Femoral metastatic pathological fractures, impending and actual fractures - A patient survival study

INTRODUCTION

The skeleton is a common site for metastases. Prostate, breast, lung, renal and thyroid carcinomas account for 80 % of the original cancers, with the femur being the most affected long bone. With improved oncological treatments, prolonged patient survival leads to an increased prevalence of osseous metastases. This study examines the impact of preventive surgery for impending femoral pathological fracture (IFF), versus treatment of pathological femur fracture (PFF) on patient mortality and morbidity.

METHODS

Retrospective cohort of 174 patients undergoing surgery due to femoral metastases (2004-2015). Eighty-two patients were with PFF, and 92 were with IFF based on the Mirels' score. The followed-up period was until 2016. Demographic data, oncological, pathological, radiation, surgical reports, outpatient clinical records, and imaging studies were examined. Exclusion criteria included primary tumours and Multiple Myeloma.

RESULTS

The mean age was 64.8 ± 13.3 and 60.2 ± 11.9 years (p = 0.02) in the PFF and the IFF cohorts, with 62.1 % women and 57 % men. The breast was the most common source of femoral metastases. The average Mirels' score was 10 ± 1.2. There was an association between tumour origin and survival. Carcinoma of the lung had the worst survival, while the prostate had the most prolonged survival. Survival rates differed between IFF and PFF (p = 0.03). Postoperative complications occurred in 26 % of the patient, with no difference between IFF & PFF.

CONCLUSION

Breast and lung are the most common tumours to metastasize the femur. Our study revalidates that pathological femoral fractures impede patient survival compared to impending fractures and should undergo preventive surgery. Postoperative complications do not differ between IFF and PFF but remain relatively high. Overall, patients with proximal femoral metastatic disease survive longer than previously published, probably due to improved treatment modalities.

Scoliosis in RETT Syndrome: A National Referral Centre Experience

STUDY DESIGN

This was a retrospective case series.

OBJECTIVE

The objective of this study was to discuss the treatment challenges in scoliosis patients with Rett syndrome (RTT) in a national referral centre for RTT. We describe structural characteristics of curves, age of onset, genetic mutation, ambulation status, and treatment through RTT progression. Based on this unique experience, we aimed to suggest guidelines for scoliosis treatment in RTT patients.

SUMMARY OF BACKGROUND DATA

RTT is a neurodevelopmental disorder associated with a mutation in the methyl-CpG binding protein 2 (MECP2) gene, primarily in females with significant features of growth failure, gastrointestinal and pulmonary dysfunction, ataxia, seizures, and intellectual disability. Scoliosis is the most common orthopedic manifestation of RTT and is present in 64%-75% of patients. No clear guidelines for scoliosis treatment in RTT are available, and typically patients are treated according to guidelines of another neuromuscular scoliosis.

METHODS

Clinical and radiographic data were gathered, including MECP2 mutation type, scoliosis characteristics, preoperative treatment, surgical treatment, functional status, and postoperative follow-up.

RESULTS

Our cohort included 102 patients with RTT. They were 36 who presented with scoliosis; 18 were treated surgically. C-curve was found in 17 patients and S-type in 19. Scoliosis treatment onset was 8.76 years in the C-type group and 13.88 years in the S-type group. The average curve at the time of surgery was 52.42 degrees. The average time until surgery was 2.44 years. Seventeen patients underwent posterior spinal fusion, and 1 patient underwent posterior spinal fusion+anterior spinal fusion with an average correction of 40 degrees. The most common mutation was R255X nucleotide (30% of cases). The most severe curves had mutations R168X and R270X nucleotides.

CONCLUSIONS

We advise early monitoring for patients with RTT and scoliosis due to early and rapid progression. Common mutations found were R255X, R168X, R270X, and T158M. We recommend surgical treatment in every curve above 45 degrees, independently of age.

Limitations of Plain Film Radiography in Identification of Hyperextension Fractures in Patients With Ankylosing Spinal Disorders

STUDY DESIGN

Efficacy study.

OBJECTIVES

To elucidate the limitations of radiography in patients with spinal ankylosing disorders (SAD) with an emphasis on thoracolumbar injuries, which have been less focused upon.

METHODS

We searched our hospital's emergency room database for patients who underwent a total spine computed tomography (CT) following a diagnosis of SAD on radiographs following a minor fall. A high-quality presentation containing 50 randomly situated anteroposterior + lateral radiographs was created. Of these, 24 contained a hyperextension type fracture diagnosed by CT. Twelve physicians-4 spine surgeons, 4 senior orthopedic residents and 4 junior orthopedic residents were requested to identify the pathologic radiographs and note the fracture level.

