Body Composition and Physical Performance 1 Year After COVID-19

OBJECTIVE

Long-term consequences after COVID-19 include physical complaints, which may impair physical recovery and quality of life.

DESIGN

We assessed body composition and physical ability in patients 12 months after COVID-19. Consecutively recruited patients recovering from mild to severe COVID-19 were assessed using bioelectrical impedance analysis, 6-min-walk test, additional scales for physical performance and health-related quality of life.

RESULTS

Overall physical recovery was good (i.e., Glasgow Outcome Scale-Extended ≥7 in 96%, Modified Rankin Scale ≤1 in 87%, Eastern Cooperative Oncology Group ≤1 in 99%). Forty-four percent of the 69 patients experienced a significant body mass index increase in the year after COVID-19 (≥1 kg/m 2 ), whereas skeletal muscle mass index was reduced in only 12%. Patients requiring intensive care treatment ( n = 15, 22%) during acute COVID-19 more often had a body mass index increase ( P = 0.002), worse 6-min-walk test-performance ( P = 0.044), and higher body fat mass ( P = 0.030) at the 1-yr follow-up when compared with patients with mild ( n = 22, 32%) and moderate ( n = 32, 46%) acute COVID-19. Body mass index increase was also more frequent in patients who had no professional rehabilitation ( P = 0.014).

CONCLUSIONS

Although patients with severe COVID-19 had increased body mass index and body fat and performed worse in physical outcome measures 1 yr after COVID-19, overall physical recovery was satisfying. Translating these findings to variants beyond the Alpha strain of severe acute respiratory syndrome coronavirus 2 virus needs further studies.

Acute TNFα levels predict cognitive impairment 6-9 months after COVID-19 infection

BACKGROUND

A neurocognitive phenotype of post-COVID-19 infection has recently been described that is characterized by a lack of awareness of memory impairment (i.e., anosognosia), altered functional connectivity in the brain's default mode and limbic networks, and an elevated monocyte count. However, the relationship between these cognitive and brain functional connectivity alterations in the chronic phase with the level of cytokines during the acute phase has yet to be identified.

AIM

Determine whether acute cytokine type and levels is associated with anosognosia and functional patterns of brain connectivity 6-9 months after infection.

METHODS

We analyzed the predictive value of the concentration of acute cytokines (IL-1RA, IL-1β, IL-6, IL-8, IFNγ, G-CSF, GM-CSF) (cytokine panel by multiplex immunoassay) in the plasma of 39 patients (mean age 59 yrs, 38-78) in relation to their anosognosia scores for memory deficits via stepwise linear regression. Then, associations between the different cytokines and brain functional connectivity patterns were analyzed by MRI and multivariate partial least squares correlations for the whole group.

RESULTS

Stepwise regression modeling allowed us to show that acute TNFα levels predicted (R² = 0.145; β = -0.38; p = .017) and were associated (r = -0.587; p < .001) with scores of anosognosia for memory deficits observed 6-9 months post-infection. Finally, high TNFα levels were associated with hippocampal, temporal pole, accumbens nucleus, amygdala, and cerebellum connectivity.

CONCLUSION

Increased plasma TNFα levels in the acute phase of COVID-19 predict the presence of long-term anosognosia scores and changes in limbic system functional connectivity.

COVID-19 and its continuing burden after 12 months: a longitudinal observational prospective multicentre trial

Background

Recovery trajectories from coronavirus disease 2019 (COVID-19) call for longitudinal investigation. We aimed to characterise the kinetics and status of clinical, cardiopulmonary and mental health recovery up to 1 year following COVID-19.

Methods

Clinical evaluation, lung function testing (LFT), chest computed tomography (CT) and transthoracic echocardiography were conducted at 2, 3, 6 and 12 months after disease onset. Submaximal exercise capacity, mental health status and quality of life were assessed at 12 months. Recovery kinetics and patterns were investigated by mixed-effect logistic modelling, correlation and clustering analyses. Risk of persistent symptoms and cardiopulmonary abnormalities at the 1-year follow-up were modelled by logistic regression.

