Good mid- to long-term results of the cemented oxford phase 3 unicompartmental knee arthroplasty in a non-designer centre.

PURPOSE: Unicompartmental knee arthroplasty (UKA) provides patients with an alternative treatment to TKA in isolated medial compartment osteoarthritis providing better functional outcomes and faster recovery in the short term. Our aim was to quantify revision rates, predictors of revision, mortality rate and functionality of the Oxford Phase 3 UKA in a non-designer institution. METHODS: This was a retrospective review of prospectively collected regional registry data. All Oxford Phase 3 UKAs performed for medial tibio-femoral osteoarthritis of the knee joint were included from a single academic institution between the period of January 1st 2006 and December 30th 2009. Kaplan-Meier survivorship curves adjusting for loss to follow-up and deceased patients were generated. Primary outcome variables included all-cause and aseptic revision. Secondary outcome variables included functional outcome scores. Patients were reviewed at 6 months, 2 years, 5 years, 10 years and 15 years. RESULTS: A total of 64 cemented Oxford phase 3 UKAs were performed between January 2006 and November 2009. Fifteen-year follow-up data were available for 51 patients, of these 12 required revision. Survival rates, adjusting for patients that were either lost to follow-up or deceased, were 87.5% at 5 years, 81.4% at 10 years and 76.4% at 15 years. The overall aseptic revision rate at the time of review was 18.75% (n = 12). The only significant predictor of postoperative WOMAC score at 15 years was the preoperative WOMAC score (p = 0.03). CONCLUSION: The Oxford Phase 3 UKA for medial tibio-femoral arthritis has promising outcomes at 15-year follow-up with a survival rate of 76.4% in a non-designer centre. LEVEL OF EVIDENCE: III.

Cohort profile: the STOP HIV/AIDS Program Evaluation (SHAPE) study in British Columbia, Canada.

PURPOSE: The Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) Program Evaluation (SHAPE) study is a longitudinal cohort developed to monitor the progress of an HIV testing and treatment expansion programme across the province of British Columbia (BC). The study considers how sociostructural determinants such as gender, age, sexual identity, geography, income and ethnicity influence engagement in HIV care. PARTICIPANTS: Between January 2016 and September 2018, 644 BC residents who were at least 19 years old and diagnosed with HIV were enrolled in the study and completed a baseline survey. Participants will complete two additional follow-up surveys (18 months apart) about their HIV care experiences, with clinical follow-up ongoing. FINDINGS TO DATE: Analyses on baseline data have found high levels of HIV care engagement and treatment success among SHAPE participants, with 95% of participants receiving antiretroviral therapy and 90% having achieved viral suppression. However, persistent disparities in HIV treatment outcomes related to age, injection drug use and housing stability have been identified and require further attention when delivering services to marginalised groups. FUTURE PLANS: Our research will examine how engagement in HIV care evolves over time, continuing to identify barriers and facilitators for promoting equitable access to treatment and care among people living with HIV. A qualitative research project, currently in the formative phase, will compliment quantitative analyses by taking a strengths-based approach to exploring experiences of engagement and re-engagement in HIV treatment among individuals who have experienced delayed treatment initiation or treatment interruptions.

Characteristic pro-inflammatory cytokines and host defence cathelicidin peptide produced by human monocyte-derived macrophages infected with Neospora caninum.

Neospora caninum is a coccidian intracellular protozoan capable of infecting a wide range of mammals, although severe disease is mostly reported in dogs and cattle. Innate defences triggered by monocytes/macrophages are key in the pathogenesis of neosporosis, as these cells are first-line defenders against intracellular infections. The aim of this study was to characterize infection and innate responses in macrophages infected with N. caninum using a well-known cell model to study macrophage functions (human monocyte THP-1 cells). Intracellular invasion of live tachyzoites occurred as fast as 4 h (confirmed with immunofluorescence microscopy using N. caninum-specific antibodies). Macrophages infected by N. caninum had increased expression of pro-inflammatory cytokines (TNFα, IL-1ß, IL-8, IFNγ). Interestingly, N. caninum induced expression of host-defence peptides (cathelicidins), a mechanism of defence never reported for N. caninum infection in macrophages. The expression of cytokines and cathelicidins in macrophages invaded by N. caninum was mediated by mitogen-activated protein kinase (MEK 1/2). Secretion of such innate factors from N. caninum-infected macrophages reduced parasite internalization and promoted the secretion of pro-inflammatory cytokines in naïve macrophages. We concluded that rapid invasion of macrophages by N. caninum triggered protective innate defence mechanisms against intracellular pathogens.

