alignment of the prosthetic components with standard instrumentation after a computer-aided navigation experience.

MATERIALS AND METHODS

One hundred fifty patients were operated by the same surgeon, with more than 5 years experience with TKA. They were equally divided in three groups: group A (operated with non-navigated technique by surgeon without computer-assisted experience); group B (operated with computer-assisted surgery by the same surgeon); group C (operated with non-navigated technique by the same surgeon after the computer-navigated experience). We evaluated by full-length weight-bearing radiographs the overall alignment of the lower limb in the coronal plane. The optimum placement of the components was considered when the angle was within the limits of ±3° varus/valgus on the coronal x-rays. Comparison between groups was done using one-way ANOVA followed by post hoc Bonferroni test and Pearson chi-square statistics for proportions of optimum placement (P<0.05).

RESULTS

In the group A 34 patients (68%) had the optimum placement on the coronal x-rays; in the group B they were 46 (92%) and in the group 41 (82%). The difference is statistically significant in comparing group A and Group B (<0.001), group A and group C (P=0.04), but not for group B and C (P=0.2).

CONCLUSION

We believe that the navigation system has an educational role to improve the ability of surgeon of positioning prosthetic components precisely in the coronal plane.

Nanohydroxyapatite-based bone graft substitute in tunnel enlargement after ACL surgery: RMN study

BACKGROUND AND AIM

A successful anterior cruciate ligament reconstruction (ACL) requires solid healing of the tendon graft in the bone tunnel. New biological strategies have already been proposed with the aim of improving ACL graft healing and therefore allowing a faster rehabilitative program. The aim of this prospective study was to clinically and radiologically evaluate the efficacy of nanohydroxyapatite bone-base grafts in facilitating bone-tendon incorporation after ACL reconstruction with hamstrings (HS). As far as we know, this is the first study that has tried to asses the efficacy of such a type of bone substitute on human beings.

MATERIALS AND METHODS

40 male patients with chronic ACL rupture who underwent surgical reconstruction with 4-strand semitendinosus and gracilis tendon autograft via a single-bundle technique. Patients were randomly assigned to enter group A (20 patients, nanohydroxyapatite group) or group B (20 patients, control group). Preoperative and postoperative clinical evaluation was always performed, in a blinded way, assessing the Lachman and Pivot-shift tests and range of motion (ROM) of the affected knee. The Lysholm knee score, Tegner activity level, subjective and objective International Knee Documentation Committee (IKDC) forms, and 30 lb KT-1000 arthrometer evaluations. Patients underwent a magnetic resonance imaging (MRI) exam at 30, 90 and 180 days after surgery by the same musculoskeletal radiologist in a blinded way.

RESULTS

As for the clinical evaluation, Lysholm, Tegner, IKDC scales, and KT-1000 arthrometer results did not show any significant difference between the two groups. Radiological data show a tendency toward better results in regard to the graft strength signal, the graftbone interface, and bone edema remodeling process, these parameters show significant differences between the two groups only at the short or mid-term follow-ups, while they are never significant at the mid-to long-term follow-up.

CONCLUSIONS

In conclusion the use of nanohydroxyapatite bone substitute does not provide significant clinical improvements in terms of better knee stability or patient satisfaction.

Efficacy of combined antiviral therapy with lamivudine and tenofovir in a liver transplanted girl with de novo hepatitis B virus infection

The management of de novo hepatitis B (HBV) infection in children after liver transplantation is not well defined. Because this infection may induce severe liver disease in the graft liver, an efficient antiviral therapy is desirable. Here, we describe the favorable viral outcome observed in a liver transplanted girl with de novo HBV infection following combination therapy with lamivudine and tenofovir.

Tibial stress fracture after computer-navigated total knee arthroplasty

A correct alignment of the tibial and femoral component is one of the most important factors determining favourable long-term results of a total knee arthroplasty (TKA). The accuracy provided by the use of the computer navigation systems has been widely described in the literature so that their use has become increasingly popular in recent years; however, unpredictable complications, such as displaced or stress femoral or tibial fractures, have been reported to occur a few weeks after the operation. We present a case of a stress tibial fracture that occurred after a TKA performed with the use of a computer navigation system. The stress fracture, which eventually healed without further complications, occurred at one of the pinhole sites used for the placement of the tibial trackers.

