Incidence of SARS-COV-2 infection among swimming athletes: data from real life in Apulia (Italy), July 2020/August 2021

BACKGROUND

As other indoor sports facilities, swimming pools were closed in Italy from March to May 2020 and from October 2020 to July 2021 due to the outbreak of the COVID-19 pandemic; access to these facilities was restricted to athletes of national relevance. This decision was based on "precautionary principles" and without evidence of a high risk of SARS-COV-2 circulation among swimming pools' attendants. The aim of this paper is to describe the pattern of SARS-COV-2 circulation among swimming athletes in Apulia (Southern Italy).

STUDY DESIGN

The study aims to investigate the hypothesis that attending a pool increases the risk of SARS-COV-2 infection. The outcome measure is the incidence of SARS-COV-2 infection among swimming athletes compared with the general population.

METHODS

This is a retrospective cross-sectional study carried out in Apulia, Southern Italy. The study was performed through the analysis of both the database of the Italian Swimming Federation and the SARS-COV-2 infections in Apulia Region, from July 2020 to August 2021.

RESULTS

Among 2,939 federally licensed athletes, 221 had an history of SARS-COV-2 infection from July 2020 to August 2021, with an incidence of 75.2 /1,000. In the general Apulian population, during the same time span, the incidence of SARS-COV-2 infection was 67.3/1,000 and - considering the incidence rate ratio - there is no difference between the two populations (IRR=1.1; 95% CI=0.9-1.3; p>0.05).

CONCLUSIONS

The incidence of SARS-COV-2 infection in Apulian swimmers showed no significant differences with the general population.

POS0905 CHARACTERISATION OF SWEDISH MYOSITIS PATIENTS WITH ANTI-MDA5 AUTOANTIBODIES AND CORRELATION OF CLINICAL FEATURES WITH AUTOANTIBODY LEVELS

Background

The association between anti-melanoma differentiation association protein 5 autoantibodies (aMDA5) and rapidly progressive interstitial lung disease (RP-ILD) in clinically amyopathic dermatomyositis is well established in Asian population cohorts. In western cohorts, ILD has been strongly associated with aMDA5 but data regarding RP-ILD have been more conflicting. It is also suggested that western cohorts have more pronounced myopathic features than Asian.

Objectives

To characterise the disease manifestations of a Swedish aMDA5 positive idiopathic inflammatory myositis (IIM) cohort and to explore antigen reactivity of the MDA5 protein.

Methods

First available serum samples collected from 28 consecutive patients with IIM and positive aMDA5 ever tested by ELISA, Line Blot (LB) or Immunoprecipitation, attending Karolinska University Hospital between 1999 and 2021, were included. Clinical data including presence of anti-SSA autoantibodies by ELISA or LB was retrieved retrospectively. An in-house ELISA was used to screen serum samples for reactivity against a recombinant MDA5 protein (rMDA5, aa A110-D1025, UniProt ID Q9BYX4) and seven MDA5-derived constructs containing different domains. Correlations between aMDA5 reactivity levels and clinical data were explored.

Results

Nine patients showed no reactivity to any of the rMDA5 constructs by ELISA and were excluded from further analysis.

Reactivity against rMDA5 was confirmed by ELISA in 19 patients (median 184.7 µg/mL (interquartile range (IQR) 277.07). The cohort included 13 male and 6 female patients, 94% Caucasian, with mean age at diagnosis of 41.05 years (standard deviation (SD) 10.5). Median disease duration at time of sampling was 0 months (IQR 1). All patients except one had signs of muscle involvement (muscle weakness, elevated muscle enzymes, muscle oedema or muscle biopsy consistent with myositis). At diagnosis 63.2% of patients reported muscle weakness (21.1 % had a manual muscle test 8 score <75). Dermatological findings were observed in 17/19 (89.7 %). During disease course nine patients (47.4%) had confirmed arthritis.