Clonal evolution revealed by whole genome sequencing in a case of primary myelofibrosis transformed to secondary acute myeloid leukemia.

Clonal architecture in myeloproliferative neoplasms (MPNs) is poorly understood. Here we report genomic analyses of a patient with primary myelofibrosis (PMF) transformed to secondary acute myeloid leukemia (sAML). Whole genome sequencing (WGS) was performed on PMF and sAML diagnosis samples, with skin included as a germline surrogate. Deep sequencing validation was performed on the WGS samples and an additional sample obtained during sAML remission/relapsed PMF. Clustering analysis of 649 validated somatic single-nucleotide variants revealed four distinct clonal groups, each including putative driver mutations. The first group (including JAK2 and U2AF1), representing the founding clone, included mutations with high frequency at all three disease stages. The second clonal group (including MYB) was present only in PMF, suggesting the presence of a clone that was dispensable for transformation. The third group (including ASXL1) contained mutations with low frequency in PMF and high frequency in subsequent samples, indicating evolution of the dominant clone with disease progression. The fourth clonal group (including IDH1 and RUNX1) was acquired at sAML transformation and was predominantly absent at sAML remission/relapsed PMF. Taken together, these findings illustrate the complex clonal dynamics associated with disease evolution in MPNs and sAML.

Staff attitudes to an ultrasound-guided peripheral nerve block room for orthopaedic patients.

Ultrasound-guided peripheral nerve blocks have well recognised benefits in orthopaedic patients. Some hospitals, to maximise these benefits, establish dedicated "block rooms" to deliver this service. Orthopaedic surgery makes up a large proportion of our hospitals work load, and many of these patients would benefit from ultrasound-guided peripheral nerve blocks. We analysed the attitudes of key staff in our hospital towards the establishment of a block room. Sixty questionnaires were distributed and 47 (78%) were completed. Orthopaedic surgeons (n = 6) were concerned ultrasound-guided peripheral nerve blocks would delay theatre lists (83%), and cause patients pain (67%) and increased anxiety (67%). Anaesthetists (n = 10) and Nurses (n = 30) were concerned there was insufficient experience in their departments to deliver this service (80% and 77%, respectively). However, 91% of all staff believed funding should be available for a block room. Our survey has identified areas of concern, and deficiencies that we must address before proceeding with the development of such a service.

An intrathecal catheter in a pregnant patient with idiopathic intracranial hypertension: analgesia, monitor and therapy?

Idiopathic intracranial hypertension is important for the obstetric anaesthetist as it is mostly seen in obese women of childbearing age. The incidence is likely to increase as the obesity pandemic grows. Management of labour analgesia in these patients can be complex and requires multidisciplinary input. We successfully managed labour analgesia in a parturient with idiopathic intracranial hypertension with an intrathecal catheter. The possibility of using this catheter as a cerebrospinal fluid drain and pressure monitor was considered and is discussed along with potential complications.

Exercise induced fatigue: unfit or unwell?

This case report outlines the diagnoses of a rare myophosphorylase deficiency (McArdle Syndrome) in a unique way. A set of characteristic values from a Cardiopulmonary Exercise Test (CPET) combined with a typical patient history pointed to a failure of the glycolytic pathway in the skeletal muscle. McArdle Syndrome was confirmed with a skeletal muscle biopsy. There is no evidence of such a diagnostic method in the literature.

Down-regulated lymphoproliferation coincides with parasite maturation and with the collapse of both gamma interferon and interleukin-4 responses in a bovine model of onchocerciasis.

Onchocerciasis is a debilitating parasitic infection caused by the filarial nematode Onchocerca volvulus. Infections are chronic, and persistence of the parasites for several years argues for highly adapted mechanisms of immune evasion. Due to the restricted host repertoire of O. volvulus, we have used the cattle parasite Onchocerca ochengi to investigate the nature of immunomodulation underpinning these long-term infections. Cattle were infected with a single inoculation of 350 infective-stage larvae under laboratory conditions (n = 6). Intradermal nodules containing immature adult worms were detected from 110 days postinfection, and microfilariae in skin were detected from day 280 postinfection. Parasite-specific responses during early infection were nonpolarized with respect to the major Th cytokines (interleukin-4 [IL-4], IL-2, and gamma interferon [IFN-gamma]) produced by antigen-stimulated peripheral blood mononuclear cells (PBMC) or serum antibody isotypes. Antigen-induced proliferation of PBMC peaked shortly after exposure and remained high during the prepatent infection. As the parasites matured and animals developed patent infections, there was a profound down-regulation of lymphoproliferation, accompanied by sharp falls in the expression of both IL-4 and IFN-gamma and a gradual decline in IL-2. Levels of immunoglobulin G2 (IgG2) fell, while those of IgG1 remained high. We conclude that neither a classical Th2 response nor a simple Th1-to-Th2 switch is sufficient to explain the immunomodulation associated with patent Onchocerca infections. Instead, there is an initial Th0 response, which matures into a response with some, but not all of the features of a Th2 response. The natural host-parasite relationship of O. ochengi in cattle may be useful as both a descriptive and predictive tool to test more refined models of immunomodulation in onchocerciasis.

