Effect of age at disease onset in the clinical profile of spondyloarthritis: a study of 1424 Brazilian patients.

OBJECTIVES: To analyse demographic and clinical variables in patients with disease onset before and after 40, 45 and 50 years in a large series of Brazilian SpA patients. METHODS: A common protocol of investigation was prospectively applied to 1424 SpA patients in 29 centres distributed through the main geographical regions in Brazil. The mean age at disease onset was 28.56 ± 12.34 years, with 259 patients (18.2%) referring disease onset after 40 years, 151 (10.6%) after 45 years and 81 (5.8%) after 50 years. Clinical and demographic variables and disease indices (BASDAI, BASFI, BASRI, MASES, ASQoL) were investigated. Ankylosing spondylitis was the most frequent disease (66.3%), followed by psoriatic arthritis (18%), undifferentiated SpA (6.7%), reactive arthritis (5.5%), and enteropathic arthritis (3.5%). RESULTS: Comparing the groups according to age of disease onset, those patients with later onset presented statistical association with female gender, peripheral arthritis, dactylitis, nail involvement and psoriasis, as well as negative statistical association with inflammatory low back pain, alternating buttock pain, radiographic sacroiliitis, hip involvement, positive familial history, HLA-B27 and uveitis. BASDAI, BASFI and quality of life, as well as physicians and patient's global assessment, were similar in all the groups. Radiographic indices showed worse results in the younger age groups. CONCLUSIONS: There are two different clinical patterns in SpA defined by age at disease onset: one with predominance of axial symptoms in the group with disease onset ≤ 40 years and another favouring the peripheral manifestations in those with later disease onset.

[Risk assessment of biomechanical overload of the limbs and spine in workers paving roads with stones]. / Valutazione del rischio da sovraccarico biomeccanico agli arti e rachide negli addetti alla pavimentazione lapidea stradale.

Aim of this study is to assess the risk from biomechanical overload for the whole musculoskeletal system and manual handling involved in the activity of stone paving of the road. According to the guidelines of the Italian Society of Occupational Medicine and Industrial Hygiene various risk assessment methods have been used: Washington State checklist, checklist of Turin and OCRA checklist to assess the risk from biomechanical overload for the upper limb and NIOSH method with the method provided by the State of Washington to assess the risk from manual handling of loads.

[Updating in occupational health for health care workers]. / Aggiornamenti in tema di tutela della salute occupazionale dei lavoratori della sanità.

The board of the Thematic Section on Preventive Medicine for Health Care Workers of the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) programmed a national conference on occupational risks of health care workers to be held in late 2009. Main topics will be: a) biohazards; b) biomechanical risk; c) psychosocial factors. Three different working groups were established to tackle critical aspects and suggest practical recommendations to occupational health professionals. Preliminary issues are presented while final results will be presented at the conference on September 2009.

[Evidence based prevention and upper limb work-related musculoskeletal disorders]. / Evidence based prevention e rischio biomeccanico per l'arto superiore.

To evaluate interventions for primary prevention of Upper limb Work-related Musculoskeletal Disorders (UWMSD) we conducted a literature search from the biomedical database Medline and the Cochrane Collaboration Occupational Health Field. A total of 41 studies were selected: the majority investigated the effect of interventions among office workers, few involved industrial workplaces. Studies were characterized by a wide range of interventions (engineering, administrative, ergonomic training) and methodological heterogeneity (in the study design and outcome measures). Only four studies examine interventions for the prevention of specific outcomes (Carpal Tunnel Syndrome and Hand Arm Vibration Syndrome). At present, the multidimensional approach of interventions and the poor outcome definitions hamper the isolation of the potentially effective component of the intervention. Future intervention studies should be based on well defined risk assessment and outcome measures, rigorous and long-term study design. Only strong levels of evidence could be the base of policy recommendations.

Evaluation of an occupational therapy program for patients with spinal cord injury.