RESULTS

Fracture diagnosis stood at 65% for the best reader. When examining the different subgroups, the mean rate of diagnosis for spine surgeons was 55% and for orthopedic residents 32%. Mean diagnosis of thoracic fractures was 26%, of lumbar fractures was 55%, and for the entire thoracolumbar spine was 40%. The interobserver agreement (kappa coefficient) was found to be 0.37 for the entire group and 0.39 for spine surgeons. This finding was statistically significant.

CONCLUSIONS

The simple radiograph is an inefficient modality for diagnosis of hyperextension type thoracolumbar fractures in patients with SAD. The poor interobserver agreement rate further amplifies this finding. Advanced imaging is recommended in these patients.

Potential neurotoxicity of titanium implants: Prospective, in-vivo and in-vitro study

Titanium dioxide (TiO₂) is a frequently used biomaterial, particularly in orthopedic and dental implants, and it is considered an inert and benign compound. This has resulted in toxicological scrutiny for TiO₂ in the past decade, with numerus studies showing potential pathologic downstream effects. Herein we describe case report of a 77-year-old male with subacute CNS dysfunction, secondary to breakdown of a titanium-based carotid stent and leading to blood levels 1000 times higher (3 ppm) than the reported normal. We prospectively collected tissues adjacent to orthopedic implants and found a positive correlation between titanium concentration and time of implant in the body (r = 0.67, p < 0.02). Rats bearing titanium implants or intravascularly treated with TiO₂ nanoparticles (TiNP) exhibited memory impairments. A human blood-brain barrier (BBB) in-vitro model exposed to TiNP showed paracellular leakiness, which was corroborated in-vivo with the decrease of key BBB transcripts in isolated blood vessels from hippocampi harvested from TiNP-treated mice. Titanium particles rapidly internalized into brain-like endothelial cells via caveolae-mediated endocytosis and macropinocytosis and induced pro-inflammatory reaction with increased expression of pro-inflammatory genes and proteins. Immune reaction was mediated partially by IL-1R and IL-6. In summary, we show that high levels of titanium accumulate in humans adjacent to orthopedic implants, and our in-vivo and in-vitro studies suggest it may be neurotoxic.

Preventing Biofilm Formation by Dairy-Associated Bacteria Using Peptide-Coated Surfaces

Biofilm-forming bacteria, which colonize the surfaces of equipment in the dairy industry, may adversely affect the safety and quality of the milk and its products. Despite numerous efforts to combat biofilm formation, there is still no effective technological means to thoroughly solve the biofilm problem in the dairy industry. Here, we introduced peptide-based coating in order to modify the physical properties of the stainless steel surface by affecting its availability for bacterial adhesion. We found that the coated surface displays a notable decrease in the ability of bacterial cells to attach and to subsequently form biofilm by Gram-positive Bacillus licheniformis and Gram-negative Pseudomonas aeruginosa. Furthermore, the coated surface retained its anti-biofilm ability following its exposure to raw milk. Importantly, the modified surface did not affect the milk coagulation process or its nutritious properties and quality. Overall, this anti-biofilm approach may serve as an attractive solution for the dairy industry in its struggle against bacterial contamination.

Eliminating the Need for Biocidal Agents in Anti-Biofouling Polymers by Applying Grafted Nanosilica Instead

A nondestructive one-step approach was applied for grafting biocide-free monodispersed silica nanoparticles (SNPs) with a diameter of 30 ± 10 nm on polystyrene, polyethylene, and polyvinyl chloride surfaces. The prepared surfaces were comprehensively characterized using spectroscopic (Fourier transform infrared attenuated total reflection, ultraviolet-visible, and X-ray photoelectron spectroscopy) and microscopic (high-resolution scanning electron microscopy and atomic force microscopy) methods. The modified polymers were found to maintain their original mechanical and physical properties, while their nanoroughness on the other hand had risen by 1.6-2.7 times because of SNP grafting. The SNP-grafted surfaces displayed anti-biofouling properties, resulting in a significant reduction in the attached Gram-positive Bacillus licheniformis or Gram-negative Pseudomonas aeruginosa bacteria compared to their nongrafted counterparts. Confocal laser scanning microscopy and scanning electron microscopy studies have confirmed that bacterial cells could not successfully adhere onto the SNP-grafted polymer films regardless of the polymer type, and their biofilm formation was therefore damaged. The presented facile and straightforward protocol allows eliminating the need for biocidal agents and resorts to grafted nanosilica instead. This strategy may serve as a feasible and safe platform for the development of sustainable anti-biofouling surfaces in biomedical devices; food, water, and air treatment systems; and industrial equipment.