ILD was diagnosed in 16/19 patients (84.2%), four of these (25%) developed a RP-ILD. One patient passed away due to RP-ILD and one required a lung transplant. Patients with ILD had a statistically significant higher mean age at diagnosis than those without (42.8.5 (SD 10.3) vs 31.3 (SD 4.7) years, p=0.02). Patients developing RP-ILD were not significantly older than patients with chronic ILD. Respiratory symptoms were reported by 75% of patients with ILD at time of diagnosis. The mean total lung capacity (TLC) of the ILD cohort was 68% (SD 17), mean diffusion capacity of carbon monoxide (DLCO) was 59% (SD 15) and mean forced vital capacity (FVC) was 62% (SD 19). There was a higher proportion of patients with CRP ≥ 3 times the reference range at diagnosis amongst patients with FVC <70 % than patients with FVC >70 % (88.9 % vs 16.7 %, p= 0.01).

Ten patients (52.6%) had anti-SSA autoantibodies, all had ILD. Anti-SSA positive patients had a statistically significant lower TLC than those without (62% vs 79% respectively, p=0.04) and a lower FVC (57% vs 76% respectively, p=0.05).

We found a weak non-statistically significant negative correlation between titres of aMDA5 and TLC, DLCO and FVC (Pearson coefficients -0.187, -0.289, -0.130 respectively). Frequency of ILD was higher in patients with aMDA5 titres >100 µg/mL than those with titers <100, but not statistically significant (81.3% vs 18.8%, respectively).

Conclusion

In this Caucasian cohort of aMDA5 positive IIM patients, ILD was present in over 80% of patients, of these, one quarter had RP-ILD. Older patients were more likely to present with ILD. Anti-SSA positivity and higher CRP levels were associated with worse lung function. We found a weak negative correlation between aMDA5 titres and lung function tests, as well as a trend of higher frequency of ILD in patients with higher aMDA5 titres. Muscle and skin involvement were found in a high proportion of patients.

Acknowledgements

D. Demirdal & E. Van Gompel contributed equally to this abstract.

Disclosure of Interests

Deniz Demirdal: None declared, Eveline Van Gompel: None declared, Edvard Wigren: None declared, Maryam Dastmalchi: None declared, Begum Horuluoglu: None declared, Angeles Shunashy Galindo-Feria: None declared, Susanne Gräslund: None declared, Karine Chemin: None declared, Ingrid E. Lundberg Shareholder of: Roche and Novartis., Consultant of: Consulting fees from Corbus Pharmaceuticals Inc, Astra Zeneca, Bristol Myer´s Squibb, Corbus Pharmaceutical, EMD Serono Research & Development Institute, Argenx, Octapharma, Kezaar, Orphazyme, and Janssen, Grant/research support from: Research grants from Astra Zeneca, Antonella Notarnicola Speakers bureau: compensation for lecture at conference sponsored by Boehringer Ingelheim.

POS0053 ABUNDANT AUTOANTIBODY ISOTYPES IN IDIOPATHIC INFLAMMATORY MYOPATHIES

Background

Anti-synthetase syndrome (ASSD), a sub-group of idiopathic inflammatory myopathies (IIM) is characterized by the presence of autoantibodies targeting aminoacyl tRNA synthetases (aaRS) and specific clinical manifestations such as myositis and interstitial lung disease (ILD) [1]. Some of the most common anti-aaRS autoantibodies in ASSD are anti-Jo1, -PL7, -PL12 and-EJ. In addition, many anti-aaRS positive patients are also positive for anti-Ro52. Having the combination of anti-Jo1 and anti-Ro52 increases the risk of developing ILD [2]. The presence of autoantibodies is an important part of the classification of ASSD, however only autoantibodies of IgG isotype are usually analyzed in the clinical setting. In rheumatoid arthritis there is evidence that anti-citrullinated protein/peptide antibodies (ACPA) can be found as IgG, IgA and IgM, and importantly, specific isotypes might correlate with disease activity [3, 4].

