COVID-19 outbreaks in hospital workers during the first COVID-19 wave.

BACKGROUND: Health care workers (HCWs) are on the frontline, playing a crucial role in the prevention of infection and treatment of patients. AIMS: This study was aimed to evaluate the prevalence of hospital-acquired coronavirus disease 2019 (COVID-19) infection at work and related factors at the University Hospital of Trieste workers exposed to COVID-19 patients. METHODS: From March 1 to May 31, of 4216 employees, 963 were in contact with COVID-19 patients or colleagues and were followed up. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in nasopharyngeal swabs was determined every 3 days, by RT-PCR. RESULTS: During the follow-up period, 193 workers were positive for COVID-19 (5%), and 165 of these (86%) were symptomatic. We identified five major cluster outbreaks of COVID-19 infection in Trieste Hospitals, four of which occurred before the implementation of universal masking for HCWs and patients (1-14 March 2020). COVID-19 infection was significantly higher in high-risk ward workers (Infectious Diseases, and Geriatric and Emergency Medicine, odds ratio [OR] 13.4; 95% confidence interval [CI] 5.8-31), in subjects with symptoms (OR 5.4; 95% CI 2.9-10) and in those with contacts with COVID-19 patients and colleagues (OR 2.23; 95% CI 1.01-4.9). CONCLUSIONS: Hospital workers were commonly infected due to contact with COVID-19 patients and colleagues, mainly in the first 15 days of the pandemic, before the implementation of universal mask wearing of HCWs and patients. Repetitive testing and follow-up permitted the identification of COVID-19 cases before symptom onset, obtaining better infection prevention and control.

Serum dehydroepiandrosterone sulphate, psychosocial factors and musculoskeletal pain in workers.

Background: The serum level of dehydroepiandrosterone sulphate (DHEA-S) has been suggested as a biological marker of stress. Aims: To assess the association between serum DHEA-S, psychosocial factors and musculoskeletal (MS) pain in university workers. Methods: The study population included voluntary workers at the scientific departments of the University of Trieste (Italy) who underwent periodical health surveillance from January 2011 to June 2012. DHEA-S level was analysed in serum. The assessment tools included the General Health Questionnaire (GHQ) and a modified Nordic musculoskeletal symptoms questionnaire. The relation between DHEA-S, individual characteristics, pain perception and psychological factors was assessed by means of multivariable linear regression analysis. Results: There were 189 study participants. The study population was characterized by high reward and low effort. Pain perception in the neck, shoulder, upper limbs, upper back and lower back was reported by 42, 32, 19, 29 and 43% of people, respectively. In multivariable regression analysis, gender, age and pain perception in the shoulder and upper limbs were significantly related to serum DHEA-S. Effort and overcommitment were related to shoulder and neck pain but not to DHEA-S. The GHQ score was associated with pain perception in different body sites and inversely to DHEA-S but significance was lost in multivariable regression analysis. Conclusions: DHEA-S was associated with age, gender and perception of MS pain, while effort-reward imbalance dimensions and GHQ score failed to reach the statistical significance in multivariable regression analysis.

Antigen-specific cytotoxic T lymphocytes target airway CD103+ and CD11b+ dendritic cells to suppress allergic inflammation.

Allergic airway inflammation is driven by the recognition of inhaled allergen by T helper type 2 (Th2) cells in the airway and lung. Allergen-specific cytotoxic T lymphocytes (CTLs) can strongly reduce airway inflammation, however, the mechanism of their inhibitory activity is not fully defined. We used mouse models to show that allergen-specific CTLs reduced early cytokine production by Th2 cells in lung, and their subsequent accumulation and production of interleukin (IL)-4 and IL-13. In addition, treatment with specific CTLs also increased the proportion of caspase(+) dendritic cells (DCs) in mediastinal lymph node (MLN), and decreased the numbers of CD103(+) and CD11b(+) DCs in the lung. This decrease required expression of the cytotoxic mediator perforin in CTLs and of the appropriate MHC-antigen ligand on DCs, suggesting that direct CTL-DC contact was necessary. Lastly, lung imaging experiments revealed that in airway-challenged mice XCR1-GFP(+) DCs, corresponding to the CD103(+) DC subset, and XCR1-GFP(-) CD11c(+) cells, which include CD11b(+) DCs and alveolar macrophages, both clustered in the areas surrounding the small airways and were closely associated with allergen-specific CTLs. Thus, allergen-specific CTLs reduce allergic airway inflammation by depleting CD103(+) and CD11b(+) DC populations in the lung, and may constitute a mechanism through which allergic immune responses are regulated.