Association between body mass index, body height, and the prevalence of spinal deformities

BACKGROUND CONTEXT

The most common spinal deformities among adolescents are adolescent idiopathic scoliosis (AIS; 2%-3% prevalence) and Scheuermann kyphosis (SK; 1%-8% prevalence). Both are believed to have a genetic influence in their etiology. The association between body mass index (BMI) and body stature and their possible association to spinal deformities is uncertain.

STUDY DESIGN

A cross-sectional prevalence study.

PURPOSE

To examine the prevalence of all adolescent spinal deformities according to the extent of their severity as well as their possible association to BMI and body height.

OUTCOME MEASURES

Subjects diagnosed as having spinal deformities were classified into one of three severity groups; "Mild," "Intermediate," or "Severe," according to their curve scoliosis or kyphosis measurement with a standing X-ray.

METHODS

The data for this study were derived from a medical database containing records of 17-year-old male and female patients before their recruitment into mandatory military service. Information on the disability codes associated with spinal deformities according to the Regulations of Medical Fitness Determination was retrieved. Logistic regression models were used to assess the association between the BMI and body height to various degrees of spinal deformities by severity.

RESULTS

The study cohort included 829,791 consecutive subjects, of whom 103,249 were diagnosed with spinal deformities (76% were mild in degree). The prevalence of spinal deformities was significantly greater among the underweight male and female patients (p<.001). Increased BMI had a protective effect for developing spinal deformities. The odds ratios for severe spinal deformities were greater compared with mild spinal deformities in the underweight groups. The risk for developing spinal deformities increased significantly with height for both genders (p<.001).

CONCLUSIONS

An association between height and the risk for spinal deformities by severity was found for all height groups. Below normal BMI is associated with severity of spinal deformities, whereas above-normal BMI apparently has a protective effect. Body height is also positively associated with the severity of spinal deformities.

Associations of body mass index and body height with low back pain in 829,791 adolescents

Body mass index (BMI) (calculated as weight (kg)/height (m)²) and height are linked to the pathogenesis of low back pain, but evidence-based confirmation is lacking. We examined the prevalence of low back pain in adolescents and its association with BMI and height. Disability clauses (official military limitations related to a person's health status) indicating low back pain severity were divided according to symptoms of low back pain alone and symptoms of low back pain with objective corroborating findings. All 829,791 males and females undergoing mandatory premilitary recruitment examinations since 1998 were included. Logistic regression models assessed the relationships of BMI and height with low back pain. Prevalence of low back pain was 0.2% for both males and females with objective findings and 5.2% for males and 2.7% for females without objective findings. Higher BMI was significantly associated with low back pain in males (for overweight, odds ratio = 1.097, P < 0.001; for obese, odds ratio = 1.163, P < 0.001) and in females (for overweight, odds ratio = 1.174, P < 0.001; for obese, odds ratio = 1.211, P < 0.001). Height was associated with increased risk of low back pain in both genders. Odds ratios for low back pain in the tallest group compared with the shortest group were 1.438 (P < 0.001) for males and 1.224 (P < 0.001) for females. Low back pain with or without objective findings was associated with overweight and obesity as well as with height.

Percutaneous Posterolateral Transforaminal Endoscopic Discectomy: Clinical Outcome, Complications, and Learning Curve Evaluation

Ongoing technological development combined with better understanding of endoscopic anatomy has made posterolateral endoscopic discectomy an appealing surgical option for the management of herniated lumbar disc. We evaluated clinical outcomes, complication rates, and surgical learning curve with the percutaneous posterolateral transforaminal endoscopic discectomy technique (PPTED). PPTED was performed on 150 patients from 2004 to 2008. And 124 patients were available for follow-up. Data regarding pain, postoperative complications, neurological status, operation time, and subjective patient satisfaction were recorded. A satisfactory clinical outcome as reflected in the VAS (mean 3.6) and ODI improvement (mean 21%) scores was reported; 20.9% of the patients required additional surgery. Learning curve assessment showed a significant difference (p = 0.043) for fewer revision surgeries as surgeons became more experienced. Patients who had endoscopic discectomy as a primary surgery achieved significantly lower VAS (p = 0.04) and ODI improvement (p = 0.004) scores compared with patients having transforaminal endoscopic discectomy as revision surgery. The complication rate was 1.6%, including one case of post-surgery hypoesthesia and one deep wound infection. The percutaneous posterolateral transforaminal endoscopic discectomy technique has a satisfactory clinical outcome with a low complication rate. Results for endoscopic surgery for revision or recurrent disc herniation are comparable to those of open revision surgery; the steep learning curve can be overcome with training and suitable patient selection.

Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: part 2--Evaluation of system accuracy

OBJECTIVE

To evaluate the accuracy of a novel bone-mounted miniature robotic system for percutaneous placement of pedicle and translaminar facet screws.

METHODS

Thirty-five spinal levels in 10 cadavers were instrumented. Each cadaver's entire torso was scanned before the procedure. Surgeons planned optimal entry points and trajectories for screws on reconstructed three-dimensional virtual x-rays of each vertebra. Either a clamp or a minimally invasive external frame was attached to the bony anatomy. Anteroposterior and lateral fluoroscopic images using targeting devices were obtained and automatically registered with the virtual x-rays of each vertebra generated from the computed tomographic scan obtained before the procedure. A miniature robot was mounted onto the clamp and external frame and the system controlled the robot's motions to align the cannulated drill guide along the planned trajectory. A drill bit was introduced through the cannulated guide and a hole was drilled through the cortex. Then, K-wires were introduced and advanced through the same cannulated guide and left inside the cadaver. The cadavers were scanned with computed tomography after the procedure and the system's accuracy was evaluated in three planes, comparing K-wire positions with the preoperative plan. A total of fifty-five procedures were evaluated.

RESULTS

Twenty-nine of 32 K-wires and all four screws were placed with less than 1.5 mm of deviation; average deviation was 0.87 +/- 0.63 mm (range, 0-1.7 mm) from the preoperative plan in this group. Sixteen of 19 K-wires were placed with less than 1.5 mm of deviation. There was one broken and one bent K-wire. Another K-wire was misplaced because of collision with the previously placed wire on the contralateral side of the same vertebra because of a mistake in planning, resulting in a 6.5-mm deviation. When this case was excluded, average deviation was 0.82 +/- 0.65 mm (range, 0-1.5 mm).

CONCLUSION

These results verify the system's accuracy and support its use for minimally invasive spine surgery in selected patients.

Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: Part I--Technical development and a test case result

OBJECTIVE

To introduce a new miniature robot (SpineAssist; MAZOR Surgical Technologies, Caesarea, Israel) that has been developed and tested as a surgical assistant for accurate percutaneous placement of pedicle screws and translaminar facet screws.

METHODS

Virtual projections in three planes-axial, lateral, and anteroposterior-are reconstructed for each vertebra from a preoperative computed tomographic (CT) scan. On a specially designed graphic user interface with proprietary software, the surgeon plans the trajectory of the screws. Intraoperative fluoroscopic x-rays with targeting devices are then matched with the CT-based virtual images, as well as the surgeon's plan. A clamp is attached to the spinous process or a minimally invasive frame (Hover-T frame; MAZOR Surgical Technologies) is mounted to the iliac crest and one spinous process. The miniature robot is then attached to the clamp and/or frame. On the basis of combined CT scan and fluoroscopic data, the robot aligns itself to the desired entry point and trajectory, as dictated by the surgeon's preoperative plan.

RESULTS

A test case in a cadaver lumbar spine was performed in which four screws and two rods were inserted, using a minimally invasive technique, combining the SpineAssist system and Hover-T frame in conjunction with the PathFinder system (Spinal Concept Inc., Austin, TX). The discrepancy between the planned and actual screw trajectories was measured by means of postprocedural CT scan. Overall, the four screws were implanted with an average deviation of 1.02 +/- 0.56 mm (range, 0-1.5 mm) from the surgeon's plan.

CONCLUSION

These preliminary results confirm the system's accuracy and support its use in minimally invasive spine surgery applications.

In-vitro characterisation of the phagocytosis and fate of anthrax spores in macrophages and the effects of anti-PA antibody

Antibodies (Abs) to the protective antigen (PA) component of the anthrax toxins have anti-spore as well as anti-toxin activities. Anti-PA antisera and purified anti-PA Abs enhance the phagocytosis by murine-derived macrophages (MQs) of spores of the Ames and Sterne strains and retard the germination of extracellular spores in vitro. The fate after phagocytosis of untreated and anti-PA-treated spores was further studied in culture medium that supported phagocytosis without stimulating spore germination (Dulbecco's minimal essential medium with horse serum 10%). The spores germinated within cells of primary peritoneal murine MQs (C3H/HeN) and MQs of the RAW264.7 MQ-like cell line; germination was associated with a rapid decline in spore viability. Exposure of MQs to inhibitors of phago-endosomal acidification (bafilomycin A and chloroquine) reduced the efficiency of MQ killing and allowed outgrowth and replication of the organisms. Treatment of spores with anti-PA Abs stimulated their phagocytosis and was associated with enhanced MQ killing of the spores. The enhanced killing of spores correlated with the greater extent of germination of anti-PA-treated spores after phagocytosis. A PA null mutant of the Ames strain exhibited none of the effects associated with anti-PA Ab treatment ofthe parental strain. Thus, the anti-PA Ab-specific immunity induced by vaccines has anti-spore activities and its role in impeding the early stages of infection with Bacillusanthracis needs to be assessed.