Findings

Out of 145 CovILD study participants, 108 (74.5%) completed the 1-year follow-up (median age 56.5 years; 59.3% male; 24% intensive care unit patients). Comorbidities were present in 75% (n=81). Key outcome measures plateaued after 180 days. At 12 months, persistent symptoms were found in 65% of participants; 33% suffered from LFT impairment; 51% showed CT abnormalities; and 63% had low-grade diastolic dysfunction. Main risk factors for cardiopulmonary impairment included pro-inflammatory and immunological biomarkers at early visits. In addition, we deciphered three recovery clusters separating almost complete recovery from patients with post-acute inflammatory profile and an enrichment in cardiopulmonary residuals from a female-dominated post-COVID-19 syndrome with reduced mental health status.

Conclusion

1 year after COVID-19, the burden of persistent symptoms, impaired lung function, radiological abnormalities remains high in our study population. Yet, three recovery trajectories are emerging, ranging from almost complete recovery to post-COVID-19 syndrome with impaired mental health.

332 THE PATIENT EXPERIENCE OF THE OLDER PERSONS REHAB AT HOME (OPRAH) SERVICE

Background

The Older Persons Rehab at Home (OPRAH) team is a novel service developed to provide patients with intensive domiciliary based therapy to regain function, mobility and social care goals. This provides rehabilitation in the patients’ own home and accelerates discharge from the acute care sector. In this study patient and carer experiences of the service were explored.

Methods

Patients were sent a postal questionnaire after discharge from the service to collect information on the patient experience of the OPRAH service. The following measures were collected: satisfaction with the service, experience of interacting with therapy staff, involvement in shared goal setting and achievement of rehabilitation goals. Data from participants who responded to feedback questionnaires from the first 12 months of the service were analysed using descriptive statistics.

Results

Ninety-five participants were sent feedback questionnaires with 31 responses received (33%). 96% of participants reported that they were satisfied with the service, with the same proportion expressing that they both felt they were treated with respect and dignity and that they had confidence and trust in the staff. All respondents felt that they could understand the answers to any questions they had while receiving rehabilitation and 92% of participants understood their rehabilitation goals, with 88% of participants feeling they achieved their rehabilitation goals. 88% of participants felt they were adequately involved in their care planning with 83% of participants feeling their family members had ample opportunity to ask questions during their rehabilitation experience. Results did not different by age group of patient or by time with the service.

Conclusion

In this structured evaluation of the OPRAH team participants highly rated the service. Our results highlight that this integrated approach to care allowed patients to be involved in shared goal setting with the majority of patients satisfied that they achieved their goals.

225 OLDER PERSONS REHAB AT HOME (OPRAH) INDICATES AN EFFECTIVE ALTERNATIVE PATHWAY TO INPATIENT REHABILITATION

Background

Older adults have longer hospital stays, higher incidence of nosocomial complications and higher readmissions rates. Older persons rehabilitation at home (OPRaH) is a novel service developed to provide patients with intensive domiciliary based therapy to regain function, mobility and social care goals. OPRaH offers a comprehensive geriatric and interdisciplinary approach. The model enables a safe and accelerated discharge from acute care to home.

Methods

Patients are identified and screened by a team coordinator. On Discharge to OPRaH the following measures were collected; basic demographics, referral source, clinical frailty score and Functional Independence Measures (FIM). Outcomes evaluated are the FIM change, readmission rates, length of inpatient stay savings and time on the service. Data from the first year of operation was analysed using descriptive statistics.

Results

109 patients have undergone rehabilitation with the service with a median age of 82 years (63-103 range). Over two thirds (68%) were classified as frail, with 44% living alone. An injurious fall was the most common reason for index hospitalisation (50%). Referral source was inpatient acute medical team in 50% of cases, with 21% from acute geriatrics , 13 % ortho geriatrics, 13% surgical. Average functional independence measure scores improved from 89 to 102 (p = 0.007). There was no difference in the magnitude of improvement by frailty status (13 vs 14, p = 0.85). The average length of stay saving was 7 days per case, with a total of 757 days saved in one year. Readmission rate within 30 days was 9.3 %. Participants highly rated the service through structured evaluation.

Conclusion

This novel service provides a valuable intervention to a wide case-mix of older adults with evidence of improvements in formal markers of functional impairment after intervention. Referral was based on definable rehabilitation goals and not just on frailty status, age, or gender.

Frequency of Abnormally Low Neuropsychological Scores in Post-COVID-19 Syndrome: the Geneva COVID-COG Cohort

OBJECTIVE

Several studies have reported poor long-term neuropsychological performances in patients following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but none has yet considered the effect of administering multiple intercorrelated neuropsychological tests and assessed the frequency of cognitive deficits in a normative population. Our aim was therefore to assess the presence of cumulative neuropsychological deficits in an actual post-coronavirus disease of 2019 (COVID-19) comparison group versus one simulated using Monte-Carlo methods.

