Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS. DATABASES AND DATA TREATMENT: A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain"). RESULTS: Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life. CONCLUSION: The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach. SIGNIFICANCE: The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.

Comparative FE biomechanical and microbial adhesion analyses on an implanted humerus.

Objective: In this study a multi fragment humeral fracture, treated with locking plate system implant, was investigate and compared with a healthy humerus by the mining of a Finite Element (FE) analysis. Locking plate implant, in this case AxSOS 3® Titanium produced by Stryker is the preferred solution in presence of multiple fracture or osteoporosis. Methods: Loading conditions were imposed by rotating of 52,5° respect the vertical axe, both the humeri (healthy and fractured), fixing distal end, and loading the top of bones with a vertical force of 543 N (Newton). This finite element analysis aimed to compare stability of implanted humerus, implant-bone interface, stress shielding, with those related to a healthy one. A microbial adhesion analysis was also performed on the implant's material. Results: Results obtained by FE analysis confirm a good agreement of the mechanical behavior of the models tested. The maximum values of the registered stressed, are of about 45 MPa (Mega Pascal) for the intact humerus and 113 MPa for the fractured one. Displacements, confirm higher values on the fractured humerus and no viable bacteria were found after microbial adhesion analyses.Conclusion: comparison between healthy and fractured humerus showed an optimal stability of the implant, when contact surfaces optimization and screws insertion are correctly performed.

Traumatic and non-traumatic spinal cord injury: Demographic characteristics, neurological and functional outcomes. A 7-year single centre experience.

Objective: The aim of this study is to evaluate demographic and clinical characteristics of a population affected by traumatic and non-traumatic spinal cord injury (SCI) and to analyze functional outcomes after rehabilitation. Methods: This study involved 112 SCI patients (75 male and 37 female) admitted at the Neurorehabilitation Unit of the University Hospital of Messina. The neurological outcomes were evaluated according to the American Spinal Injury Association Impairment Scale (AIS) and by using length of stay, Functional Independence Measure (FIM) and Barthel Index (BI). Results: NT-SCI patients were significantly older, numerous (75,89%) and affected by greater lesions when admitted, than T-SCI ones. Most of lesions were incomplete (93%) and associated with paraplegia (71%). FIM and BI outcomes are similar in both groups, even if T-SCI patients showed greater improvement when discharged. No significant differences were found in the length of stay. The most common complication in non-traumatic SCI group was urinary tract infection and this was observed in 25 patients (29,41%). Linear regression models explained 26% of the variance of LOS and 38% of the variance of functional outcome. Functional status on admission was the strongest determinant of LOS and completeness of the lesion was the strongest determinant of functional outcome. Etiology (traumatic versus non-traumatic) was a weak independent determinant of LOS but was not an independent determinant of functional outcome. Conclusion: SCI patient's rehabilitation should be carried out by taking into account etiology of the injury. It is important to consider this information while developing the targets and planning of the rehabilitation program. In particular, older age negatively influence the degree of disability on admission and the entity of functional recovery in both populations. Non-traumatic lesions could have minor benefits after rehabilitation therapy if compared with traumatic ones.

Statistical investigation about spinal clinical asymmetry in a school population.

BACKGROUND: Spinal disorders and obesity are increasing and are an important cause for concern among healthcare and educational bodies. There is a wide variability in the literature of clinical positivity for scoliosis in the examination of the spine. AIM: Our study aims to investigate a relationship between scoliosis hump in schoolchildren and obesity, evaluating different kind of variables. METHODS: The sample was comprised by 478 schoolchildren from Italy, with a mean age of 12.6 years (SD: 1.861). They were classified by using ATR test, body mass index (BMI), the Edinburgh Inventory, the deep flexion test. RESULTS: Results of ATR test evidence 26 subjects (5,4%) positive for ATR ≥ 7; 102 subjects (21,3%) positive for ATR ≥ 6; and finally 191 subjects (40,0%) positive for ATR ≥ 5. There were 191 (40%) subjects with scoliosis; obesity was present in 62 (13%) cases and, after the regression, associations were found between scoliotic posture and gender, presence of obesity, and flexibility. CONCLUSIONS: Our study confirms a relationship between obesity and scoliosis, which increases with the age. Female subjects have higher risks to develop humps and spinal disorders. It is advisable to use a combination of several parameters to achieve a more sensitive evaluation.

Tuberculosis transmission of predominant genotypes of Mycobacterium tuberculosis in northern suburbs of Buenos Aires city region.