[Occupational risks and health disorders in transport drivers]. / Rischi e malattie nei lavoratori del settore dei trasporti di merci e persone.

This paper presents a review of occupational risks and health disorders in professional drivers employed in public and private transport. Epidemiological studies suggest an excess risk for cardiovascular diseases and musculoskeletal disorders in several categories of professional drivers, such as bus drivers, taxi drivers, truck drivers and forklift truck drivers. Although cardiovascular and musculoskeletal disorders are of multifactorial origin, some characteristics of occupational exposure in transport drivers (stress, workshift, traffic pollutants, awkward postures, exposure to noise and whole body vibration) may exert at least a concausal role for the onset and the development of these disorders. The predominant role of some confounding factors (inappropriate diet, drinking and smoking habits) makes it more difficult to establish causal associations between professional driving and other adverse health effects (respiratory, gastrointestinal, and genito-urinary disorders, and neoplastic diseases).

[Study of peripheral sensorineural function in a cohort of dental hygienists]. / Studio della funzione neurosensitiva periferica in una coorte di igienisti dentali.

The aim of this study was to investigate over time the changes in thermotactile and vibrotactile sensitivity in a cohort of dental hygiene students exposed to high-frequency vibration from dental tools. Thermal perception thresholds for warmth and cold (TPT in degrees C) and vibrotactile perception thresholds (VPT in ms-2 r.m.s) at 31.5 Hz and 125 Hz were measured at the fingertips of the 2nd digit and 5th digit of both hands in 52 controls and 30 dental hygiene students. At baseline, there were no significant differences in either TPT or VPT between the two groups. No significant changes in tactile sensitivity were observed in the dental hygienists over 1-year follow-up period. In conclusion, shortterm exposure to high-frequency vibration from dental tools did not affect tactile sensitivity in a cohort of young dental hygienists.

Memory T cells in cancer immunotherapy: which CD8 T-cell population provides the best protection against tumours?

Cancer immunotherapy strategies often fail because of immunosuppressive mechanisms present in the tumour-bearing host. Adoptive T-cell transfer therapy circumvents this problem by activating tumour-specific CD8(+) T cells in vitro and transferring them back into the patient. Classically, effector T cells have been used in these studies because of their potent anti-tumour activity. However, it is becoming apparent that highly activated effector cells may become terminally differentiated, display impaired proliferation and survival in vivo, and mediate short-term anti-tumour effects. In contrast to effector cells, memory cells have enhanced proliferative potential and survival, and the potential to provide more robust and enduring protection against tumours. Here, we discuss key studies in the field of adoptive T-cell transfer, along with some of our own results relating to this area. Based on the body of existing research, it is clear that CD8(+) T cells with memory potential are superior to terminally differentiated effectors in mediating successful tumour clearance. Opinions remain divided as to whether the central memory or effector memory T-cell subset is capable of providing the best protection against tumours. We propose that as these cell types have different but complementary benefits for the anti-tumour immune response, the ideal cell population to use for adoptive T-cell transfer should consist of a heterogeneous mixture of memory cells.

[Neck and upper limb disorders caused by combined exposures to ergonomic risk factors and hand-transmitted vibration]. / Patologie muscolo-scheletriche da esposizione combinata a fattori biomeccanici e vibrazioni trasmesse all'arto superiore.