METHOD

Validated neuropsychological Monte-Carlo simulation methods were applied to scores from a battery of neuropsychological tests (memory, executive, attentional, perceptual, logical reasoning, language, and ideomotor praxis) administered to 121 patients who had had mild, moderate, or severe COVID-19 (mean age: 56.70 years; 32% women), 222 ± 43 days post-infection. The cumulative percentages of the three severity subgroups were compared with the results of a false discovery rate-corrected probability analysis based on normative data.

RESULTS

The cumulative percentages of deficits in memory and executive functions among the severe and moderate patients were significantly higher than those estimated for the normative population. Moderate patients also had significantly more deficits in perception and logical reasoning. In contrast, the mild group did not have significantly more cumulative deficits.

CONCLUSIONS

Moderate and severe forms of COVID-19 cause greater long-term neuropsychological deficits than those that would be found in a normative population, reinforcing the hypothesis of long-term effects of SARS-CoV-2 on cognitive function, independent of the severity of the initial infection.

Chest CT of Lung Injury 1 Year after COVID-19 Pneumonia: The CovILD Study

Background

The long-term pulmonary sequelae of COVID-19 is not well known.

Purpose

To characterize patterns and rates of improvement of chest CT abnormalities 1 year after COVID-19 pneumonia.

Materials and Methods

This was a secondary analysis of a prospective, multicenter observational cohort study conducted from April 29 to August 12, 2020, to assess pulmonary abnormalities at chest CT approximately 2, 3, and 6 months and 1 year after onset of COVID-19 symptoms. Pulmonary findings were graded for each lung lobe using a qualitative CT severity score (CTSS) ranging from 0 (normal) to 25 (all lobes involved). The association of demographic and clinical factors with CT abnormalities after 1 year was assessed with logistic regression. The rate of change of the CTSS at follow-up CT was investigated by using the Friedmann test.

Results

Of 142 enrolled participants, 91 underwent a 1-year follow-up CT examination and were included in the analysis (mean age, 59 years ± 13 [SD]; 35 women [38%]). In 49 of 91 (54%) participants, CT abnormalities were observed: 31 of 91 (34%) participants showed subtle subpleural reticulation, ground-glass opacities, or both, and 18 of 91 (20%) participants had extensive ground-glass opacities, reticulations, bronchial dilation, microcystic changes, or a combination thereof. At multivariable analysis, age of more than 60 years (odds ratio [OR], 5.8; 95% CI: 1.7, 24; P = .009), critical COVID-19 severity (OR, 29; 95% CI: 4.8, 280; P < .001), and male sex (OR, 8.9; 95% CI: 2.6, 36; P < .001) were associated with persistent CT abnormalities at 1-year follow-up. Reduction of CTSS was observed in participants at subsequent follow-up CT (P < .001); during the study period, 49% (69 of 142) of participants had complete resolution of CT abnormalities. Thirty-one of 49 (63%) participants with CT abnormalities showed no further improvement after 6 months.

Conclusion

Long-term CT abnormalities were common 1 year after COVID-19 pneumonia.

© RSNA, 2022

Online supplemental material is available for this article.

See also the editorial by Leung in this issue.

SARS-CoV-2 and Guillain-Barré syndrome: AIDP variant with a favourable outcome

BACKGROUND AND PURPOSE

The spectrum of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2), includes different neurologic manifestations of the central and peripheral nervous system.

METHODS

From March through April 2020, in two university hospitals located in western Switzerland, we examined three patients with Guillain-Barré syndrome (GBS) following SARS-CoV-2.

RESULTS

These cases were characterized by a primary demyelinating electrophysiological pattern (Acute inflammatory demyelinating polyneuropathy or AIDP) and a less severe disease course compared to recently published case series. Clinical improvement was observed in all patients at week five. One patient was discharged from hospital after full recovery with persistence of minor neurological signs (areflexia). Two of the three patients remained hospitalized: one was able to walk and the other could stand up with assistance.

CONCLUSIONS

We report three cases of typical GBS (AIDP) occurring after SARS-CoV-2 infection and presenting with a favourable clinical course. Given the interval between COVID-19-related symptoms and neurological manifestations (mean of 15 days) we postulate a secondary immune-mediated mechanism rather than direct viral damage.