Achilles tendon surgical revision with synthetic augmentation

In this paper we report about a 50-year-old patient who underwent a surgical revision procedure for rupture of the right Achilles tendon with the use of Ligastic((R)) synthetic graft in 1995, and in which a strong reactive immune response took place over the graft 11 years after. As far as we know, this is the first case described in literature of long-term follow-up inflammatory reaction after the use of such augmentation grafts in Achilles tendon repair.

T-bet and pSTAT-1 expression in PBMC from coeliac disease patients: new markers of disease activity

Coeliac disease (CD) is considered a T cell-mediated autoimmune disease, and up-regulation of T-bet and phosphorylated signal transducers and activators of transcription (pSTAT)1, key transcription factors for the development of T helper type 1 (Th1) cells, has been described in the mucosa of patients with untreated CD. Using transcription factor analysis, we investigated whether T-bet and pSTAT1 expressions are up-regulated in the peripheral blood of CD patients and correlate with disease activity. Using flow cytometry, we analysed T-bet, pSTAT1 and pSTAT3 expression in CD4(+), CD8(+) T cells, CD19(+) B cells and monocytes from peripheral blood of 15 untreated and 15 treated CD patients and 30 controls, and longitudinally in five coeliac patients before and after dietary treatment. We evaluated using enzyme-linked immunosorbent assay (ELISA), interferon (FN)-gamma, interleukin (IL)-17 and IL-10 production by peripheral blood mononuclear cell (PBMC) cultures. T-bet expression in CD4(+), CD8(+) T cells, CD19(+) B cells and monocytes and IFN-gamma production by PBMC was higher in untreated than in treated CD patients and controls. pSTAT1 expression was higher in CD4(+)T cells, B cells and monocytes from untreated than from treated CD patients and controls. pSTAT3 was increased only in monocytes from untreated patients compared with CD-treated patients and controls. The data obtained from the longitudinal evaluation of transcription factors confirmed these results. Flow cytometric analysis of pSTAT1 and T-bet protein expression in peripheral blood mononuclear cells could be useful and sensible markers in the follow-up of CD patients to evaluate disease activity and response to dietary treatment.

Spontaneous Achilles tendon ruptures treated with a mini-open technique: clinical and functional evaluation

AIM AND METHODS

Spontaneous ruptures of the Achilles tendon are frequent among occasional and high level athletes. Despite the frequency of this problem, there is no agreement about the treatment of this pathology. The purpose of this study was to show the results of 20 consecutive patients (14 males and 6 females) surgically treated between 1995 and 2001 with a mini-open technique (mean follow-up: 52 months; range 20-95 months). Postoperatively, all these patients were assessed with a new functional scoring scale and a functional jumping test (Ergo-Jump Bosco System).

RESULTS

A very low rate of minor complications have been reported and most of these patients are now practicing their favoured sport at the same pre-injury level.

CONCLUSIONS

Mini open repair should be considered an excellent method of treatment of this pathology, with a very low rate of complications. The authors recommend this technique for young professional and occasional athletes.

T-bet, pSTAT1 and pSTAT3 expression in peripheral blood mononuclear cells during pregnancy correlates with post-partum activation of multiple sclerosis

In pregnant women affected by multiple sclerosis (MS) we observed increased percentages of CD4(+)CD25(+)Foxp3(+) T regulatory cells at the 1st and the 2nd trimester of gestation that was associated with a decreased T-bet expression in CD4(+) T cells. In women showing clinical relapse and/or new lesions at MRI after delivery we found, a higher expression of T-bet, pSTAT1 and pSTAT3 in CD4(+), CD8(+) T cells and CD14(+) cells, associated with an increase of IFNgamma and IL17 production by PBMC at the 3rd trimester of gestation and after delivery. Our data suggest that the expansion of circulating CD4(+)CD25(+)Foxp3(+) regulatory T cells and the lower expression of T-bet in CD4(+) T cells may account for the decreased MS activity during pregnancy. The expression of T-bet, pSTAT1 and pSTAT3 in peripheral blood CD4(+) and CD8(+) T cells and monocytes could be useful to identify MS patients who will develop a relapse after delivery.