Objectives

To verify if other autoantibody isotypes, besides IgG, might be present in sera of patients with IIM/ASSD and to compare with the corresponding frequencies in population controls (PC).

Methods

Stored sera collected from consecutive 366 IIM patients and 156 age/gender matched PC at Karolinska University Hospital were retrospectively selected. The serum samples were screened for the presence of autoantibodies of isotypes IgG, IgA and IgM, against a panel of 20 antigens representing Jo1 (HisRS), PL7 (ThrRS), PL12 (AlaRS), EJ (GlyRS), and Ro52 (TRIM21) using a multiplex bead array assay.

Results

We identified IIM patients with autoantibodies of different isotypes, and a low frequency in PC (Figure 1). For anti-Jo1 autoantibodies we could detect IIM patients with only IgG (n=13), only IgM (n=8) and only IgA (n=4), but the majority had a combination of two (n=32) or three isotypes (n=16). For the other anti-aaRS autoantibodies the distribution was more equal to each of the three isotypes with anti-PL12 and anti-PL7 being represented by a slightly higher frequency of IgG and only a few patients had antibodies of more than one isotype targeting PL12, PL7 or EJ. The majority of anti-Ro52 positive IIM patients (n=52) only harbored IgG isotype. The combination of anti-Ro52 and anti-aaRS autoantibodies was identified in 28 patients (anti-Jo1 (n=19), -PL12 (n=2), -PL7 (n=3), and -EJ (n=4)). Most patients with such combination had anti-Ro52 IgG together with anti-aaRS IgG or IgG in combination with IgA and/or IgM. The exception was observed for three anti-Jo1 positive patients who had the combination anti-Ro52 IgG with only anti-Jo1 IgM and one anti-PL7 positive patient who had anti-Ro52 IgA together with anti-PL7 IgA and IgG.

Figure 1.

Venn diagrams showing reactivity in idiopathic inflammatory myopathies (IIM) (top) and population controls (PC) (bottom) for the three autoantibody isotypes IgG, IgA and IgM against five myositis antigens: Jo1 (HisRS), PL12 (AlaRS), ThrRS (PL7), EJ (GlyRS) and Ro52 (TRIM21).

Conclusion

The frequency of the different autoantibody isotypes seems to be autoantigen dependent. Our results suggest that for anti-aaRS autoantibodies it could be important to investigate additional autoantibody isotypes, as some patients only harbor autoantibodies of IgM or IgA isotypes but not IgG. The clinical relevance of the different antibody isotypes still needs to be determined.

References

[1]Mahler, M., et al., Rev, 2014. 13(4-5): p. 367-71.

[2]Huang, H.L., et al., J Clin Neurosci, 2020.

[3]Arlestig, L., et al., Ann Rheum Dis, 2012. 71(6): p. 825-9.

[4]Roos Ljungberg, K., et al., Arthritis Res Ther, 2020. 22(1): p. 274.

Table 1.

Total number of individuals and percentage (n (%)) in each group for each of the isotypes and antigens.

anti-Jo1anti-PL12anti-PL7anti-EJanti-Ro52IIMPCIIMPCIIMPCIIMPCIIMPCIgG61 (16.7)1 (0.6)7 (1.9)0 (0.0)7 (1.9)0 (0.0)3 (0.8)0 (0.0)54 (14.8)5 (3.2)IgA20 (5.5)0 (0.0)2 (1.2)1 (0.6)3 (0.8)2 (1.3)1 (0.3)1 (0.6)3 (0.8)1 (0.6)IgM56 (15.3)1 (0.6)1 (0.3)2 (1.3)7 (1.9)0 (0.0)1 (0.3)0 (0.0)3 (0.8)2 (1.3)

Acknowledgements

SciLifeLab facilities Autoimmunity and Serology Profiling and Human Antibody Therapeutics (Drug Discovery and Development). IMI project EUbOPEN, This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 875510. The JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA and Ontario Institute for Cancer Research, Royal Institution for the Advancement of Learning McGill University, Kungliga Tekniska Hoegskolan, Diamond Light Source Limited.