A review of neck and upper limb disorders caused by combined exposures to hand-transmitted vibration and ergonomic risk factors (repetitiveness, force, posture) suggested the following conclusions: (1) hand-transmitted vibration has a dominant role in the etiopathogenesis of Raynaud's phenomenon and various forms of peripheral neuropathy with sensory impairment (digital, multifocal) in users of vibrating tools; (2) vibration of low frequency and high amplitude from percussive tools concur, together with adverse ergonomic factors, to produce degenerative changes in the bones and joints of the upper limbs, mainly in the wrist and elbow; (3) there is strong epidemiological and experimental evidence that combined exposures to hand-transmitted vibration and physical load are associated with an excess risk of carpal tunned syndrome; (4) there is limited evidence for an association between Dupuytren's contracture and vibration exposure owing to the small number of currently available epidemiological studies; (5) there is insufficient evidence for a contribution of hand-transmitted vibration to the development of chronic pain and clinical syndromes in the neck and upper limb, while excessive physical load and ergonomic stress have a primary role in the etiopathogenesis of these disorders.

B-Lymphocytes activated by CD40 ligand induce an antigen-specific anti-tumour immune response by direct and indirect activation of CD8(+) T-cells.

In this report, we describe the ability of CD40-ligand (CD40L)-activated, antigen-loaded B-cells to initiate antigen-specific anti-tumour immune responses in vivo. Mice immunized by means of intravenous administration of CD40L-activated B-cells loaded with an MHC class-I-binding peptide, and challenged with a tumour cell line expressing the same class-I epitope, showed a marked delay in tumour growth, compared to non-immunized controls or to mice receiving either freshly isolated B-cells or B-cells activated with lipopolysaccharide or interleukin-4. The ability of CD40L-activated B-cells to induce antigen-specific T-cell activation appeared to be through a combination of cross-presentation of antigen from activated B-cells to resident antigen-presenting cells and direct T-cell activation by the administered B-cells themselves. Immunization with CD40L-activated B-cells may, therefore, represent a means by which to stimulate anti-tumour CD8(+) T-cell responses in vivo.

Tumor-specific Tc1, but not Tc2, cells deliver protective antitumor immunity.

We investigated whether secretion of multiple cytokines by CD8+ T cells is associated with improved protection against tumor challenge. We show that antitumor immunity induced by immunization with dendritic cells and a MHC class I-binding tumor peptide are dependent on secretion of IFN-gamma but not IL-4 or IL-5 by host cells. To further address the role of IL-4 and IL-5 in antitumor immunity, tumor-specific TCR-transgenic CD8+ T cells were activated in vitro to generate cytotoxic T (Tc) 1 cells that secrete high IFN-gamma and no IL-4 or IL-5 or Tc2 cells that secrete IL-4, IL-5, and some IFN-gamma. Both cell types killed target cells in vitro. Tc1 and Tc2 cells were adoptively transferred into syngeneic hosts, and their ability to protect against tumor challenge was compared. Tc1 cells were able to significantly delay tumor growth, whereas Tc2 cells or Tc2 cells from IFN-gamma(-/-) donors had no effect. This was due to neither the inability of Tc2 cells to survive in vivo or to migrate to the tumor site nor their inability to secrete IL-4 and/or IL-5 in the presence of limiting amounts of anti-CD3. However, IFN-gamma secretion by Tc2 cells was triggered inefficiently by restimulation with Ag compared with anti-CD3. We conclude that the ability to secrete "type 2" cytokines, and cytotoxic ability, have a limited role in antitumor immune responses mediated by CD8+ T cells, whereas the capacity to secrete high amounts of IFN-gamma remains the most critical antitumor effector mechanism in vivo.

Gene microarrays reveal extensive differential gene expression in both CD4(+) and CD8(+) type 1 and type 2 T cells.