STUDY DESIGN: Clinical controlled trial. OBJECTIVES: To evaluate the effectiveness of an occupational therapy (OT) program combined with neuromotor rehabilitation, by assessing the degree of functional independence reached by patients with spinal cord injuries at first hospitalization. SETTINGS: Subjects selected from the Spinal Cord Unit of the Rehabilitation Institute of Montecatone (Imola, Italy). PARTICIPANTS: Thirty-six male patients below age 60, with complete paraplegia (ASIA-A) in thoracic-lumbar level, at first hospitalization. METHODS: Patients were divided into experimental and control groups. Subjects in the experimental group underwent neuromotor rehabilitation coupled with an OT program, whereas those in the control group followed neuromotor rehabilitation only. Increase in functional independence at discharge was evaluated by the Valutazione Funzionale Mielolesi (VFM) assessment scale. RESULTS: Patients in the experimental group showed a significant increase in the total VFM score, and in domains concerning transfers and wheelchair use. A significant improvement was observed in unmarried patients as compared to married ones. CONCLUSION: An OT service within a Spinal Cord Unit allows us to achieve a higher level of functional independence.

Potential of ultrasonography for epidemiological study of work-related wrist tenosynovitis.

OBJECTIVE: To explore the possible role of ultrasonography in case definitions for epidemiological studies of work-related wrist tenosynovitis. METHODS: Clinical and ultrasonography (7.5 MHz linear probe) data systematically collected from meat workers (n = 128) with biomechanical exposure characterisation were analysed. The diagnostic accuracy of different combinations of potentially relevant ultrasonography findings (nonhomogeneity, thickening and anechoic halo) was evaluated using symptomatology as a reference standard. The concordance between ultrasonography findings and symptoms was then analysed. RESULTS: Analysis of wrist biomechanical exposure was suggestive of increased prevalence of musculoskeletal disorders. Using symptoms as a reference standard, each of the three ultrasonography findings (and their combinations) showed good specificity (> or =85%) accompanied by low sensitivity (<60%); the positive likelihood ratio for at least two findings was 4.1. kappa Values (95% confidence intervals) between symptoms and different sets of ultrasonography findings were as follows: for non-homogeneity, kappa = 0.31 (0.19 to 0.43); at least one finding, kappa = 0.28 (0.16 to 0.40); at least two findings, kappa = 0.32 (0.20 to 0.44); all p<0.01. CONCLUSION: The use of ultrasonography in symptomatic subjects could contribute to a more specific epidemiological case definition of wrist tenosynovitis. The results of this study could help orient future research in this direction.

[Usefulness of surface electromyography of hand muscles in the assessment of myoelectric parameters changes due to repetitive manual tasks]. / Applicazione dell'elettromiografia di superficie dei muscoli della mano nello studio delle patologie da sovraccarico biomeccanico.

The aim of this project was to investigate the possible role of sEMG in the diagnosis of Carpal tunnel syndrome (CTS). The study group consisted of 37 subjects, of whom 14 (control group) were not employed in manual tasks and 23 (exposed) were engaged in repetitive and forceful manual tasks. Of the 23 exposed workers, 10 reported CTS symptoms, whereas all the subjects of the control group resulted asymptomatic. The surface electromyography signal was recorded from the abductor pollicis brevis muscle, using different levels of isometric contraction: 20% and 50% of the maximum voluntary contraction (MVC), respectively. The initial values and rate of change of the average rectified value (ARV), mean power spectral frequency (MNF) and conduction velocity (CV) were calculated. Moreover the study protocol included clinical evaluation and electrodiagnostic study of the median nerve. Data from the exposed and control group were compared. Statistically significant differences between the two groups were found for ARV initial value and for CV and MNF rate of change at 50% MVC. These parameters resulted lower in the exposed group, with the lowest values among symptomatic subjects. Possible explanations may be the loss of motor units, particularly affecting the fast and fatigable type II muscle fibers, involved in the myoelectric manifestation of fatigue. In conclusion, this technique was able to show different myoelectric patterns and manifestations of fatigue between subjects exposed and nonexposed to manual intensive work, suffering or not suffering from CTS.