Disclosure of Interests

Charlotta Preger Grant/research support from: IMI project EUbOPEN, Grant no 875510, Antonella Notarnicola: None declared, Cecilia Hellström: None declared, Edvard Wigren Grant/research support from: IMI project EUbOPEN, Grant no 875510, Ingrid E. Lundberg Shareholder of: Roche and Novartis, Consultant of: Corbus Pharmaceuticals Inc, Astra Zeneca, Bristol Myer´s Squibb, Corbus Pharmaceutical, EMD Serono Research & Development Institute, Argenx, Octapharma, Kezaar, Orphazyme, and Janssen, Grant/research support from: Astra Zeneca, Per-Johan Jakobsson Shareholder of: Gesynta Pharma, Consultant of: UCB, Grant/research support from: Gesynta Pharma, Helena Persson Employee of: Affibody AB, Susanne Gräslund Grant/research support from: IMI project EUbOPEN, Grant no 875510

Evaluation of risk factors and biomarkers related to arterial and venous thrombotic events in idiopathic inflammatory myopathies

Objectives: This study aimed to assess the contribution of traditional/disease-related risk factors and biomarkers linked to arterial and venous thrombotic events (TEs) in patients with idiopathic inflammatory myopathies (IIMs).Method: The occurrence of arterial and/or venous TEs at the time of or after IIM diagnosis was retrospectively evaluated in a cohort of 253 patients with IIMs, resulting in a final population of 246 IIM patients, 51 with reported TE (cases) and 195 without a history of TE (comparators). Information on disease characteristics and traditional risk factors for arterial and venous TE (essential hypertension, diabetes, dyslipidaemia, smoking, malignancy) was retrieved. Serum levels of anti-phospholipid antibodies (aPLs) and adhesion molecules were analysed at the time of IIM diagnosis and at the time of the TE in cases.Results: One in five IIM patients (21%) had experienced a TE, arterial TE in 22 and venous TE in 29 patients, with a peak prevalence within 5 years after diagnosis. Among traditional/disease-related risk factors, only older age was associated with both arterial and venous TEs, after adjusting for other covariates. Low serum levels of e-selectin were associated with higher odds of developing a TE, without specific association with either arterial or venous TEs. Only 6% of IIM patients had aPLs, with no significant difference between cases and comparators.Conclusions: An increased risk of both venous and arterial TEs should be considered in IIM patients, particularly close to diagnosis and in elderly people. Low serum levels of e-selectin may predict TE in IIM patients, but the underlying biological mechanism is not known.

SAT0288 CHARACTERIZATION OF ANTI-AMINOACYL TRNA SYNTHETASE AUTOANTIBODIES IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES

Background:

Idiopathic inflammatory myopathies (IIM) are rare chronic inflammatory diseases associated with high mortality and morbidity [1]. One sub-group of IIM, anti-synthetase syndrome (ASS), is characterized by the presence of autoantibodies that target aminoacyl transfer(t) RNA synthetases (aaRS), together with specific clinical manifestations such as myositis, interstitial lung disease (ILD), arthritis, mechanic’s hand, Raynaud’s syndrome and fever [2]. The most common anti-aaRS autoantibody, anti-Jo1 targeting histidyl tRNA synthetase (HisRS), is present in up to 20-30% of patients with IIM, and up to 90% of patients with myositis and ILD [3, 4]. Besides Jo1, there are today seven other identified autoantigens within the aaRS family.

Objectives:

A large part of patients with IIM, including individuals with clinical manifestations indicating ASS, test seronegative to all known myositis specific autoantibodies. However, these patients could potentially harbor autoantibodies against targets not tested for in clinic. In this study, we aimed at extending the detection of autoantibodies by including all cytoplasmic aaRS in the analysis of patients with IIM. We hypothesized the existence of new potential autoantigens within this protein family.