Primary intravascular synovial sarcoma of the femoral vein in a male patient, case report

Synovial Sarcoma (SS) is an aggressive neoplasm commonly affecting deep soft tissues of the extremities. In rare instances SS can arise in large veins of the lower extremities or trunk. We report the first case of intravascular synovial sarcoma (IVSS) occurring in a male patient. A biphasic tumor was diagnosed by histology and immunohistochemistry. Molecular analysis at RNA level confirmed the diagnosis demonstrating the chromosomal translocation t(X;18) (p11.2;q11.2) in the tumor. Although extremely rare, IVSS should be considered in the differential diagnosis of primary intravascular neoplasms and as a potential cause of deep vein thrombosis and thromboembolism.

Double Right Bronchial Artery Aneurysm Treated with Combined Procedures

PURPOSE

Bronchial artery aneurysms occur rarely. We present an unusual case.

CASE REPORT

We present a patient with double right bronchial artery aneurysms that were treated with a combination of endovascular and surgical procedures.

CONCLUSION

This case report illustrates the treatment options for this unusual problem.

The mechanism of galactosamine toxicity revisited; a metabonomic study

1H NMR spectroscopy was used to investigate the metabolic effects of the hepatotoxin galactosamine (galN) and the mechanism by which glycine protects against such toxicity. Rats were acclimatized to a 0 or 5% glycine diet for 6 days and subsequently administered vehicle, galN (500 mg/kg), glycine (5% via the diet), or both galN and glycine. Urine was collected over 12 days prior to administration of galN and for 24 hours thereafter. Serum and liver tissue were sampled on termination, 24 hours post-dosing. The metabolic profiles of biofluids and tissues were determined using high-field 1H NMR spectroscopy. Orthogonal-projection to latent structures discriminant analysis (O-PLS-DA) was applied to model the spectral data and enabled the hepatic, urinary, and serum metabolites that discriminated between control and treated animals to be determined. Histopathological data and clinical chemistry measurements confirmed the protective effect of glycine. The level of N-acetylglucosamine (glcNAc) in the post-dose urine was found to correlate strongly with the degree of galN-induced liver damage, and the urinary level of glcNAc was not significantly elevated in rats treated with both galN and glycine. Treatment with glycine alone was found to significantly increase hepatic levels of uridine, UDP-glucose, and UDP-galactose, and in view of the known effects of galactosamine, this suggests that the protective role of glycine against galN toxicity might be mediated by changes in the uridine nucleotide pool rather than by preventing Kupffer cell activation. Thus, we present a novel hypothesis: that administration of glycine increases the hepatic uridine nucleotide pool which counteracts the galN-induced depletion of these pools and facilitates complete metabolism of galN. These novel data highlight the applicability of NMR-based metabonomics in elucidating multicompartmental metabolic consequences of toxicity and toxic salvage.

31P MAS-NMR of human erythrocytes: independence of cell volume from angular velocity

31P magic angle spinning NMR (MAS-NMR) spectra were obtained from suspensions of human red blood cells (RBCs) that contained the cell-volume-sensitive probe molecule, dimethyl methylphosphonate (DMMP). A mathematical representation of the spectral-peak shape, including the separation and width-at-half-height in the 31P NMR spectra, as a function of rotor speed, enabled us to explore the extent to which a change in cell volume would be reflected in the spectra if it occurred. We concluded that a fractional volume change in excess of 3% would have been detected by our experiments. Thus, the experiments indicated that the mean cell volume did not change by this amount even at the highest spinning rate of 7 kHz. The mean cell volume and intracellular 31P line-width were independent of the packing density of the cells and of the initial cell volume. The relationship of these conclusions to other non-NMR studies of pressure effects on cells is noted.

[Degree of hepatitis C infection risk in the health care setting]

BACKGROUND

Hepatitis C virus is the most important aetiologic agent for non A-non B hepatitis. The study of the prevalence of hepatitis C in health care workers is of primary interest because of the possible chronic evolution and the risk of cirrhosis and liver cancer.

OBJECTIVES

The purpose of this study was to determine the prevalence of HCV among health care workers in 5 main hospitals and local health units in Turin and analyze the influence of occupational and non occupational risk factors.