In 2003, the incidence of tuberculosis in Argentina showed an increase compared to 2002. The severe national crisis at the end of the 90s has probably strongly contributed to this situation. The goal of this work was to estimate the extent of the spread of the most predominant Mycobacterium tuberculosis strains and to assess the spread of predominant M. tuberculosis clusters as determined by spoligotyping and IS6110 RFLP. The study involved 590 pulmonary, smear-positive TB cases receiving medical attention at health centers and hospitals in Northern Buenos Aires (NBA) suburbs, from October 2001 to December 2002. From a total of 208 clinical isolates belonging to 6 major clusters, 63 (30.2%) isolates had identical spoligotyping and IS6110 RFLP pattern. Only 22.2% were shown to have epidemiological connections with another member of their respective cluster. In these major clusters, 30.2% of the 208 TB cases studied by both molecular techniques and contact tracing could be convincingly attributable to a recently acquired infection. This knowledge may be useful to assess the clonal distribution of predominant M. tuberculosis clusters in Argentina, which may make an impact on TB control strategies.

First description of Mycobacterium tuberculosis Beijing genotype in Argentina.

During a population-based study to genotype isolates of Mycobacterium tuberculosis from Buenos Aires Northern suburbs, we found isolates with molecular patterns related to those of the Beijing genotype. Five out of 590 (0.85%) patients had isolates with spoligopattern identical to that of the Beijing family. Since two of these isolates showed identical IS6110RFLP pattern, we found only four different patterns containing 11 to 19 bands. The isolates were obtained from young people (including a 7 years-old child) who were born in Argentina, and were living in a small area of our region. However, conventional contact tracing did not prove epidemiological linkage among them. These isolates were fully drug-susceptible to the first-line drugs. The comparison of the IS6110RFLP patterns from our isolates against a set of 19 reference Beijing patterns from the RIVM (The Netherlands) confirmed that the strains belonged to the Beijing lineage. These findings might be partially explained by the important migration phenomena occurred during the last decade. Further surveillance studies would help in the following of Beijing family strain dissemination in our community.

Cloning of a novel polymorphic GC-rich repetitive DNA from Mycobacterium bovis.

A repetitive DNA from a wild-type Mycobacterium bovis isolate was cloned and characterized. The repeated segment was present in M. bovis and M. tuberculosis but was absent from the six other mycobacteria tested. Sequence analysis demonstrated that this repetitive element belonged to the polymorphic GC-rich repeat sequence type, a family of interspersed repeated DNA. This fragment, when used as a probe in restriction fragment length polymorphism analyses, was able to detect polymorphism in M. bovis genotypes that went undetected when the established IS6110 was used as a probe. This repetitive element should be useful in epidemiological studies of bovine tuberculosis.

An mpb-64 flanking sequence specific for Mycobacterium bovis.

A clone carrying a plasmid with the mpb-64 gene and 3' flanking sequences (plasmid pMBA122) was detected during the screening of a Mycobacterium bovis genomic library with sera from infected cattle. When the pMBA122 insert was used as a probe in Southern blots against PvuII-digested mycobacterial DNA, it distinguished the different M. tuberculosis complex species. This probe hybridized with a 7-kb band in M. tuberculosis, a 5-kb band in M. bovis and a 3-kb band in M. tuberculosis complex strains from wild seals. Smal genomic digestions enabled us to locate this polymorphic region downstream of the mpb-64 gene. In order to clone this particular region, we designed a pair of PCR primers. Unexpectedly, these primers amplified only M. bovis DNA; no amplification was seen in M. tuberculosis DNA. When the annealing temperature was lowered from 70 to 55 degrees C, an amplification product of the same size was obtained with M. tuberculosis. This product was cloned and sequenced, and showed partial homology to the M. bovis amplified fragment. Therefore, this region comprises M. bovis sequences with a lower homology with M. tuberculosis than other compared sequences. This suggests that a more precise differentiation method at the species level for the M. tuberculosis complex could be achieved using PCR directed to this region.

A low cost, home-made, reverse-line blot hybridisation assay for rapid detection of rifampicin resistance in Mycobacterium tuberculosis.

SETTING: Cetrangolo Hospital, Vicente Lopez, Argentina, 1995-1999. OBJECTIVE: To describe a home-made reverse-line blot hybridisation assay for the detection of rifampicin resistance-associated mutations in the rpoB gene of Mycobacterium tuberculosis, and to evaluate the usefulness of this rifampicin oligonucleotide, or 'RIFO' assay, to predict rifampicin resistance. DESIGN: A total of 135 M. tuberculosis isolates from the Cetrangolo Hospital were tested using the RIFO assay, the proportion method and the Mycobacterial Growth Indicator Tube (MGIT 960). In addition, 120 drug-susceptible isolates from the Netherlands were included. RESULTS: The results obtained with the proportion method and the MGIT 960 system were in full agreement. In the RIFO assay, 90 of the 97 rifampicin-resistant isolates were correctly identified (sensitivity 92.8%, positive predictive value 100%). All of the drug-susceptible isolates were correctly predicted by the RIFO assay. CONCLUSIONS: With this home-made molecular test, rifampicin resistance in M. tuberculosis can be predicted in colonies isolated in culture in only 1 day, and can therefore shorten the laboratory turn around time for rifampicin susceptibility testing by weeks. In principle the test can also be applied directly to Zichl-Neelsen slides and clinical material, as has been demonstrated for another reverse-line blot-based assay for M. tuberculosis, spoligotyping.