Tunnel enlargement after anterior cruciate ligament reconstruction in patients with post-operative septic arthritis

Tunnel enlargement is a frequent issue after ACL reconstruction and the "synovial bathing effect" is thought to be among the biological factors contributing to this phenomenon. Since the amount and the pressure of the synovial fluid inside the knee joint are higher and the length of its presence is longer in patients with post-operative septic arthritis after ACL reconstruction, we reviewed the tunnel enlargement in these cases in order to better evaluate this phenomenon in such a hostile environment. The null hypothesis of this study was that the highly represented phenomenon of the "synovial bathing effect" that occurs in an infected ACL reconstruction would not affect the amount of post-operative tunnel widening. A case-control study was done. At a mean follow up of 10 months (range 9-11 months) eight patients with septic arthritis following ACL reconstruction (group A) were radiologically reviewed using a CT scan and the diameters of femoral and tibial tunnels were measured. The results were compared with a control group (B) of uncomplicated ACL reconstruction cases operated by the same surgeon using the same technique. Although patients of Group A experienced a bigger amount of tunnel enlargement than patients of group B both on femoral (9.53 +/- 1.07 vs. 9.35 +/- 1.52 mm) and tibial side (10.07 +/- 1.3 vs. 9.92 +/- 0.74 mm), no clinical or statistically significant differences were detected between the groups (P > 0.05). No significant tunnel enlargement could be detected in patients of group A when compared with patients of group B. This seems to minimize the role of biological factors contributing to tunnel widening.

Movement disorders in multiple sclerosis: causal or coincidental association?

Despite the relatively frequent involvement of the basal ganglia and subthalamic nucleus by multiple sclerosis (MS) plaques, movement disorders (MD), other than tremor secondary to cerebellar or brainstem lesions, are uncommon clinical manifestations of MS. MD were present in 12 of 733 patients with MS (1.6%): three patients had parkinsonism, two blepharospasm, five hemifacial spasm, one hemidystonia, and one tourettism. MD in patients with MS are often secondary to demyelinating disease. Also in cases without response to steroid treatment and demyelinating lesions in critical regions, it is not possible to exclude that MD and MS are causally related.

Identification of the intermediate hosts of Habronema microstoma and Habronema muscae under field conditions

A polymerase chain reaction (PCR)-based assay was used for the specific detection of Habronema microstoma and Habronema muscae (Nematoda, Spirurida) in order to identify the intermediate hosts of both nematode species under field conditions. A total of 1087 netted and 165 laboratory-bred flies were tested. Flies were identified as Musca domestica Linnaeus 1758, Musca autumnalis De Geer 1776, Haematobia irritans (Linnaeus 1758), Haematobia titillans (De Geer 1907) and Stomoxys calcitrans (Linnaeus 1758) (Muscidae). Genomic DNA was extracted from pools of fly heads, thoraces and abdomens, and 703 samples were subjected to a duplex two-step semi-nested PCR assay to specifically detect diagnostic regions within the ribosomal ITS2 sequence of both H. microstoma and H. muscae. Stomoxys calcitrans specimens were positive for H. microstoma DNA and M. domestica specimens were positive for H. muscae DNA. In particular, PCR-positive samples derived from both farm-netted and laboratory-bred flies. The present study represents the first evidence of the vectorial competence of different fly species as intermediate hosts of Habronema stomachworms under field conditions. We discuss the roles of S. calcitrans and M. domestica in transmitting H. microstoma and H. muscae.

Is resistin a link between highly active antiretroviral therapy and fat redistribution in HIV-infected children?

OBJECTIVES

To assess the features of fat redistribution, detected by clinical and ultrasound (US) methods, and the presence of metabolic disorders in HIV-infected children undergoing antiretroviral therapy. To evaluate if serum levels of resistin, a hormone produced only by visceral adipose tissue, are a marker of fat redistribution in these patients.

DESIGN AND METHODS

Forty-five consecutive symptomatic HIV-infected children were considered for inclusion in the study. Patients were enrolled if treated for at least 6 months with antiretroviral therapy with or without protease inhibitor (PI) and if compliant to the study protocol. Patients were evaluated for: anthropometric measures, fat redistribution by clinical and US methods, serum lipids, parameters of insulin resistance by homeostasis model assessment for insulin resistance, serum resistin levels by an enzyme-linked immunosorbent assay.