METHODS

Health care personnel were administered anonymous questionnaires and testing for anti-HCV antibody was performed.

RESULTS

Prevalence rates in 4517 health care workers was 1.97%; the prevalence was higher in elderly workers (> 45 years) than in younger ones. The risk analysis did not reveal any significant correlation between HCV seroconversion and accidental blood exposure. However, a significant correlation was found with non-occupational risk factors. Unapparent infection was an unimportant risk factor for seroconversion.

CONCLUSIONS

Hepatitis C prevalence in the population under study was comparable to that found in the general population. These results point to the need to reconsider the assumption that there is an increase of risk of seroconversion for health-care workers, in the absence of any occupational accidental exposure to hepatitis C virus.

Transmyocardial CO(2) laser revascularization improves symptoms, function, and quality of life: 12-month results from a randomized controlled trial

PURPOSE

To describe differences in health status (symptoms, physical function, and quality of life) between continued medical management and transmyocardial revascularization with a carbon dioxide laser in patients with severe, symptomatic, inoperable coronary artery disease.

SUBJECTS AND METHODS

This prospective, multicenter trial randomized 98 patients to transmyocardial revascularization and 99 to continued medical therapy. Health status was assessed with the Seattle Angina Questionnaire and the Short Form-36 at baseline and at 3, 6, and 12 months. A new analytic technique, the benefit statistic, was developed to facilitate interpretability of disease-specific health status assessments over time.

RESULTS

Of the 99 patients assigned to medical therapy, 59 (60%) subsequently underwent transmyocardial revascularization. By an intention-to-treat analysis, patients initially randomized to transmyocardial revascularization had 44% of their angina eliminated versus 21% for the medical treatment group (difference = 23%; 95% confidence interval [CI], 11% to 34%). Differences in the benefits of transmyocardial revascularization on physical limitations (33% vs 11% in the medical arm [difference = 23%; 95% CI, 15% to 31%]) and quality of life (47% vs 20% in the medical arm [difference = 26%; 95% CI, 18% to 35%]) were similarly large. These benefits were apparent at 3 months and sustained throughout the 1 year of follow-up. An efficacy analysis that excluded patients who crossed over from the medical treatment to transmyocardial revascularization arm suggested greater treatment benefits.

CONCLUSIONS

Transmyocardial revascularization may offer a valuable palliative alternative to patients with severe limitations in health status for whom no standard revascularization options exist.

Investigation of water environments in a C18 bonded silica phase using 1H magic angle spinning (MAS) nuclear magnetic resonance (NMR) spectroscopy

High resolution 1H magic angle spinning (MAS) nuclear magnetic resonance (NMR) spectra have been obtained on typical C18 bonded silicas used in chromatographic solid-phase extraction separations. It has been shown for the first time that water molecules distributed in distinct physico-chemical environments within the chromatographic system can be detected directly using a simple 1H MAS NMR measurement. The resonances assigned to water protons in differing physico-chemical environments have distinct chemical shifts, line widths, relaxation times (T1 and T2) and also exhibit temperature dependent coalescence behaviour. This novel MAS approach may lead to a better understanding of the environments of other analytes in mixtures during such separations.

New-onset delusions and hallucinations in patients infected with HIV

OBJECTIVE

To assess the relationship between HIV-associated psychotic symptoms (i.e., delusions, hallucinations) and demographic, psychopathological and medical variables by comparing patients with and without cerebral opportunistic infections or metabolic encephalopathy.

DESIGN

Cross-sectional study.

PATIENTS

26 patients admitted to hospital with HIV and new-onset psychotic symptoms, defined according to DSM-III-R criteria.

OUTCOME MEASURES

A semistructured psychiatric interview using the Psychopathology Assessment Scale (AMDP-4) of the Association for Methodology and Documentation in Psychiatry system. Comprehensive medical assessments, including laboratory tests and computed tomographic scans, were also performed.

RESULTS

Patients with cerebral opportunistic infections or metabolic encephalopathy (i.e., "secondary" psychosis, n = 13) were more likely to show disorders of consciousness, disorders of orientation and disturbances of attention and memory than those with no evidence of HIV-related cerebral disease (i.e., "primary" psychosis, n = 13); 10 patients (77%) with cerebral opportunistic infections or metabolic encephalopathy and only 1 (8%) patient without (p < 0.001) were diagnosed with delirium. These associations were stronger for the "secondary" patients with no focal brain lesions than for those with lesions.