Determination of the virulence of the pigmentation-deficient and pigmentation-/plasminogen activator-deficient strains of Yersinia pestis in non-human primate and mouse models of pneumonic plague

The current human plague vaccine, a killed Yersinia pestis whole-cell preparation, does not protect against aerosol challenge and is reactogenic and antigenically undefined. Live attenuated Y. pestis, such as pigmentation-deficient (Pgm-) strains, have been used frequently as vaccines and are efficacious. They are used widely in plague research and assumed to be safe. However, they can cause serious adverse reactions, and their aerosol infectivity is not known. We tested the virulence of a defined Pgm- variant of the C092 strain of Y. pestis in mouse and non-human primate models of pneumonic plague. The ten-fold lower median lethal dose by the aerosol compared to the subcutaneous (s.c.) routes of the Pgm- strain in mice suggested that the Pgm- strain might be less attenuated by the former than by the latter route. After exposure of 16 African green monkeys to inhaled doses ranging from 1.1 x 10(4) to 8.1 x 10(7)cfu, eight died and eight survived. The terminal cultures collected from five of the non-survivors were all positive for Y. pestis. Two of the remaining three non-survivors were culture-negative but had pathologic and immunologic evidence of infection with Y. pestis, specimens could not be obtained nor the cause of death determined for the third one. The deaths were not dose-related, and there were some differences in the pathology associated with infection by the Pgm- strain compared to the wild-type (wt) strain. However, the Pgm- derivative was clearly virulent for monkeys by the aerosol route. A mutant of the Pgm- strain, which has a deletion in the plasminogen activator (Pla) virulence locus (pla), appeared to be more attenuated than was either the Pgm- single mutant (in NHPs and mice) or the Pla- single mutant strain (in mice) and has potential as a live vaccine.

Anti-V antigen antibody protects macrophages from Yersinia pestis -induced cell death and promotes phagocytosis

The pathogenic Yersinia spp. harbor a common plasmid (pYV) essential for virulence. The plasmid encodes a type III secretion system that functions to translocate Yersinia outer proteins (Yops) into the host cytosol. Within the host cell, the Yops act to inhibit phagocytosis and induce apoptosis. One of the plasmid-encoded proteins, virulence antigen (V), is a major protective immunogen that is involved in Yop translocation. Yersinia pestis, like the enteric Yersinia spp., was both resistant to phagocytosis by and cytotoxic for J774.A1, a murine macrophage cell line. Both of these activities were dependent on culture of the bacteria at 37 degrees C for 1.5-2 h before infection. However, extending the preculture period at 37 degrees C to 24 h, which induced formation of a capsule, completely blocked cytotoxicity. Treating the bacteria with either rabbit polyclonal anti-V antibodies (R anti-V) or monoclonal antibody (MAb) 7.3, antibodies specific for V and protective against plague in vivo, protected J774.A1 cells from Y. pestis -induced cell death and also reversed the inhibition of phagocytosis. Whereas protection against cell cytotoxicity was afforded by the F(ab')(2) portion of R anti-V, the ability of anti-V to induce uptake of Y. pestis appeared to be dependent on the Fc portion of the Ab. The protective epitope(s) recognized by R anti-V was contained in the central region of Y. pestis V (aa 135-275) and were partially cross reactive with Y. pseudotuberculosis and Y. enterocolitica serotype 08 V antigens.

DNA viruses and oncogenesis

This review addresses the biology and role of DNA viruses in oncogenesis.

Endogenous proviruses

Sequences related to different retroviruses are present in the mammalian genome, being inherited through the germ line, and some of these sequences are expressed as RNA and protein products. The ubiquitous presence of these viral sequences suggests that they are related to some essential cellular functions. However, these functions remain to be defined. The possible role of endogenous provirus expression in cell differentiation and proliferation as well as in tumorigenic processes remains enigmatic. Available evidence strongly suggests that endogenous retroviruses present in the human and nonhuman mammalian genome are not oncogenic.