An important subdivision of effector T cells can be made based on patterns of cytokine production and functional programs. Type 1 T cells produce IFN-gamma and protect against viral pathogens, whereas type 2 cells produce cytokines such as IL-4 and IL-5 and protect against large extracellular parasites. Both CD4(+) and CD8(+) T cells can be polarized into type 1 or type 2 cytokine-secreting cells, suggesting that both populations play a regulatory role in immune responses. In this study, we used high-density oligonucleotide arrays to produce a comprehensive picture of gene expression in murine CD4(+) Th1 and Th2 cells, as well as CD8(+) type 1 and type 2 T cells. Polarized type 1 and 2 cells transcribed mRNA for an unexpectedly large number of genes, most of which were expressed in a similar fashion between type 1 and type 2 cells. However, >100 differentially expressed genes were identified for both the CD4(+) and CD8(+) type 1 and 2 subsets, many of which have not been associated with T cell polarization. These genes included cytokines, transcription factors, molecules involved in cell migration, as well as genes with unknown function. The program for type 1 or type 2 polarization was similar for CD4(+) and CD8(+) cells, since gene expression patterns were roughly the same. The expression of select genes was confirmed using real-time PCR. The identification of genes associated with T cell polarization may give important insights into functional and phenotypic differences between effector T cell subsets and their role in normal responses and inflammatory disease.

CD80 costimulation is required for Th2 cell cytokine production but not for antigen-specific accumulation and migration into the lung.

The CD28 ligands CD80 and CD86 are expressed on APC, and both provide costimulatory function. However, the reason for the expression of two separate CD28 ligands remains unclear. We have previously shown that blockade of CD80 costimulation by Y100F-Ig, a CTL-associated Ag-4 (CTLA4)-Ig mutant that does not bind CD86, inhibits the development of lung inflammatory immune responses, but does not affect blood eosinophilia or Ab production. Each of those responses was inhibited by treatment with CTLA4-Ig, which binds both CD80 and CD86. To clarify the mechanism underlying these observations we have developed a model of lung inflammation using adoptively transferred CD4(+) T cells expressing a Valpha11(+)Vbeta3(+) transgenic TCR specific for I-E(k) and moth cytochrome c. Treatment with Y100F-Ig inhibited the induction of lung eosinophilia in adoptively transferred mice. However, Y100F-Ig did not detectably affect the accumulation of Ag-specific T cells at the site of peptide deposit or in the draining lymphoid tissues. Acquisition of an activated phenotype and expression of adhesion molecules required for migration into the lung were modestly affected. Importantly, treatment with Y100F-Ig diminished the ability of T cells to produce the cytokines IL-4 and IL-5 following intranasal challenge with Ag. All the responses examined were severely inhibited by treatment with CTLA4-Ig. We conclude that T cells require CD80 costimulation for the optimal production of IL-5 following intranasal administration of Ag. Decreased IL-5 production is the most likely explanation for the diminished airway eosinophilia observed.

Dendritic cell elimination as an assay of cytotoxic T lymphocyte activity in vivo.

We show in this paper that the survival of antigen-loaded dendritic cells in vivo may be used as a sensitive readout of CTL activity. We have previously shown that dendritic cells labeled with the fluorescent dye CFSE and injected sub-cutaneously into mice migrate spontaneously to the draining lymph node where they persist for several days. In the presence of effector CTL responses, dendritic cells loaded with specific antigen rapidly disappear from the draining lymph node. In this paper we extend the above observations and set up a simple and sensitive method to reveal CTL activity in individual mice in vivo. Dendritic cells were labeled with two different fluorochromes, loaded with antigen or left untreated, and mixed together before injection into mice. We show that only the dendritic cells loaded with specific antigen were cleared from the draining lymph node, while dendritic cells not loaded with antigen remained unaffected. Cytotoxic responses generated by immunization with peptide-loaded dendritic cells, or by infection with influenza virus, could be revealed using this method. Comparison of the differential survival of dendritic cells populations mixed together also allowed us to accurately evaluate the disappearance of dendritic cells, irrespective of variability in the injection site and other parameters. Given the ability of dendritic cells to efficiently take up and present complex antigens, nucleic acids and apoptotic bodies, this method may also allow the evaluation of cytotoxic activity against antigens that are not characterized in terms of peptide epitopes.