CONCLUSIONS

These findings suggest that "organic" symptoms of psychosis in those infected with HIV are related to the systemic and cerebral complications of HIV infection rather than to the psychotic process itself.

The role of metals in autoimmune vasculitis: epidemiological and pathogenic study

BACKGROUND

A possible relationship between Silica (Si) exposure and antineutrophil cytoplasm antibodies (ANCA)-associated vasculitis has been reported. Furthermore, tuberculosis (TBC) has been frequently described in patients with silicosis, and TBC infection shares with ANCA-associated vasculitis the formation of granulomas. Therefore, an intriguing network including Silica, Vasculitis, TBC and ANCA might be hypothesized. The aim of this work was to further investigate these correlations using both epidemiological and pathogenic approaches.

METHODS

Study I--epidemiological study. A case-control study to compare the occupational histories of 31 cases of biopsy proven vasculitis (18 pauci-immune crescentic glomerulonephritis, 9 microscopic polyangitis, 4 Wegener's granulomatosis) with those of 58 age, sex and residence-matched controls (affected by other kidney diseases), was performed. Occupational Health physicians designed an appropriate questionnaire in order to evaluate a wide spread of exposures and calculate their entity by the product of Intensity x Frequency x Duration. Study II--tuberculosis association. A case-control study to evaluate the frequency of a previous history of tuberculosis (TBC) in 45 patients with vasculitis and 45 controls were performed. Study III--ANCA positivity. A case-control study to evaluate the presence of ANCA was performed by testing blood samples of 64 people with previous professional exposure and 65 sex/age matched patients hospitalized in a General Medicine Unit. Furthermore, the same evaluation was made in a pilot study in 16 patients with ongoing or previous TBC. Study IV--experimental study. The oxygen free radicals (OFR) and IL-12 production (both involved in the pathogenesis of vasculitis) from human phagocytic cells stimulated with an amorphous (diatomaceous earth) and a crystalline (quartz) form of Si at the doses of 10 and 100 microg ml(-1) was evaluated.

RESULTS

Study I--a positive history of exposure to Si resulted in significantly more present in cases (14/31 = 45%) than in controls (14/58 = 24%, P = 0.04, OR = 2.4) and no other significant exposure association was found (including asbestos, mineral oil, formaldehyde, diesel and welding fumes, grain and wood dust, leather, solvents, fungicides, bitumen, lead and paint). Study II--past TBC infection was significantly more present in patients with vasculitis (12/45 = 26%) than in controls (4/45 = 8%, P < 0.05). Study III--ANCA was present in 2/64 exposed people (vs. 0/65 controls, P = NS) and 0/16 patients with TBC. Study IV--both amorphous and crystalline Si forms represented a stimulus for OFR and IL-12 production, but quartz resulted as a greater inductor.

CONCLUSIONS

We conclude that Si exposure might be a risk factor for ANCA-associated vasculitis, possibly enhancing endothelial damage by phagocyte generation of oxygen free radicals and Th1 differentiation by an excessive IL-12 phagocyte production. Frequency of TBC was significantly higher in vasculitis patients. ANCA was not frequent in the preliminary examination of people with previous professional exposure or patients with TBC, but the number of samples evaluated is too small to allow conclusions.

Novel inhibitors of Erm methyltransferases from NMR and parallel synthesis

The Erm family of methyltransferases confers resistance to the macrolide-lincosamide-streptogramin type B (MLS) antibiotics through the methylation of 23S ribosomal RNA. Upon the methylation of RNA, the MLS antibiotics lose their ability to bind to the ribosome and exhibit their antibiotic activity. Using an NMR-based screen, we identified a series of triazine-containing compounds that bind weakly to ErmAM. These initial lead compounds were optimized by the parallel synthesis of a large number of analogues, resulting in compounds which inhibit the Erm-mediated methylation of rRNA in the low micromolar range. NMR and X-ray structures of enzyme/inhibitor complexes reveal that the inhibitors bind to the S-adenosylmethionine binding site on the Erm protein. These compounds represent novel methyltransferase inhibitors that serve as new leads for the reversal of Erm-mediated MLS antibiotic resistance.

Intractable pruritus in HIV infection: immunologic characterization

BACKGROUND

Severe, intractable pruritus, often associated with erythematopapular skin lesions and hypereosinophilia, is a condition observed in some nonatopic, HIV-infected patients. We performed immunovirologic analyses of this condition.