Weak anamnestic responses of inbred mice to Yersinia F1 genetic vaccine are overcome by boosting with F1 polypeptide while outbred mice remain nonresponsive

The role of immunity to intracellular Ags in resistance to infection by Yersinia is not well established. The enteropathogenic bacteria Yersinia pseudotuberculosis and Yersinia enterocolitica actively translocate Ags to the cytosol of eukaryotic cells. Whereas Yersinia pestis does not always express the requisite cellular adhesins, results have varied as to whether similar cytosolic translocation of Ags occurs in vitro. We used a genetic vaccine to induce intracellular expression of the fraction 1 (F1) capsular protein of Y. pestis within host mammalian cells and examined the ensuing immune response. The F1 genetic vaccine stimulated only weak CTL responses in BALB/c mice. Substantial Ab responses to the F1 genetic vaccine were obtained in all inbred strains of mice tested, but Ab levels were less than those resulting from vaccination with the F1 polypeptide. In contrast, outbred mice did not respond to the F1 plasmid, suggesting that some inbred mouse strains may exhibit exaggerated responses to plasmid vaccines. A primary immunization with the F1 genetic vaccine followed by a boost with recombinant F1 polypeptide produced a vigorous Ab response from inbred mice that was equivalent to three injections of F1 polypeptide. We conclude that cytosolic expression of the F1 Ag efficiently primes immunity, while secondary exposure to the F1 polypeptide is required for optimal Ab induction.

V antigen of Yersinia pestis inhibits neutrophil chemotaxis

V antigen (V), a secreted protein encoded by the 70 kb low-calcium response plasmid of Yersinia pestis, is an essential virulence factor. In animal models, it inhibits the early host inflammatory response to infection which is associated with decreased blood and tissue levels of proinflammatory cytokine synthesis. To elucidate further the pathogenetic mechanism(s) of V, in vitrosystems are needed to measure and analyse relevant functional activities of V. We studied the effect of V on the migration of neutrophils to a chemoattractant both in vivo and in vitro. Peripheral injection of V was associated with a reduction in the number of PMN migrating into s.c. sponges and i.p. exudates. Similarly, pre-incubating human peripheral blood neutrophils with >/=ng/ml V significantly inhibited the in vitro chemotactic response to the peptide chemoattractant FMLP. The inhibitory activity of V was inactivated by heat and was neutralized by rabbit polyclonal anti-V IgG as well as by sera from mice surviving infection with Y. pestis. Recombinant polyhistidine-tagged V fusion proteins retained biological activity compared to V proteins lacking the tag. Inhibition of chemotaxis appears to be the first demonstration of an in vitro biological effect of V and may be a useful model to elucidate its molecular mechanism of action.

Experimental anthrax vaccines: efficacy of adjuvants combined with protective antigen against an aerosol Bacillus anthracis spore challenge in guinea pigs

The efficacy of several human anthrax vaccine candidates comprised of different adjuvants together with Bacillus anthracis protective antigen (PA) was evaluated in guinea pigs challenged by an aerosol of virulent B. anthracis spores. The most efficacious vaccines tested were formulated with PA plus monophosphoryl lipid A (MPL) in a squalene/lecithin/Tween 80 emulsion (SLT) and PA plus the saponin QS-21. The PA+MPL in SLT vaccine, which was lyophilized and then reconstituted before use, demonstrated strong protective immunogenicity, even after storage for 2 years at 4 degrees C. The MPL component was required for maximum efficacy of the vaccine. Eliminating lyophilization of the vaccine did not diminish its protective efficacy. No significant alteration in efficacy was observed when PA was dialyzed against different buffers before preparation of vaccine. PA+MPL in SLT proved superior in efficacy to the licensed United States human anthrax vaccine in the guinea pig model.

Adoptive CD8+ T-cell immunotherapy of AIDS patients with Kaposi's sarcoma

This article reviews published and original findings from two clinical trials of adoptive CD8+ T-cell immunotherapy of patients with acquired immunodeficiency syndrome (AIDS) and Kaposi's sarcoma (KS). In the first trial, AIDS patients with either KS or oral hairy leukoplakia (OHL) received five rounds of reinfusions of 10(8)-10(10) ex vivo expanded and activated autologous CD8+ T cells. Recombinant interleukin-2 (rIL-2) was coadministered only with the fifth and final infusion. Improvement, and in some cases, resolution of OHL, KS, and candidiasis was observed with no side effects. The observation that clinical improvement of KS was more pronounced when reinfusion of CD8+ T cells was followed by rIL-2 infusion led to a second clinical trial designed to examine the effect of repeated infusions of autologous CD8+ T cells with concomitant rIL-2 administration in the treatment of AIDS-related KS. Improvement of KS status was observed in four out of the eight patients studied (three partial and one complete response). The CD8+ T-cell immunotherapy protocol also provided the opportunity to comparatively study CD8+ T-cell-associated genetic programs. Baseline expression patterns of soluble and surface immune markers by CD8+ T cells from AIDS patients and uninfected controls were predominantly of the type 1 type and differed mainly at a quantitative or kinetic level. Deficiencies in immune mediator expression by CD8+ T cells from AIDS patients tended to dissipate with progression through the protocol. Findings are discussed in the context of current knowledge and therapeutic implications of CD8+ T-cell function in AIDS and neoplasia.