RESULTS

Eighteen children fulfilled the inclusion criteria and were enrolled in the study. Twelve (66%) children had clinical and/or US evidence of fat redistribution; 9 (75%) of them were on PI therapy; only 3 of 6 children without fat redistribution were on PI therapy (p<0.05). Serum lipids and insulin resistance parameters did not differ between children with or without fat redistribution. There was a highly significant linear correlation between visceral fat detected by US and circulating resistin levels (r=0.87; p<0.0001).

CONCLUSIONS

Fat redistribution occurred in most HIV-infected children undergoing PI therapy. Because serum resistin levels reflect the amount of visceral fat, they could be considered a sensitive marker of fat redistribution in HIV-infected children.

Dermatophytoses in cats and humans in central Italy: epidemiological aspects

Two hundred hair/skin samples were collected from 2002 to 2004 from two groups of cats (privately owned and stray cats from a shelter) and 165 samples were obtained during the same period from persons in whom dermatophyte infection was highly suspected. The epidemiological data were statistically evaluated. Thirteen of the 100 privately owned cats (13%) and 100% of the stray cats were positive; of the 165 human samples examined 109 (66%) were positive for dermatophytes. Microsporum canis was the most common dermatophyte isolated in both cat groups while Trichophyton mentagrophytes was the most common in humans. Interestingly, a geophylic dermatophyte species (Microsporum gypseum) was found to be present and associated with clinical signs. Living in the countryside proved to be a risk factor for dermatophytoses in privately owned cats while in humans the main risk factor for M. canis was contact with animals followed by young age. None of the variables considered was associated with positivity for T. mentagrophytes while positivity for other fungi was correlated with life in the countryside.

Clinical utility of electrophysiological evaluation in Crigler-Najjar syndrome

We evaluated the neurological and neurophysiological features in ten patients with genetically characterized Crigler-Najjar (CN) syndrome: four with typical type I CN had undergone orthotopic liver transplantation (OLT); six had type II CN, and three of them developed severe hyperbilirubinemia with a limited response to phenobarbital leading to an intermediate phenotype I/II. Clinical neurological and multimodal electrophysiological evaluations [electroencephalogram (EEG), visual (VEPs), motor (MEPs) and brainstem auditory (BAEPs) evoked potentials] were performed. Neurological examinations showed mild hand tremor in four patients (one pre-OLT and one post-OLT type I, two type I/II). EEG revealed high voltage paroxysmal discharges in four patients (three type I/II, and one type I with a marked improvement after OLT). VEPs showed P100 wave increased latency in five patients (three type I, and two type I/II considered for OLT evaluation). MEPs showed prolonged central motor conduction time in five patients (two type I; one type I/II; two type II). Only EEG and VEPs findings showed a correlation with high bilirubin levels. BAEPs were normal. In conclusion, VEPs and EEG contribute to identify and monitor bilirubin neurotoxic effects, and may play a decisional role in some cases of severe hyperbilirubinemia without overt neurologic damage.

A preliminary study of oscillating electromagnetic field effects on human spermatozoon motility

Some effects of extremely low frequency electromagnetic fields (ELF-EMFs) on human spermatozoa are reported. Significant increases in the values of the motility and of the other kinematic parameters have been observed when spermatozoa were exposed to an ELF-EMF with a square waveform of 5 mT amplitude and frequency of 50 Hz. By contrast, a 5 mT sine wave (50 Hz) and a 2.5 mT square wave (50 Hz) exposure did not produce any significant effect on sperm motility. The effects induced by ELF-EMF (50 Hz; 5 mT) during the first 3 h of exposure persisted for 21 h after the end of the treatment. These results indicate that ELF-EMF exposure can improve spermatozoa motility and that this effect depends on the field characteristics.