METHODS

Immunologic (mitogen-stimulated production of cytokines, tumor necrosis factor-alpha [TNF-alpha], and soluble CD23; serum levels of soluble CD23, ICAM-1, TNF-alpha, IgG, IgE, and IgA) and virologic (HIV viral load) parameters were analyzed in six patients with therapy-resistant pruritus. Hypereosinophilia was present in all these patients. Results were compared to those of seven HIV-seropositive individuals similar to the first one in terms of CD4 counts and clinical staging, but without pruritus.

RESULTS

Hypereosinophilia; hyper-IgE and hyper-IgA; augmented interleukin (IL)-4, IL-5, and sCD23; and reduced interferon-gamma production by mitogen-stimulated peripheral blood mononuclear cells (PBMC) were detected when patients with pruritus were compared to HIV controls. HIV viral load was also augmented in patients in whom pruritus was present.

CONCLUSIONS

The results suggest that therapy-resistant, intractable pruritus accompanied by hypereosinophilia may be used to define a subset of HIV-seropositive individuals showing prototypic hyperactivation of humoral immunity, and in whom augmented HIV viral load is present.

Scapular avulsion fracture of a high school wrestler

This case study details a rare injury managed conservatively with aggressive therapy with early return to competition. A 17-year-old high school wrestler suffered indirect trauma to the right upper extremity. The patient was forced to the mat where he felt pain in the posterior aspect of his shoulder and was point tender over the inferior pole of his right scapula. Radiographs reveal an avulsion fracture at the inferior angle of the scapula. Aggressive therapy included modalities to control inflammation and muscle guarding in addition to early scapular mobility. Maintenance of glenohumeral motion and upper extremity strengthening was started within a week. The patient was able to wrestle in the state tournament 3 weeks after initial injury. At the 6-month follow-up, the patient had no clinical tenderness, full range of motion, and no motor deficits. The outcome resulted in clinical and radiological healing of the fracture and no functional deficits.

Quadrupled semitendinosus-gracilis autograft fixation in the femoral tunnel: a comparison between a metal and a bioabsorbable interference screw

Although semitendinosus-gracilis (SG) grafts for anterior cruciate ligament reconstruction have many potential benefits, effective fixation remains a challenge. This study assessed differences between the maximum pullout forces needed to detach a quadrupled SG graft from a femoral tunnel when secured by either a metal or a bioabsorbable interference screw. Sixteen paired fresh frozen quadrupled SG autografts (x, 8.4 mm; range, 7-10 mm) from 8 donors were anchored into cadaveric femoral tunnels by either a 7-mm metal or a 7-mm bioabsorbable screw after bone mineral density (BMD) assessment and before undergoing a longitudinal 20 mm/min traction force. Statistical analysis compared BMD (gm/cm2), insertional torque (N-m), and maximum load at pullout (N) between screw types. Insertional torques (.28-1.21, N-m range) did not correlate (P>.05) to BMD or maximum load at pullout (x +/- S.D.) 242 +/- 90.7 N (metal screw) and 341.1 +/- 162.9 N (bioabsorbable screw). Differences did not exist between the maximum load at pullout for bioabsorbable or metal screw fixation (P = .16). Careful graft preparation, sizing, and matched tunnel placement enables interference fit and fixation capable of reliably withstanding the low-level rehabilitation loads to which the graft is exposed until bony ingrowth occurs.

Interferon-alpha is effective in the treatment of HIV-1-related, severe, zidovudine-resistant thrombocytopenia. A prospective, placebo-controlled, double-blind trial

OBJECTIVE

To determine the effect of interferon-alpha for severe, zidovudine-resistant, HIV-1-related thrombocytopenia.

DESIGN

Prospective, randomized, double-blind, placebo-controlled, multicenter, crossover trial.

SETTING

Outpatient clinics in Central Northern Italy.

PATIENTS

15 sequential patients positive for HIV-1 with platelet counts less than 25 x 10(9)/L who were refractory to 1 month of full-dose (1000 mg/d) zidovudine.

INTERVENTION

Interferon-alpha (3 million units) or placebo (1 mL saline) three times a week subcutaneously for 4 weeks, followed by a 4-week washout period. Patients were then switched to the alternative treatment for the next 4 weeks, followed by another 4 weeks of washout, and they were randomly assigned to either sequence of treatment. Patients received zidovudine (200 mg three times daily) throughout the study.