Central arteriovenous malformations of the maxillofacial skeleton: case report

Central arteriovenous malformation of the maxillofacial skeleton, though rare, is a well-documented entity. Past treatments have usually included some form of surgical intervention. Surgical resection as an attempt to cure has been effective but costly, ie, in relationship to patient morbidity and hospital expenditures. A case of vascular malformation is presented in which selective angiography and embolization as a primary treatment were used rather than ablative surgery. The patient tolerated the procedures well, with complete resolution of bleeding.

Spinal bone mineral density measured with quantitative CT: effect of region of interest, vertebral level, and technique

This study documents the relationship between different vertebral bone compartments with quantitative computed tomography (CT). Four distinct patient groups were investigated: healthy pre- and early postmenopausal women as well as healthy and osteoporotic late postmenopausal women. Three different regions of interest (ROIs) were employed: the elliptical ROI located in the anterior trabecular portion of the vertebral body, the peeled ROI of irregular shape that circumscribes most of the trabecular bone, and the integral ROI including all bone except for the transverse processes. Both single- and dual-energy quantitative CT techniques were employed at T-12 through L-3. Correlation between measurements in the elliptical and peeled ROIs was high (r = .985). The authors concluded that either ROI is acceptable for clinical use. The decrements in bone mineral density (BMD) for the integral ROI were smaller than those for the elliptical ROI. Dual-energy measurements were consistently higher than single-energy measurements. BMD as a function of vertebral level decreased systematically from T-12 to L-3. However, the average density of T-12 through L-3 can be accurately predicted by the average density of L-1 and L-2 (r = .997). Precision did not deteriorate significantly when BMD was expressed as the average of L-1 and L-2 (1.5%) instead of T-12 through L-3 (1.4%). In this study the data suggest a modified quantitative CT protocol for clinical applications in which BMD of only L-1 and L-2 are measured at a fixed gantry tilt.

Preventing osteoporosis with exercise: a review with emphasis on methodology

Exercise is thought to have considerable potential as a preventive for osteoporosis. We critically examined 27 studies that address the prophylactic role of exercise in osteoporosis. The results from both cross-sectional and longitudinal studies showed that differences in bone mass were more pronounced in the axial skeleton as opposed to the peripheral compact skeleton. The 17 cross-sectional studies demonstrated greater bone mass among highly trained athletes compared with sedentary subjects, while results among recreational athletes were inconsistent. The 10 prospective investigations examining the effect of exercise on bone mass yielded conflicting results; only one study of six found an overall positive response in compact bone mass at the radial site, and only one study examining the spine showed a significant gain among the exercisers. Additionally, all the prospective investigations included serious methodologic flaws; most failed to employ a randomized design, appropriate estimates of sample size were lacking, none provided information on blind outcome assessment, and most studies were of short duration. Current evidence suggests that exercise may have only limited value in affecting bone mass in the short term and widespread recommendations for the prophylactic use of exercise should await further validation using better methodological rigor.

Precise determination of paraspinous musculature by quantitative CT

The ability to quantify muscular size has important implications in monitoring the effects of muscle disorders, in assessing the efficacy of interventions aimed at abbreviating muscle atrophy, and in examining the association between muscle and bone as a correlate of osteoporosis. We have developed an autocontouring technique for the precise determination of paraspinous musculature that can be implemented as an adjunct to our current CT method of spinal trabecular densitometry without additional scanning time or radiation exposure. Using two distinct patient groups, we evaluated the validity of this technique by assessing intra- and interobserver variability. Using the average coefficient of variation (CV) as an estimate of precision, we found intraobserver variability to be essentially equivalent whether evaluated in young, healthy men (0.69%) or in older, mildly osteoporotic women (0.74%). When the muscle evaluations of two observers were compared, the variability was somewhat higher, 1.81 and 1.83% in older and younger subjects, respectively. We scanned an additional 10 subjects twice, with intermediate repositioning, and found the reproducibility (CV) of determining paraspinous muscle area to be 0.97%. Given this estimated high level of precision, we derived the approximate magnitude of change in muscle size that could be observed using two-point measurements in time. Small average changes, on the order of 1-2%, could be detected using small groups of subjects (10-20/group). Moreover, we found that, even in the individual patient, relatively small changes (3-6%) could be detected given our low imprecision estimate. We believe this quantitative approach holds promise for monitoring muscle changes in vivo as well as for rigorously exploring the relationship between muscle and bone.