A lateral minimal-incision technique in total hip replacement: a prospective, randomizes, controlled trial

Minimally invasive surgery has become a trend over the last few years in all aspects of orthopaedic surgery, including total hip arthroplasty. So-called mini-incision techniques involve limiting the length of the skin incision to 10 cm with use of either an anterior, lateral or posterior approach. Between March 2004 and December 2005 one hundred consecutive unilateral total hip replacements were performed by the same senior surgeon in our institute. All patients were randomly assigned to study group (group A) or control group (group B). In group A (50 patients) the skin incision was 8 cm; in group B (50 patients) the skin incision was standard (about 12-14 cm). Patient demographic data, including sex, age, height, weight, BMI, diagnosis and preoperative Harris hip score were recorded. Other criteria evaluated included the perioperative and postoperative complications, the surgical time, the blood loss, the length of the incision, the acetabular and stem positions, the length of hospital stay, Harris Hip Score (HHS) and the WOMAC osteoarthritis index at six months. No significant differences were found between the groups with respect to the average surgical time, the acetabular and stem position, the length of hospital stay and the Harris Hip Score (HHS) and the WOMAC osteoarthritis index at six months. A significant lower blood loss was found in the mini-incision group. A higher percentage of peri-operative complications was recorded in Group A (two stupor of sciatic nerve and one fracture of the greater trochanter). On the basis of our experience we could speculate that minimally invasive surgery should be directed to the new surgical approach with muscle sparing, instead of a shorter skin incision using standard approaches.

Reconstruction of the anterior cruciate ligament with the tendons of the semitendinosus and gracilis doubled: a comparison with reconstruction using the patellar tendon

A total of sixty consecutive cases of anterior chronic laxity of the knee the pre- and intraoperative features of which corresponded to the criteria of inclusion considered, hospitalized in our institute between September and December 1998 and submitted to reconstruction of the ACL were reviewed at a follow-up of 74 months. The series was made up of two groups that were homogeneous in terms of sex, age, degree of preoperative laxity and number and type of associated meniscal lesions; in the first group (20 cases) reconstruction was carried out using the patellar tendon (BPTB) and in the other (40 cases) the doubled semitendinosus and gracilis tendons (DGST) were used with the association in cases with greater rotatory laxity (20 cases) of peripheral reinforcement reconstruction. An accelerated rehabilitation protocol was used in the first group, a more prudent one with immobilization in extension for two weeks was used in the second group. The results, evaluated based on the IKDC form, appeared to be better in the DGST group, with a statistically significant difference; joint stability, evaluated at follow-up with a KT1000 arthrometer also proved to be better in the DGST group, with a difference that was not statistically significant. The present study seems to show that reconstruction of the ACL with DGST, a prudent rehabilitation protocol and peripheral reinforcement reconstruction in selected cases is capable of providing better long-term results as compared to standard reconstruction with the patellar tendon and accelerated rehabilitation protocol. Among methods used to reconstruct the anterior cruciate ligament (ACL), those that utilize the central third of the patellar tendon (BPTB) or the semitendinosus and gracilis tendons (DGST) continue to be those used most frequently. Although the debate between orthopedics is still going on as to which of the two methods is to be preferred, studies that compare the two methods do not seem to report essential differences in medium-term results. In a recent meta-analysis of the most important international literature, to this regard Freedman et al. concluded that despite a significant major presence of anterior pain reconstruction with BPTB is capable of guaranteeing better joint stability and patient satisfaction, with a minor incidence of transplant failure. Nonetheless, if methods of reconstruction with BPTB seem to be rather standardized in terms of the method used to obtain the specimen and that used for stabilization (with very few differences between interference screws and transverse stabilization), and in postoperative rehabilitation (so-called accelerated), when DGST is used there are many technical variables capable of influencing the final results (choice of methods of stabilization, postoperative rehabilitation in particular). For this reason we still cannot obtain an absolute comparison of the two methods, but can only compare reconstruction with BPTB and a particular method used with DGST. It is the purpose of this study to present the medium-term results not so much of ACL reconstruction with the semitendinosus and gracilis doubled, but as a more articulate approach to the pathology of the ACL, so that DGST is only one phase, even if it is the most important one. Because we wished to verify whether it is possible, even in terms of joint stability and patient satisfaction, to improve the results of the so-called gold standard for reconstruction of the ACL, reconstruction by BPTB with transverse femoral reconstruction and accelerated postoperative rehabilitation protocol was chosen as a term of paragon.