A drug-unresponsive and protease-resistant CNOX protein from human sera.

Sodium dodecyl sulfate-polyacrylamide gel electrophoresis and ammonium sulfate fractionation were employed in series to purify and concentrate a 12.5-kDa protein fragment with a periodic (24-min period) proteinase K-resistant and drug-unresponsive NADH oxidase (CNOX) activity from pooled sera from healthy volunteers. The activity was unresponsive to capsaicin to distinguish it from the previously isolated cancer-associated NOX form (tNOX). Polyclonal antisera generated to the CNOX fragment cross-reacted with 20.5- to 24-kDa proteins of human sera, human lymphocytes, and plasma membranes from Escherichia coli with the molecular weight depending on source and conditions of treatment with proteinase K.

African swine fever virus multigene family 360 and 530 genes are novel macrophage host range determinants.

Pathogenic African swine fever virus (ASFV) isolates primarily target cells of the mononuclear-phagocytic system in infected swine and replicate efficiently in primary macrophage cell cultures in vitro. ASFVs can, however, be adapted to grow in monkey cell lines. Characterization of two cell culture-adapted viruses, MS16 and BA71V, revealed that neither virus replicated in macrophage cell cultures. Cell viability experiments and ultrastructural analysis showed that infection with these viruses resulted in early macrophage cell death, which occurred prior to viral progeny production. Genomic cosmid clones from pathogenic ASFV isolate E70 were used in marker rescue experiments to identify sequences capable of restoring MS16 and BA71V growth in macrophage cell cultures. A cosmid clone representing a 38-kbp region at the left terminus of the genome completely restored the growth of both viruses. In subsequent fine-mapping experiments, an 11-kbp subclone from this region was sufficient for complete rescue of BA71V growth. Sequence analysis indicated that both MS16 and BA71V had significant deletions in the region containing members of multigene family 360 (MGF 360) and MGF530. Deletion of this same region from highly pathogenic ASFV isolate Pr4 significantly reduced viral growth in macrophage cell cultures. These findings indicate that ASFV MGF360 and MGF530 genes perform an essential macrophage host range function(s) that involves promotion of infected-cell survival.

The African swine fever virus thymidine kinase gene is required for efficient replication in swine macrophages and for virulence in swine.

African swine fever virus (ASFV) replicates in the cytoplasm of infected cells and contains genes encoding a number of enzymes needed for DNA synthesis, including a thymidine kinase (TK) gene. Recombinant TK gene deletion viruses were produced by using two highly pathogenic isolates of ASFV through homologous recombination with an ASFV p72 promoter-beta-glucuronidase indicator cassette (p72GUS) flanked by ASFV sequences targeting the TK region. Attempts to isolate double-crossover TK gene deletion mutants on swine macrophages failed, suggesting a growth deficiency of TK- ASFV on macrophages. Two pathogenic ASFV isolates, ASFV Malawi and ASFV Haiti, partially adapted to Vero cells, were used successfully to construct TK deletion viruses on Vero cells. The selected viruses grew well on Vero cells, but both mutants exhibited a growth defect on swine macrophages at low multiplicities of infection (MOI), yielding 0.1 to 1.0% of wild-type levels. At high MOI, the macrophage growth defect was not apparent. The Malawi TK deletion mutant showed reduced virulence for swine, producing transient fevers, lower viremia titers, and reduced mortality. In contrast, 100% mortality was observed for swine inoculated with the TK+ revertant virus. Swine surviving TK- ASFV infection remained free of clinical signs of African swine fever following subsequent challenge with the parental pathogenic ASFV. The data indicate that the TK gene of ASFV is important for growth in swine macrophages in vitro and is a virus virulence factor in swine.

Vaccinia virus A17L open reading frame encodes an essential component of nascent viral membranes that is required to initiate morphogenesis.