[OCTOPUS: longitudinal study on carpal tunnel syndrome and work]. / OCTOPUS: uno studio longitudinale su Sindrome del Tunnel Carpale ed attività lavorative.

Carpal tunnel syndrome (CTS), the commonest nerve entrapment syndrome, is one of the most frequent occupational disorders related to manual work. Both occupational and personal risk factors make it difficult to recognize the true origin of its occurrence and to devise prevention strategies. Most of the information available about occupational CTS originates from cross-sectional studies on various job titles, where the prevalence of the disease has been reported to vary between 0.6% and 61%. Few longitudinal studies are available on occupational CTS. Consensus has been reached about the criteria to diagnose CTS in epidemiological studies. However, different methods are used by different investigators to assess exposure to repetition and force, the two factors which appear to be most important in originating the disease. This could help explain the difficulty in establishing a sound exposure-effect relationship (an indispensable basis for setting exposure limits). To help fill the gap in knowledge regarding occupational CTS incidence and its relationship to occupational exposure we are performing a large longitudinal multisector study, denominated OCTOPUS. OCTOPUS has been designed to assess the incidence of CTS in a large cohort of workers employed in different sectors and exposed to different level of repetitive and forceful manual work and to relate the incidence of the disease to the possible casual factors and their variation over time. Herein, the study protocol is described.

[Carpal tunnel syndrome among supermarket cashiers]. / La sindrome del tunnel carpale nelle cassiere dei supermercati.

We studied Carpal Tunnel Syndrome prevalence in part time and full time female supermarket cashiers and in a control group (female primary school teachers). Subjects underwent a clinical examination in which information about personal, physiological, pathological and occupational factors were collected by a physician with a questionnaire and a self-administered Katz's hand diagram. The study protocol included median nerve conduction studies (NCS) for each worker, performed bilaterally according to the palmar technique described by J. Kimura. Case definition of Carpal Tunnel Syndrome was based on the combination of typical symptoms (classic/probable or possible) and electrodiagnostic findings according to the Consensus Criteria for the Classification of Carpal Tunnel Syndrome published by Rempel et al. in 1998. Biomechanical risk for upper limb was assessed by a group of trained observer using videotape and scales of hand activity level (HAL) and normalized peak of force (PF) proposed by the American Conference of Governmental Industrial Hygienists (ACGIH): supermarket cashier job tasks resulted on the threshold limit value line, confirming high biomechanical risk factors for CTS. Both symptoms and case prevalence resulted higher in supermarket cashiers than in control group and in full time cashiers if compared with part time ones. This difference between groups of part-/full-time cashiers could be due to total hours of exposure during the week and/or to the amount of recovery time between work sessions. Further longitudinal study could give more information about the role of different biomechanical risk factors in the onset of cumulative trauma disorders of the upper limb.

Oligodeoxynucleotides as probes for in situ hybridization with transmission electron microscopy to specifically localize phytoplasma in plant cells.

Phytoplasmas are plant-pathogenic mollicutes restricted to phloem. They belong to several groups in a unique phylogenetic clade. Non-related phytoplasmas may infect the same plant species, often with similar symptoms. Hence methods are needed to specifically localize phytoplasmas and to study their multiplication and movement in their hosts. Conditions for post-embedding in situ hybridization (ISH) with transmission electron microscopy using oligodeoxynucleotides as probes for labelling of phytoplasmas in plant tissues have been searched. Sections of acrylic resin-embedded tissues of phytoplasma-infected periwinkle were submitted to ISH using digoxigenin or biotin-labelled oligoprobes (22 mers). These probes were the complementary sequences of primers used in group-specific polymerase chain reaction (PCR) amplification of 16S rDNA of stolbur and elm yellows phytoplasma, respectively. Together with preliminary digestion with pepsin, different in situ denaturation conditions and formamide concentrations were tested. The grids were incubated in the hybridization mixture at 37 degreesC overnight. Detection of hybridized material was performed with gold immunocytochemistry. Specificity of labelling was checked with appropriate controls. Stringency conditions could be found to ensure specific hybridization with such short probes. A specific labelling was obtained for stolbur phytoplasma on groups of mature as well as senescent phytoplasma cells. The results show that oligonucleotides may be used as probes for phytoplasma identification in post-embedding ISH with electron microscopy.