Methods:

The presence of anti-aaRS autoantibodies was determined using a multiplex suspension bead array assay on 242 IIM patients from the Karolinska University Hospital myositis cohort. A panel of 186 recombinant constructs, representing 57 proteins that included full-length or partial sequence overlaps between constructs of all cytoplasmic aaRS as well as other myositis related proteins, were coupled to magnetic color-coded beads and each plasma sample was tested against the complete antigen panel.

Results:

By the use of this multiplex method we identified patients with autoantibodies against many of the tested aaRS. Autoantibodies binding to HisRS have previously been shown to bind with higher reactivity to the WHEP domain of HisRS and this was also confirmed in this study. We confirmed reactivity against three of the other aaRS tested for in the clinic (PL-12, PL-7, and EJ). In addition, we identified patients positive for anti-Zo, -KS and -HA, autoantibodies usually not screened for in routine. Finally, our data indicates that there are autoantibodies binding to other aaRS than the previously known eight autoantigens, which will be presented.

Conclusion:

In this study, we could detect autoantibodies in plasma from patients with IIM, both against the most common aaRS autoantigens, but also against other aaRS that are usually not tested for in clinic. We conclude that it is important to continue the studies of anti-aaRS autoantibodies, and their correlation to clinical manifestations, and in the long run also include more aaRS autoantigens in clinical practice.

References:

[1]Dobloug, G.C., et al., Mortality in idiopathic inflammatory myopathy: results from a Swedish nationwide population-based cohort study. Ann Rheum Dis, 2018. 77(1): p. 40-47.

[2]Barsotti, S. and I.E. Lundberg, Myositis an evolving spectrum of disease. Immunol Med, 2018. 41(2): p. 46-54.

[3]Vencovsky, J., H. Alexanderson, and I.E. Lundberg, Idiopathic Inflammatory Myopathies. Rheum Dis Clin North Am, 2019. 45(4): p. 569-581.

[4]Richards, T.J., et al., Characterization and peripheral blood biomarker assessment of anti-Jo-1 antibody-positive interstitial lung disease. Arthritis Rheum, 2009. 60(7): p. 2183-92.

Disclosure of Interests:

Charlotta Preger: None declared, Antonella Notarnicola: None declared, Cecilia Hellström: None declared, Edvard Wigren: None declared, Catia Cerqueira: None declared, Peter Nilsson: None declared, Ingrid E. Lundberg Grant/research support from: Bristol Meyer Squibb, Corbus Pharmaceuticals, Inc and Astra Zeneca, Helena Persson: None declared, Susanne Gräslund: None declared, Per-Johan Jakobsson Shareholder of: Gesynta Pharma, Grant/research support from: Gesynta Pharma, AstraZeneca,

SAT0335 SERUM AND BALF-DERIVED ANTI-JO1 AUTOANTIBODIES EXHIBIT HIGH REACTIVITY TO DISTINCT HISRS DOMAINS AND ASSOCIATE WITH LUNG AND JOINT INVOLVEMENT IN PATIENTS WITH IIM/ASS

Background:

Autoantibodies that target aminoacyl transfer(t) RNA synthetases (aaRS) represent the serological marker of the anti-synthetase syndrome (ASS), a major subgroup of the idiopathic inflammatory myopathies (IIM) (1). Among the anti-aaRS, anti-histidyl tRNA synthetase (HisRS) autoantibodies (anti-Jo1) are the most common. Up to 90% of IIM/ASS patients diagnosed with interstitial lung disease (ILD) harbor anti-Jo1 autoantibodies (2).

Objectives:

Reactivity and affinity of anti-Jo1 autoantibodies from serum and broncheoalveolar lavage fluid (BALF) were investigated against HisRS autoantigen. Associations with clinical data from patients IIM/ASS were addressed.