We generated an antiserum to the predicted C-terminal peptide of the A17L open reading frame (ORF), which encodes a 23-kDa polypeptide with hydrophobic regions characteristic of membrane proteins. Immuno-electron microscopy of infected cells indicated that the A17L protein is intimately associated with the earliest characteristic viral membranes, even those formed in the presence of the drug rifampin. To study the role of the A17L protein in morphogenesis, we constructed recombinant vaccinia viruses in which the endogenous A17L ORF was deleted and a copy of the ORF under the control of the bacteriophage T7 RNA polymerase and the Escherichia coli lac repressor was inserted into an alternative site in the vaccinia virus genome. Growth of these recombinant viruses was entirely dependent on the induction of A17L expression by isopropyl-beta-D-thiogalactopyranoside. Electron microscopic examination of cells infected in the absence of inducer revealed the accumulation of large, well-demarcated electron-dense aggregates but no characteristic membrane-associated viral structures. Viral late protein synthesis occurred under these conditions, although the maturational proteolytic processing of structural proteins was inhibited. We conclude that the product of the A17L gene is an essential component of the immature viral membrane and has an early function in viral morphogenesis.

Retinoic acid and interferon in human cancer: mechanistic and clinical studies.

Various combinations of retinoids, metabolic and synthetic derivatives of vitamin A, and interferons (IFNs) have demonstrated synergistic antiproliferative, differentiating, and antiangiogenic activity in some human hematologic and solid-tumor systems. This synergistic antitumor activity may be due to enhanced gene expression. In several cell systems, the actions of IFNs are enhanced by differentiation of cells with retinoic acid (RA). Combined RA-IFN effects have been correlated with the induction of higher levels of IFN-stimulated genes than the levels induced by either agent alone. Natural and synthetic retinoids have been found to augment the antiproliferative activity of IFNs in several squamous cell carcinoma (SCC) and breast tumor cell lines. Results of recent clinical trials indicate substantial activity of 13-cis-RA (13cRA) combined with IFN against advanced SCC of the skin and cervix, and possibly against other solid tumors. Two phase II trials have confirmed activity against locally advanced SCC of the cervix. Successful integration of this regimen with radiotherapy appears to be the most probable means of optimizing clinical outcome. Further studies are needed to determine the mechanistic details of the RA-IFN interaction.

Phenotypic and functional characterization of mouse attenuated and virulent variants of foot-and-mouth disease virus type O1 Campos.

A series of genetically related variants arising from a parental wild-type isolate of O1 Campos and its tissue culture adapted variant were differentiated by various cell culture markers (temperature sensitivity, plaque size, viral yield) and lethality in mice. These isolates were additionally characterized functionally and biochemically by examining poly(C) length, RNA synthesis, protein synthesis, and cell receptor binding. In primary bovine kidney cells, the virulent isolates had greater levels of protein synthesis, whereas in baby hamster kidney cells, the attenuated variant outproduced the wild-type parent. The tissue culture adapted variant had substantially greater ability to attach to cells than the parental wild type. The parental wild-type and the tissue culture-adapted variant were similarly neutralized by various sera against whole virus, but the parental wild type was less effectively neutralized by sera prepared from either full or truncated (variable region) bacterially expressed VP1 polypeptides. The capsid region of the genomes of both these variants was sequenced and a nucleotide substitution resulting in a change in amino acid 56 in VP3 was found. The nucleotide sequence change for the remaining two variants was that of the parental wild-type virus.

The electrically evoked vestibulo-ocular reflex: I. Normal subjects.

Recent animal studies indicate that electric currents applied through perilymphatic-space electrodes stimulate vestibular primary afferent neurons directly. These findings suggest that electrical stimulation may provide a testing method by which the vestibular nerve and central pathways could be evaluated separately from the vestibular end-organ. The goal of this study was to obtain normative data on human beings for an electrically evoked vestibulo-ocular reflex (EVOR). Sinusoidal electrical stimuli (0.0125 to 0.8 Hz, 4 mA peak intensity) were applied along the interaural axis through mastoid electrodes in 10 subjects. Horizontal eye movements were recorded by an infrared limbus-tracking device. The subjects also underwent rotational stimulation at the same frequencies so that their horizontal vestibulo-ocular reflex (VOR) could be evaluated. Nystagmus was observed in the EVOR at lower stimulus frequencies, whereas purely sinusoidal eye deviations occurred at higher frequencies. The phase of the EVOR slow-component eye velocity consistently lagged the stimulus. This contrasts with the phase measurements of the VOR in the same subjects, which exhibited a lead relative to head velocity. These findings suggest that currents applied to human beings may activate vestibular primary afferents independent of peripheral receptor mechanisms and thereby provide a "site-of-lesion" testing method by which the vestibular nerve and central pathways can be evaluated separately from the vestibular end-organ.