Immunotherapy with dendritic cells and tumor major histocompatibility complex class I-derived peptides requires a high density of antigen on tumor cells.

Immunization with dendritic cells and unfractionated MHC class I-binding peptides derived from autologous tumor cells has been shown to induce effective antitumor immunity. However, the importance of the relative abundance of tumor peptides on the surface of tumor cells is not known. We have addressed this question using peptides isolated from three tumor cell lines transfected with a minigene encoding amino acids 33-41 of the lymphocytic choriomeningitis virus glycoprotein (LCMV(33-41)). The three cell lines expressed different levels of MHC class I molecules and had different abilities to stimulate proliferation of LCMV(33-41)-specific T cells in vitro. We found that antitumor immune responses were best elicited by immunizing mice with dendritic cells and synthetic LCMV(33-41) peptide. Peptide preparations from a given tumor cell line conferred protection against challenge with the same tumor cell line. However, protective immunity to a different tumor could be induced only if the cell line used for peptide preparation presented a high relative proportion of LCMV(33-41) in association with MHC class I. Our results suggest that multiple peptide epitopes are required for the induction of an effective antitumor immune response using MHC class I-binding peptides from tumor cells. Also, the ability to induce an antitumor immune response appears to correlate with the proportion, rather than the absolute amount, of tumor-specific peptide in the mixture used for immunization.

CD8+ T cell-dependent elimination of dendritic cells in vivo limits the induction of antitumor immunity.

The fate of dendritic cells (DC) after they have initiated a T cell immune response is still undefined. We have monitored the migration of DC labeled with a fluorescent tracer and injected s.c. into naive mice or into mice with an ongoing immune response. DC not loaded with Ag were detected in the draining lymph node in excess of 7 days after injection with maximum numbers detectable approximately 40 h after transfer. In contrast, DC that had been loaded with an MHC class I-binding peptide disappeared from the lymph node with kinetics that parallel the known kinetics of activation of CD8+ T cells to effector function. In the presence of high numbers of specific CTL precursors, as in TCR transgenic mice, DC numbers were significantly decreased by 72 h after injection. The rate of DC disappearance was extremely rapid and efficient in recently immunized mice and was slower in "memory" mice in which memory CD8+ cells needed to reacquire effector function before mediating DC elimination. We also show that CTL-mediated clearance of Ag-loaded DC has a notable effect on immune responses in vivo. Ag-specific CD8+ T cells failed to divide in response to Ag presented on a DC if the DC were targets of a pre-existing CTL response. The induction of antitumor immunity by tumor Ag-loaded DC was also impaired. Therefore, CTL-mediated clearance of Ag-loaded DC may serve as a negative feedback mechanism to limit the activity of DC within the lymph node.

Differential requirement for CD80 and CD80/CD86-dependent costimulation in the lung immune response to an influenza virus infection.

The CD28 costimulatory pathway is critical to T cell activation. Blockade of the interaction of CD28 with its ligands CD80 and CD86 using CTLA4-Ig has been proposed as a therapy for a number of immune-based disorders. We have used a murine model of influenza virus infection to study the role of CD28-dependent costimulation in the development of antiviral immune responses. In vivo treatment with CTLA4-Ig to block the interaction of CD28 with CD80 and CD86 reduced virus-specific cytotoxicity and IFN-gamma production by bronchoalveolar lavage fluid CD8+ T lymphocytes in vitro. It also resulted in decreased numbers of virus-specific CD8+ T lymphocytes in the bronchoalveolar lavage fluid, lung, and spleen and lowered virus-specific Ab titers. Mice treated with CTLA4-Ig were able to control and clear the virus infection, but this was delayed compared with controls. Treatment with Y100F-Ig, a mutant form of CTLA4-Ig which selectively binds to CD80 and blocks the CD28-CD80 interaction leaving CD28-CD86 binding intact, did not affect Ab production, spleen cytotoxic precursors, or clearance of virus. However, Y100F-Ig treatment had a clear effect on lung effector cell function. Secretion of IFN-gamma by bronchoalveolar lavage fluid CD8+ T lymphocytes in vitro was decreased, and the number of virus-specific CD8+ T lymphocytes in the bronchoalveolar lavage fluid and lungs of infected mice was reduced. These results indicate that CD28-dependent costimulation is important in the antiviral immune response to an influenza virus infection. The individual CD28 ligand, CD80, is important for some lung immune responses and cannot always be compensated for by CD86.