Evaluation of the polymerase chain reaction for the detection of Mycobacterium tuberculosis.

The development of nucleic acid-based technologies has improved the sensitivity, specificity and speed of detection of Mycobacterium tuberculosis in clinical samples. Both commercially available and 'in-house' polymerase chain reaction (PCR) systems are in use, and a significant number of reports compare such systems with more traditional diagnostic tools for tuberculosis. Few studies, however, have focused on the reproducibility of the results when submitting a sample batch to PCR in different laboratories, especially in developing countries. Consequently, PCR results obtained from six laboratories in six different Latin American countries for samples reconstituted with defined amounts of M. tuberculosis cells were evaluated. Each laboratory used specific conditions of sample processing, nucleic acid amplification and amplicon detection. Analysis of results allowed large differences in sensitivity and specificity to be observed. We conclude that in its present setting, in-house PCR cannot be used as a single diagnostic tool for tuberculosis, and that special care needs to be taken upon interpretation of results by inclusion of a proper number of positive and negative controls.

Antigenic characterization of mycobacteria from South American wild seals.

Tuberculosis-producing mycobacteria have been previously described in marine mammals (Cousins et al., 1990, 1993; Romano et al., 1995; Bernardelli et al., 1996). The strains belonged to the M. tuberculosis complex (M. tuberculosis, M. bovis, M. microti and M. africanum), but showed genetic and biochemical differences. The antigenic composition of mycobacteria isolated from wild seals was analyzed by Western blots, using antibodies against some selected antigens. The antigenic content was compared with that of M. bovis, M. tuberculosis and M. microti isolates. The lack of Hsp65 protein in supernatants suggested a low degree of cell lysis in the three-week cultures used. SOD, P27 lipoprotein, MPB64 and antigen 85 were observed in all the strains studied. The wild seal strains, as well as M. tuberculosis, did not produce MPB70 and MPB83. Only very weak bands of P36 antigen were observed in culture supernatants from wild seal mycobacteria. Summarizing, the antigenic composition of mycobacterial strains from wild seals is different from M. bovis strains.

Genetic characterization of mycobacteria from South American wild seals.

Tuberculosis has been recently diagnosed in four wild seals found stranded in the Atlantic coast of Argentina. By bacteriological studies and IS6110 hybridization, these isolates were characterized as belonging to the Mycobacterium tuberculosis complex. A genetic characterization using RFLP (Restriction fragment length polymorphism) and a species-specific probe of M. tuberculosis, called mtp40, showed hybridization with this probe on a single band. A similar band was also found in M. tuberculosis H37Rv. This showed a relationship between M. tuberculosis and the wild seal isolates. However these would also seem to belong to a different genetic group in the M. tuberculosis complex, since they do not grow on glycerol-egg containing medium (Lowenstein-Jensen) as typical M. tuberculosis strains usually do. Repeated sequences pMBA2, pTNB12, DR and IS6110 were used as probes to evaluate the epidemiological relationships between the 4 cases of tuberculosis. A low degree of polymorphism was observed, that suggested that these isolates were epidemiologically related.

Comparison of different genetic markers for molecular epidemiology of bovine tuberculosis.

In the present study three different genetic markers were used in an RFLP study to differentiate Mycobacterium bovis (M. bovis) isolated in Argentina. The markers were: the insertion sequence IS6110, the direct repeat (DR) sequence flanking IS6110, and a polymorphic GC-rich repetitive sequence (PGRS), called pMBA2. Two restriction enzymes were used, PvuII for IS6110 and DR (DR/PvuII) and AluI for DR (DR/AluI) and pMBA2. DNA from 85 of M. bovis isolates was digested with PvuII and hybridized with IS6110 and Dr. IS6110 was not useful to differentiate M. bovis because most of the isolates contain a single monomorphic copy. The use of DR allowed a limited degree of differentiation. DNA from 44 of these isolates was also digested with AluI and hybridized with DR and pMBA2. In this condition these probes differentiated the isolates in many different RFLP types. By combining the patterns generated with DR/AluI and pMBA2 it was possible to increase the differentiation up to obtain 30 different RFLP types and 54% of the isolates were differentiated because they showed a unique pattern. Six isolates of M. bovis involved in two different outbreaks of bovine tuberculosis were correctly identified. Thus, DR and pMBA2 could be, at the moment, the probes of choice for comparisons of M. bovis isolates in different regions and for epidemiological surveillance of bovine tuberculosis.