Interferon treatment in children with chronic hepatitis C: long-lasting remission in responders, and risk for disease progression in non-responders

BACKGROUND AND AIM

Large interferon-based therapeutic trials are still lacking in children with hepatitis C and the long-term safety and efficacy of interferon is unknown. This study describes the outcome of hepatitis C in 43 children enrolled in an open-label interferon trial, and were followed up to 66 months after stopping treatment.

PATIENTS AND METHODS

All patients received interferon alfa2a (5MU/m(2)) thrice weekly for 6 months; children with genotype 1b received 3MU/m(2) thrice weekly for 6 additional months.

RESULTS

Nine children discontinued interferon for adverse events and three were not compliant to treatment. Eight (19%, intention to treat analysis), including 2/20 (10%) with genotype 1b and 6/12 (50%) with genotypes 2 or 3, were sustained responders 12 months after stopping therapy. During further follow-up (mean+/-S.D.: 44.7+/-14.6 months), response was maintained; two non-responders cleared viremia, while a young boy progressed to cirrhosis.

CONCLUSIONS

Small sample size and therapy withdrawal are the major limitations in the interpretation of our results. Nevertheless, our data, suggesting that response to interferon in children with hepatitis C is genotype-related and stable, agree with the results of large studies in adults. The outcome in non-responders was variable, including persistence of viremia and mild-moderate cytolysis (most cases), progression to cirrhosis, or eventual sustained viremia clearance.

Semi-nested PCR for the specific detection of Habronema microstoma or Habronema muscae DNA in horse faeces

Habronema microstoma and Habronema muscae (Spirurida: Habronematidae) are parasitic nematodes which infect the stomach and/or skin of equids. The accurate diagnosis of gastric habronemosis is central to studying its epidemiology, but data on its distribution and prevalence are lacking, mainly due to the limitations of clinical and coprological diagnosis in live horses. To overcome this constraint, a two-step, semi-nested PCR-based assay was validated (utilizing genetic markers in the nuclear ribosomal DNA) for the specific amplification of H. microstoma or H. muscae DNA from the faeces from horses (n = 46) whose gastrointestinal parasite status had been determined at autopsy and whose faeces were examined previously using a conventional parasitological approach. Of these horses examined at autopsy, some harboured adults of either H. microstoma (n= 19) or H. muscae (n =4), and others (n = 7) harboured both species. Most of them were also infected with other parasites, including strongylid nematodes (subfamilies Cyathostominae and Strongylinae), bots and/or cestodes; there was no evidence of metazoan parasites in 2 horses. Larvated spirurid eggs were detected in the faeces of 1 of the 30 horses (3.3 %) shown to be infected with Habronema at autopsy. For this set of 46 samples, the PCR assay achieved a diagnostic specificity of 100 % and a sensitivity of approximately 97 % (being able to specifically detect as little as approximately 0.02 fg of Habronema DNA). The specificity of the assay was also tested using a panel of control DNA samples representing horse, the gastric spirurid Draschia megastoma and 26 other species of parasites from the alimentary tract of the horse. H. microstoma, H. muscae and D. megastoma could be readily differentiated from one another based on the sizes of their specific amplicons in the PCR. The results of this study showed that the performance of the PCR for the diagnosis of gastric habronemosis was similar to that of autopsy but substantially better than the traditional coprological examination procedure used. The ability to specifically diagnose gastric habronemosis in equids should have important implications for investigating the epidemiology and ecology of H. microstoma and H. muscae.

Mimicry between the hepatitis C virus polyprotein and antigenic targets of nuclear and smooth muscle antibodies in chronic hepatitis C virus infection