The role of B7 costimulation in T-cell immunity.

CD4+ T cells are considered to be the major controlling element of the adaptive immune response. They recognize foreign peptides by interaction of the T cell receptor (TCR) with peptide complexed to major histocompatibility complex (MHC) class II molecules on the surface of antigen presenting cells (APC). Once activated, CD4+ T cells orchestrate the various phases of the immune response. They are responsible for the production of numerous cytokines, which activate specific immune effector cell populations including B cells, eosinophils, mast cells and macrophages. Not surprisingly, the activation of CD4+ T cells needs to be tightly regulated and is subject to finely tuned control mechanisms. The requirement for a second or 'costimulatory' signal, in addition to the antigenic signal, provides a key element for the exquisite control of T cell activation. One of the major signalling pathways responsible for delivery of this costimulatory signal is induced by interaction of CD28 on T cells with B7 molecules found only on APC. The present review outlines our current understanding of the physiological role of B7 costimulatory signals in regulating CD4+ T cell responses.

Impaired ability of MHC class II-/- dendritic cells to provide tumor protection is rescued by CD40 ligation.

The contribution of CD4+ T cells to dendritic cell (DC) activation and to the induction of CD8+ T cell responses in vivo was investigated using a model of antitumor immune responses. Immunization with peptide-loaded MHC class II-deficient (MHC class II-/-) DC induced the activation of Ag-specific CD8+ T cells and their accumulation in the lymph nodes and spleens of immunized mice. The accumulation induced by MHC class II-/- DC immunization was lower than the accumulation observed after immunization with MHC class II+/+ DC. Similarly, immunization with peptide-loaded, MHC class II-/- DC induced some degree of protection against tumor challenge, but this protection was lower than the protection achieved after immunization with MHC class II+/+ DC. Incubation with a membrane-associated form of CD40 ligand resulted in the up-regulation of costimulatory molecules on MHC class II-/- DC and fully rescued their ability to induce antitumor immunity. We conclude that CD4+ T cells play a critical role in the generation of antitumor immune responses through their capacity to induce the activation of DC via CD40/CD40 ligand interaction, and thus maximize CD8+ T cell responses.

Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) can regulate dendritic cell-induced activation and cytotoxicity of CD8(+) T cells independently of CD4(+) T cell help.

The mechanisms that regulate the strength and duration of CD8(+) cytotoxic T cell activity determine the effectiveness of an antitumor immune response. To better understand the antitumor effects of anti-cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) antibody treatment, we analyzed the effect of CTLA-4 signaling on CD8(+) T cells in vitro and in vivo. In vitro, cross-linking of CTLA-4 on purified CD8(+) T cells caused decreased proliferative responses to anti-CD3 stimulation and rapid loss of activation marker expression. In vivo, blockade of CTLA-4 by neutralizing anti-CTLA-4 mAb greatly enhanced the accumulation, activation, and cytotoxic activity of CD8(+) T cells induced by immunization with Ag on dendritic cells (DC). This enhanced response did not require the expression of MHC class II molecules on DC or the presence of CD4(+) T cells. These results demonstrate that CTLA-4 blockade is able to directly enhance the proliferation and activation of specific CD8(+) T cells, indicating its potential for tumor immunotherapy even in situations in which CD4(+) T cell help is limited or absent.