Oligonucleotides as hybridization probes to localize phytoplasmas in host plants and insect vectors.

ABSTRACT Protocols have been developed using 20- to 24-mer oligodeoxynucleotides, originally designed as polymerase chain reaction primers, as hybridization probes for the nonradioactive detection of Italian clover phyllody (ICPh) phytoplasma in plant (Chrysanthemum carinatum) and leafhopper (Euscelidius variegatus) tissue. In situ hybridization of paraffin-embedded tissue sections was carried out using oligodeoxynucleotides 5' end-labeled with either Cy5 fluorochrome, biotin, or digoxigenin. The Cy5-labeled oligonucleotide probes that hybridized to phytoplasmas present in plant tissue were visualized by confocal microscopy. The biotin- and digoxigeninlabeled probes were detected in both plant and insect tissue using a chromogenic alkaline phosphatase-nitro blue tetrazolium chloride/5-bromo-4-chloro-3-indolyl-phosphate reaction. An enhancement of a signal was observed in plant tissue when a tyramide signal-amplification procedure was incorporated into the biotin or digoxigenin detection systems. The results obtained using these techniques with the ICPh phytoplasma system showed that they can provide a rapid means of confirming vector status in insects. Due to the potential ability of short, labeled, oligonucleotide probes to specifically distinguish between different phytoplasmas present in multiple infections, this technique should provide a powerful new tool for epidemiological and vector ecology studies.

[Biomechanical pathology of the upper limb: a new epidemic?]. / La patologia biomeccanica dell'arto superiore: una nuova epidemia?

Work-related upper limb disorders are one leading occupational diseases in many industrialized countries. The paper reviews the evidence of work-relatedness of the most common upper limb disorders (namely carpal tunnel syndrome, hand-wrist and shoulder tendinitis, trapezius myalgia, hand hammer syndrome). Attention is drawn to the difference in the number of reported cases in Italy and other countries, assuming, as an underlying cause, underreporting of such conditions in Italy.

[Entrapment of the ulnar nerve at the elbow caused by repetitive movements: description of a clinical case]. / Intrappolamento del nervo ulnare al gomito da movimenti ripetitivi: descrizione di un caso clinico.

The paper describes a case of ulnar neuropathy in a man who made household fittings and toys using bamboo. Several years after starting the job he showed symptoms and physical signs of ulnar nerve entrapment at the elbow, which were confirmed by electrophysiological findings. Job analysis revealed biomechanical risk factors consisting of a high repetition of forceful flexion and extension of the elbow, wrist and fingers without sufficient rest periods. Chronic musculoskeletal overuse gradually leads to tendon and nerve disorders. The ulnar neuropathy described can be classed under cumulative occupational trauma, which is the most important cause of musculoskeletal disorders among the working population.

A new risk of occupational disease: allergic asthma and rhinoconjunctivitis in persons working with beneficial arthropods.

Allergic asthma and rhinoconjunctivitis have been reported in workers who are constantly in close contact with arthropods during the course of breeding and research. We investigated a group of ten people working with beneficial arthropods in a "bio-factory." The following tests were carried out: skin prick test with allergens present in the workplace, baseline pulmonary function test, aspecific bronchial provocation test with ultrasonically nebulized distilled water, and pulmonary function test after workplace exposure in two subjects. The results demonstrated a good correlation between skin prick test, previous RAST positive reactions, clinical symptoms, and exposure. Pulmonary function test after workplace exposure proved positive in one asthmatic subject and in one subject with rhinoconjunctivitis. It is concluded that the evidence supports the occupational nature of these allergic diseases and that there is a need for careful surveillance and environmental monitoring within the workplace.