Autoantibodies to smooth muscle (SMA) and nuclear components (ANA) arise in the natural course of chronic infection with hepatitis C virus. In view of the growing evidence for 'molecular mimicry' as a mechanism of autoimmunity we investigated whether cross-reactive immune reactions between host smooth muscle/nuclear components and HCV antigens may contribute to the formation of SMA and ANA in chronic HCV infection. Computer-assisted protein database search methods were used to identify three smooth muscle (smoothelin698-717, myosin1035-1054, vimentin69-88) and three nuclear (matrin722-741, histone H2A11-30, replication protein A133-152) host antigens with the highest local sequence similarity to the HCV polyprotein and 20-mer peptides corresponding to these regions were constructed. Sera from 51 children with chronic HCV infection [median age: 8 (2-16); 27 boys], 26 SMA positive and five ANA positive, were tested for reactivity to the synthesized HCV peptides and their human homologues by enzyme linked immunosorbent assay (ELISA). Sera from patients with HBV infection and chronic liver disease of different aetiologies were used as controls. 'Double reactivity' to HCV peptides and smooth muscle/nuclear homologues was associated strongly with HCV infection (P < 0.001 for both). Humoral cross-reactivity was established as the basis for double recognition by competition ELISA. Double-reactivity to smooth muscle and HCV peptide antigens correlated with SMA positivity by indirect immunofluouresence (P = 0.05). Of 15 patients double-reactive to myosin1035-1054 and its HCV homologue, 13 recognized whole myosin by immunoblot. These results suggest that ANA and SMA in chronic HCV infection may arise, at least in part, as a consequence of cross-reactive immune responses to HCV and host smooth muscle/nuclear antigens.

Trabecular minimodeling in human iliac bone

In adult human beings, remodeling creates nearly all of new bone tissue. However, Frost hypothesized that modeling can go on in trabeculae throughout life. As this hypothesis has not been verified, we looked for histologic evidence of trabecular modeling (minimodeling) during bone histomorphometry of transiliac bone biopsy specimens obtained from 34 patients (age range, 38-81 years; mean age, 58.4 years; female, 31/34) at the time of total hip arthroplasty. Before the bone biopsy study, we performed quantitative bone scintigraphy of bilateral hip joints and bilateral iliac crests in 10 other patients with unilateral hip disease and confirmed that the bone biopsy site was not affected by ipsilateral hip joint disease. Patients who had metabolic bone diseases or who had taken medications known to affect bone metabolism were excluded from the study. During modeling where bone formation and bone resorption are not coupled, bone formation can occur on quiescent bone surfaces without preceding bone resorption and create smooth cement lines. Therefore, the combination of fluorochrome labeling and a smooth cement line without interruption of surrounding collagen fibers was regarded as evidence of minimodeling. Histologic evidence of minimodeling was detected in 21 of the entire 34 specimens (62%) and 17 of 27 specimens obtained from postmenopausal patients (63%). Bone volume of minimodeling sites was less than 1% of the trabecular bone volume, and these sites accounted for less than 2% of the entire bone surface on average. However, osteoid volume of minimodeling sites comprised approximately one-tenth of the entire osteoid volume, and their labeled surface constituted one-fourth to half of the entire labeled surface on average. Therefore, when performing bone histomorphometry of adult cancellous bone, minimodeling should be taken into account when dealing with parameters related to osteoid volume and mineralization. A comparison of specimens with and without minimodeling demonstrated that the presence of minimodeling was correlated with smaller physique of patients, accelerated mineralization (as indicated by the higher mean MS/BS and MAR values and the shorter mean Omt), and higher metabolic turn-over of bone (as indicated by the higher mean BFR/BV value). Although the findings still need to be verified in a larger number of normal subjects without hip joint disease, they support Frost's hypothesis that minimodeling can continue throughout human life.

Possible role for Ca(2+) calmodulin-dependent protein kinase II as an effector of the fertilization Ca(2+) signal in mouse oocyte activation

The present study shows that Ca(2+) calmodulin-dependent protein kinase II (CaM kinase II) is physiologically activated in fertilized mouse oocytes and is involved in the Ca(2+) response pathways that link the fertilization Ca(2+) signal to meiosis resumption and cortical granule (CG) exocytosis. After 10 min of insemination, CaM kinase II activity increased transiently, then peaked at 1 h and remained elevated 30 min later when most of the oocytes had completed the emission of the second polar body. In contrast, in ethanol-activated oocytes the early transient activation of CaM kinase II in response to a monotonic Ca(2+) rise was not followed by any subsequent increase. Inhibition of CaM kinase II by 20 micromol/l myristoylated-AIP (autocamtide-2-related inhibitory peptide) negatively affected MPF (maturing promoting factor) inactivation, cell cycle resumption and CG exocytosis in both fertilized and ethanol-activated oocytes. These results indicate that the activation of CaM kinase II in mouse oocytes is differently modulated by a monotonic or repetitive Ca(2+) rise and that it is essential for triggering regular oocyte activation.