Molecular epidemiology of Mycobacterium bovis isolates from South America.

One hundred seventy-eight isolates of Mycobacterium bovis were subjected to DNA restriction fragment length polymorphism (RFLP) analysis, using the direct repeat element (DR) and the polymorphic GC-rich repeat sequence (PGRS) as probes. By combining the patterns generated by the two repeat DNA elements, 93 different patterns were observed. One hundred-one isolates were grouped in clusters, which include 25 different clusters. One pattern was the most frequently observed, clustering 18.5% of isolates. It was only found in the Center and northeast regions of Argentina and in one isolate from Paraguay. The isolates from Brazil analyzed here presented exclusive patterns (only found in a particular region). The number of exclusive patterns was high in all argentine regions: northeast 78%, center 81%, and Buenos Aires 81%.

Identification of Mycobacterium bovis antigens by analysis of bovine T-cell responses after infection with a virulent strain.

Purification and characterization of individual antigenic proteins are essential for the understanding of the pathogenic mechanisms of mycobacteria and the immune response against them. In the present study, we used anion-exchange chromatography to fractionate cell extracts and culture supernatant proteins from Mycobacterium bovis to identify T-cell-stimulating antigens. These fractions were incubated with peripheral blood mononuclear cells (PBMC) from M. bovis-infected cattle in lymphoproliferation assays. This procedure does not denature proteins and permits the testing of mixtures of potential antigens that could be later identified. We characterized protein fractions with high stimulation indices from both culture supernatants and cell extracts. Proteins were identified by two-dimensional gel electrophoresis followed by N-terminal sequencing or MALDI-TOF. Culture supernatant fractions containing low molecular weight proteins such as ESAT6 and CFP10 and other proteins (85B, MPB70), and the novel antigens TPX and TRB-B were associated with a high stimulation index. These results reinforce the concept that some low molecular weight proteins such as ESAT6 and CFP10 play an important role in immune responses. Also, Rv3747 and L7/L12 were identified in high stimulation index cell extract fractions. These data show that protein fractions with high lymphoproliferative activity for bovine PBMC can be characterized and antigens which have been already described and new protein antigens can also be identified in these fractions.

Expression of the Mycobacterium bovis P36 gene in Mycobacterium smegmatis and the baculovirus/insect cell system.

In the present study we evaluated different systems for the expression of mycobacterial antigen P36 secreted by Mycobacterium bovis. P36 was detected by Western blot using a specific antiserum. The P36 gene was initially expressed in E. coli, under the control of the T7 promoter, but severe proteolysis prevented its purification. We then tried to express P36 in M. smegmatis and insect cells. For M. smegmatis, we used three different plasmid vectors differing in copy number and in the presence of a promoter for expression of heterologous proteins. P36 was detected in the cell extract and culture supernatant in both expression systems and was recognized by sera from M. bovis-infected cattle. To compare the expression level and compartmentalization, the MPB70 antigen was also expressed. The highest production was reached in insect cell supernatants. In conclusion, M. smegmatis and especially the baculovirus expression system are good choices for the production of proteins from pathogenic mycobacteria for the development of mycobacterial vaccines and diagnostic reagents.

Multidrug resistant tuberculosis outbreak in Buenos Aires. DNA fingerprinting analysis of isolates.

In order to determine the possible relationship among HIV patients coinfected with multidrug resistant tuberculosis strains who had been receiving clinical assistance in our Hospital, clinical and epidemiological information from 28 patients was collected. DNA fingerprinting by restriction fragment length polymorphism (RFLP) pattern was performed on the mycobacterial isolates from these patients, using the restriction enzyme Pvull and IS 6110 as genetic marker. A unique RFLP pattern was found in 10 isolates from 10 different patients who had a disease caused by a single strain. Our findings confirm RFLP as a reliable and useful tool to analyze TB transmission.

[The genotype of the principal Mycobacterium bovis in Argentina is also that of the British Isles: did bovine tuberculosis come from Great Britain?]. / El genotipo de Mycobacterium bovis mayoritario en la Argentina lo es también en las islas Británicas: la tuberculosis bovina provino de Gran Bretaña?

Bovine tuberculosis is a highly prevalent animal disease in Argentina. In this work evidence was obtained showing that a major Mycobacterium bovis group in Argentina had been introduced with the bovine bulls imported from the United Kingdom at the end of the XIX century. This evidence came from two sources: historical, obtained by bibliographical references, and from laboratory results, using a molecular typing method called spoligotyping. These strains are also present in other countries that introduced cattle from the same origin.