Immunological aspects of murine infection with the rat nematode Strongyloides ratti Sandground, 1925

In a study of the immune response of the rat to infection with the nematode Strongyloidis ratti, the antigens of the infective larval stage (L3) and of the parasitic, parthenogenetic female (Fp) were investigated. From both the larvae and the adult females, one metabolic (exoantigen) and two somatic antigens were extracted. Of the two somatic antigens, one was soluble and obtainable by physical means while the other was separated by chemical means from the tegument of the parasite. Humoral responses to the various antigens were evaluated by immunodiffusion and ELISA techniques, while the overall immune response was assayed by the worm burden in the immunized and subsequently infected rats. Agar-gel double diffusion yielded precipitin bands only with larval somatic antigens. ELISA proved positive at a titer of 20,000 with larval metabolic antigen and sera of rats immunized against either larval metabolic or somatic antigens. By 20 days post challenge infection, however, this titer diminished to 4000. In vivo studies of worm burden in rats immunized with the various antigens and then exposed to the live L3 of the nematode showed that there were significantly fewer adult worms in the rats immunized with larval somatic antigen and adult metabolic antigen than in those immunized with adult somatic antigen or larval metabolic antigen.

Effects of anthrax toxin components on human neutrophils

The virulence of Bacillus anthracis has been attributed to a tripartite toxin composed of three proteins designated protective antigen, lethal factor, and edema factor. The effects of the toxin components on phagocytosis and chemiluminescence of human polymorphonuclear neutrophils were studied in vitro. Initially, it was determined that the avirulent Sterne strain of B. anthracis (radiation killed) required opsonization with either serum complement or antibodies against the Sterne cell wall to be phagocytized. Phagocytosis of the opsonized Sterne cells was not affected by the individual anthrax toxin components. However, a combination of protective antigen and edema factor inhibited Sterne cell phagocytosis and blocked both particulate and phorbol myristate acetate-induced polymorphonuclear neutrophil chemiluminescence. These polymorphonuclear neutrophil effects were reversible upon removal of the toxin components. The protective antigen-edema factor combination also increased intracellular cyclic AMP levels. These studies suggest that two of the protein components of anthrax toxin, edema factor and protective antigen, increase host susceptibility to infection by suppressing polymorphonuclear neutrophil function and impairing host resistance.

The glutathione status of Ephestia cautella (Walker) pupae exposed to carbon dioxide

The exposure of E. cautella pupae, 0-24 hr old, to controlled atmospheres high in carbon dioxide reduces their tissue glutathione levels. If the period of exposure is not too long the levels return to control values after three days. Evidence is presented to show that exposure to CO2 inhibits the biosynthesis of glutathione. The implications of such inhibition at cellular and higher levels are discussed.

A study of handicapped children in a typical urban community in Cape Town

The provision of health, welfare, education and community services for children with severe mental retardation and for those with cerebral palsy, and the extent to which these were made use of, were examined. There was found to be a lack of day training facilities and educational services for mentally handicapped children. Day training and educational facilities for the less severely affected children with cerebral palsy were good, but there were no facilities for the untrainable, severely handicapped children. The presence and management of additional handicaps were examined, as were the needs of patients and their families in the regard. The prevalence of mental handicap was 2,5/1000 children aged under 18 years and that of cerebral palsy 1,25/1000.

Ergonovine test in coronary disease

The authors present the role of the Ergonovine test in establishing the diagnosis of the angina produced by coronary spasm. ECG alterations induced by Ergonovine, like transparietal ischemia (monophasic wave) or subendocardic ischemia, not only make possible a correct diagnosis, but they also underline the mechanism of angina and the therapeutical measures. Severe arrhythmias and the danger of sudden death are the two elements illustrating the importance of this coronary spastic mechanism. Nitroglycerine, isosorbidinitrate and calcium antagonists are the drugs of election for the prevention and also for the treatment of coronary spasm.

Triglyceride metabolism in Ephestia cautella pupae exposed to carbon dioxide

The triglyceride content of Ephestia cautella pupae exposed to increased carbon dioxide atmospheres at low relative humidity was not markedly affected. There was a significant increase in weight loss of pupae exposed to low relative humidity. Results indicate that for E. cautella, metabolic water formation by fat utilization can hardly regulate water exigencies for the pupae and cannot fully compensate for water losses in high carbon dioxide atmospheres.