MEASUREMENTS

The primary end point was the platelet count (measured weekly). Secondary end points were qualitative assessment of the platelet response; bleeding time; p24 antigen in serum; CD4/CD8 counts; beta 2-microglobulin in serum; and platelet-associated IgG.

RESULTS

Interferon-alpha significantly increased platelet counts in the 12 patients who completed the study (baseline level, 15.6 +/- 7.1 x 10(9)/L; after 4 weeks of interferon-alpha therapy, 82.2 +/- 52.2 x 10(9)/L). The estimated increase in the platelet count after interferon-alpha compared with placebo was 60.0 x 10(9)/L (95% CI, 23.2 to 96.8 x 10(9)/L). The increase was already statistically significant after 3 weeks (66.6 +/- 49.7 x 10(9)/L) and remained significantly increased 1 week after discontinuing interferon-alpha therapy (58.2 +/- 45.0 x 10(9)/L). Placebo did not modify the platelet count. The bleeding time was significantly shortened by interferon-alpha. Four of 12 patients who had more serious alterations of some measures reflecting disease severity did not respond to interferon-alpha. No relevant side effects were observed.

CONCLUSIONS

Interferon-alpha is a safe and effective treatment for zidovudine-resistant, HIV-related thrombocytopenia.

Comparison of two dose regimens of zidovudine in an open, randomized, multicentre study for severe HIV-related thrombocytopenia

OBJECTIVE

To compare the effect of two dose regimens of zidovudine in the treatment of severe HIV-related thrombocytopenia (TP).

DESIGN

Eighty-four patients with severe HIV-related TP and platelet counts < 50 x 10(9)/l were enrolled in an open study at six centres. Patients were randomized into two groups to receive zidovudine (group A, 500 mg per day; group B, 1000 mg per day) for 6 months.

METHODS

Platelet counts were determined monthly and patients categorized as complete responders (CR; platelets > 100 x 10(9)/l), partial responders (PR; platelets > 50 to < 100 x 10(9)/l), or failures (F; platelets to < 50 x 10(9)/l). CD4+ and CD8+ lymphocytes, HIV antigenaemia, beta 2-microglobulin, white blood cells, mean cell volume and haemoglobin were also determined.

RESULTS

Seventy-one patients (35 and 36 in groups A and B, respectively) completed the study; 11.4% of group A patients were CR and 45.7% PR; 38.9% of group B were CR and 33.3% PR. Increase in mean platelet counts was dose-related, more rapid in the higher dose group and remained significantly higher after 6 months of treatment (56.4 x 10(9)/l in group A versus 98.2 x 10(9)/l in group B; P < 0.01).

CONCLUSIONS

The results confirm the efficacy of zidovudine in the treatment of severe HIV-related TP. The average for CR and PR in the two groups was 64.8%; the higher dose of zidovudine was more effective at increasing platelet counts.

Long-term treatment with zidovudine in patients with human immunodeficiency virus (HIV)-associated thrombocytopenia: modes of response and correlation with markers of HIV replication

The effects of zidovudine on the platelet count were studied in 152 patients with HIV-related thrombocytopenia of severe grade (platelet count < 50 x 10(9)/l) and moderate grade (platelet count < 100 and > 50 x 10(9)/l). In both groups of patients there was a significant increase in the mean platelet count from the baseline value, after 2 weeks (from 21 x 10(9)/l to 48 x 10(9)/l and from 75 x 10(9)/l to 97 x 10(9)/l) and 3 months of therapy (to 59 x 10(9)/l and to 144 x 10(9)/l). Sixty-five and 39 patients were followed up for 12 and 18 months, respectively, and the mean platelet values after 12 and 18 months of therapy were still significantly increased, compared to the respective mean baseline values, in both groups of patients. Clinical progression of the disease was observed in 23 treated patients, none of them showing concomitant reductions of the platelet number. An increase in the mean CD4+ cell count after 3 months of therapy was followed by a progressive decline in the 65 patients with a 12-month follow-up, while no significant changes of the p24 antigenemia rates were observed after 1 year of therapy in 53 patients evaluated. The long-term effects of zidovudine on the platelet count, but not on other parameters of clinical outcome, might be explained by the involvement of specific mechanisms in the pathogenesis of this kind of thrombocytopenia and of its response to zidovudine.