A new risk of occupational disease: allergic asthma and rhinoconjunctivitis in persons working with beneficial arthropods. Preliminary data.

For some years, biological pest control has been re-evaluated as an alternative to the indiscriminate use of pesticides. The number of "bio-factories" in Europe has been constantly increasing and today more than 100 technicians work in mass rearing of arthropods. Seven cases of asthma and allergic rhinitis are reported in 13 workers engaged in the production of beneficial arthropods. The subjects suffered from attacks of asthma and rhinitis when they came into contact with eggs and scales or waste of Chrysoperla carnea, Leptinotarsa decemlineata, Ostrinia nubilalis and Ephestia kuehniella. These attacks occurred after an average exposure period of 18 months. A RAST test, prepared by Lofarma, was carried out on subjects' serum against the above-mentioned allergens and was positive in all symptomatic subjects (7 of 13) and negative in the others. This demonstrates IgE direct sensitization mediated by complete antigens.

Preferential binding of Chlamydia trachomatis to subsets of human lymphocytes and induction of interleukin-6 and interferon-gamma.

The interactions between Chlamydia trachomatis and human blood mononuclear leukocytes were studied using flow cytometry, immunofluorescence, electron microscopy and cytokine assays. Under serum-free conditions, elementary bodies (EB) of C. trachomatis were found to bind to human T lymphocytes as well as to B cells and monocytes/macrophages (M phi). For all cell types the binding was saturable, rapid, temperature-independent and independent of the chlamydia-specific serological status of the donor. Similar proportions of T and B cells bound EB at similar levels. In the T cell population, proportionally less CD8+ cells bound EB. Whereas M phi phagocytosed and destroyed the bound micro-organisms for lymphocytes, the Chlamydia remained at the surface, adherent to morphologically featureless membrane areas and showed no evidence of uptake even after long periods at 37 degrees C. Host molecules modulated these basic binding patterns: a heat-stable serum factor inhibited EB binding to T cells and a heat-labile serum factor enhanced binding to B cells. Stimulation with C. trachomatis EB rapidly elicited cytokine production by lymphocytes including interleukin-6 from B cells and interferon-gamma (IFN-gamma) from T and/or nonT/nonB cells. The responses were irrespective of the serological status of the donor. The findings suggest that C. trachomatis-leucocyte interactions may differ from the interactions of other bacteria and human leucocytes. The possible relationship between leucocyte-binding, cytokine induction, and the pathognomonic development of lymphoid follicles during mucosal C. trachomatis infections is discussed.

Synthesis of a select group of proteins by Neisseria gonorrhoeae in response to thermal stress.

We report the thermal conditions that induce the heat shock response in Neisseria gonorrhoeae. Under conditions of thermal stress, Neisseria gonorrhoeae synthesizes heat shock proteins (hsps), which differ quantitatively from conventionally studied gonococcal proteins. Gonococci accelerate the rate of synthesis of the hsps as early as 5 min after the appropriate stimulus is applied, with synthesis continuing for 30 min, as demonstrated by in vivo labeling experiments with L-[35S]methionine. Two of the gonococcal hsps are immunologically cross-reactive with the hsps of Escherichia coli, DnaK and GroEL, as demonstrated by Western blot (immunoblot) analysis. Ten hsps can be identified on two-dimensional autoradiograms of whole gonococci (total protein). Four hsps can be identified on two-dimensional autoradiograms of 1% N-lauroylsarcosine (sodium salt) (Sarkosyl)-insoluble membrane fractions. Two of the hsps from the 1% Sarkosyl-insoluble fraction are found exclusively in this fraction, suggesting that they are membrane proteins. The identification of this group of proteins will facilitate further study of the function of these proteins and provide insight into the possible role of hsps in disease pathogenesis.