Cancer of the tongue base treated by a transpharyngeal approach.

Tongue base resection plays an important role in the management of the patient with cancer of the posterior tongue. The considerable morbidity resulting from loss of functional tongue includes compromised deglutition, chronic aspiration, and altered speech articulation. The particular operative approach used dictates additional secondary morbidity, which may include cosmetic and functional defects of the mandibular arch, malocclusion, lip and chin scars, and postoperative changes in the oral cavity. Our recent experience with a transpharyngeal approach in 13 patients with tongue base cancer is reviewed. Adequate operative exposure was obtained in all cases. Persistent aspiration was not a problem, and all patients learned to swallow effectively. The transpharyngeal approach avoids unnecessary surgical trauma to the mandible and anterior oral cavity and minimizes cosmetic deformity. Our early experience with this approach is encouraging.

Occult primary tumors. The management of isolated submandibular lymph node metastases.

The management of patients with cervical metastases from unknown primary tumors presents a therapeutic challenge to both the head and neck surgeon and radiotherapist. If after careful search the primary tumor remains truly occult, traditional methods of radiotherapy encompassing fields from the base of skull to clavicles are often employed, with significant attendant morbidity. To determine if more limited therapy would be effective in cases of isolated regional lymph node metastases, the patterns of tumor spread to nodes in the submandibular region were studied. A retrospective analysis of 472 radical neck specimens obtained from 1975 to 1985 revealed 19 cases (4.0%) of cervical metastases limited to the submandibular triangle. Sources of these tumors included lip (3), buccal mucosa (4), nasal vestibule (1), floor of mouth (4), alveolar ridge (3), oral tongue (1), and unknown (3). It appears that solitary submandibular nodal metastases predominantly arise from sites in the oral or nasal cavity. This suggests that in patients with isolated submandibular lymph node metastases from occult primary sites, a more conservative therapeutic approach to potential primary sites is indicated after treatment of the metastatic focus.

Antibodies elicited by a biosynthetic peptide related to a major immunogenic area of FMDV A12.

Foot-and-mouth disease virus (FMDV) capsid contains 60 copies each of four structural proteins, virus proteins 1-4. Virus protein 1 (VP1) plays an important immunogenic role, being the only VP that is immunogenic as an isolated protein. Even peptides representing a partial amino acid (AA) sequence of VP1 can induce protective immunity in experimental hosts. A 32 AA residue, in a tandem repeat configuration (32dimer), of sero/subtype A-12 Lp ab VP1 (AA 132-168) was highly immunogenic for its homologous subtype and partially protective for FMDV serotype A strain A24. This cross-reactivity was further demonstrable in the ELISA and mouse protection tests. Three different antibody populations were isolated by affinity chromatography (AFC) from the serum of a steer immunized with the 32dimer. Each population seems to recognize a different epitope on the 32dimer peptide since each fraction was defined as unique by its reactivity with different subtypes of FMDV virus in RIA, ELISA, neutralization and competition assays. Considering the neutralizing activity of each of the antibody populations the pattern of neutralization of the 32dimer elicited antiserum can be described. Two of the three epitopes were mapped by competition assays using synthetic peptides.

Analysis of neutralizing antigenic sites on the surface of type A12 foot-and-mouth disease virus.

A series of seven neutralizing monoclonal antibodies (nMAbs) directed against type A12 foot-and-mouth disease virus was used to generate neutralization-resistant variants. Both plaque reduction neutralization and microneutralization assays showed that the variants were no longer neutralized by the nMAbs used to generate them, although some of the variants still reacted with the nMAbs at high antibody concentrations. Results of cross-neutralization studies by both plaque reduction neutralization and microneutralization assays suggested the presence of at least one immunodominant antigenic site on the surface of type A12 foot-and-mouth disease virus, along with evidence of a second antigenic site on the viral surface. Two of the variants had reduced virulence in tissue culture as evidenced by their inability to inhibit cellular protein synthesis and a marked reduction in virus-induced cellular morphological alterations. Nucleotide sequencing of the variant genomes placed three epitopes of the major antigenic site on VP1 and the fourth epitope on VP3 and VP1. The one epitope of the minor site appears to reside only on VP1.