Methods:

Total IgGs were purified by affinity chromatography. Samples and clinical data were obtained from: i) 26 anti-Jo1+patients (19 at diagnosis, 16/19 at follow-up, 7 BALF/matching serum at baseline; ii) 29 anti-Jo1-(25 serum at diagnosis, 4 BALF/matching serum at baseline); iii) 24 age/gender matched healthy controls. Anti-Jo1 IgG and IgA response against HisRS was evaluated by ELISA and western blot. Affinity was measured by surface plasmon resonance. HisRS full-length (HisRS-FL), two HisRS domains (ABD and CD), and two HisRS splice variants (WHEP and WHEP + ABD splice variant (SV)) were tested. Correlations between autoantibody reactivity and clinical data, at baseline and over disease course, were evaluated.

Results:

Anti-Jo1 autoantibodies from serum and lung bound HisRS-FL, WHEP and SV with high reactivity and affinity already at diagnosis and recognized both conformational and linear HisRS epitopes (Fig. 1). Levels of autoantibodies (against HisRS-FL, -domains and -splice variants) varied among patients and overtime. Patients with ILD, arthritis and less skin involvement presented higher anti-Jo1 titers compared to those with lower anti-Jo1 titers and to the anti-Jo1 negative group (Fig. 2). Anti-WHEP reactivity in BALF strongly correlated with poor pulmonary function.

Conclusion:

High reactivity and affinity at time of diagnosis indicates that autoimmunity against HisRS is most likely initiated before IIM/ASS diagnosis. Reactivity to specific splice variants of HisRS may be employed as diagnostic and prognostic markers.

References:

[1]Marguerie C, Bunn CC, Beynon HL, Bernstein RM, Hughes JM, So AK, Walport MJ: Polymyositis, pulmonary fibrosis and autoantibodies to aminoacyl-tRNA synthetase enzymes. Q J Med 1990, 77(282):1019-1038

[2]Richards TJ, Eggebeen A, Gibson K, Yousem S, Fuhrman C, Gochuico BR, Fertig N, Oddis CV, Kaminski N, Rosas IO et al: Characterization and peripheral blood biomarker assessment of anti-Jo-1 antibody-positive interstitial lung disease. Arthritis Rheum 2009, 60(7):2183-2192.

Fig. 1.

Anti-Jo1 reactivity in total IgG purified from the first available serum sample

Fig. 2.

Reactivity of total anti-Jo1+ IgG purified from the first available serum close to IIM/ASS diagnosis in relation to clinical data

Disclosure of Interests:

Antonella Notarnicola: None declared, Charlotta Preger: None declared, Susanna Lundström: None declared, Nuria Renard: None declared, Edvard Wigren: None declared, Eveline Van Gompel: None declared, Angeles Shunashy Galindo-Feria: None declared, Helena Persson: None declared, Maryam Fathi: None declared, Johan Grunewald: None declared, Per-Johan Jakobsson Shareholder of: Gesynta Pharma, Grant/research support from: Gesynta Pharma, AstraZeneca,, Susanne Gräslund: None declared, Ingrid E. Lundberg Grant/research support from: Bristol Meyer Squibb, Corbus Pharmaceuticals, Inc and Astra Zeneca, Catia Cerqueira: None declared

Prevalence of cigarette smoking: a cross-sectional survey between individual and team sport athletes

BACKGROUND

Studies on the relationship between sport and smoking among adolescents and young adults reported contradictory results: some findings indicate that sport is a protective factor against smoking initiation, while other studies documented the inclination to unhealthy habits among athletes. The aim of this study was to evaluate smoking prevalence in a sample of young athletes practicing team (football, basket) or individual (swim) sports.

STUDY DESIGN

Cross-sectional study carried out in a convenience sample of athletes.

METHODS

The survey was performed by a self-administered, anonymous questionnaire.

RESULTS

The study included 327 athletes, 81.0% male, with an average age of 16 years; 36.7% play football, 31.8% basketball, and 31.5% swim. Smoking prevalence among participants was 16.8%. Basket and soccer players were 3 times more likely to be current smokers (20.1%), particularly those aged 16-18 years (35.9%), compared to swimmers (7.8%; in 16-18 year-old: 11.3%). Moreover, basket and soccer players were 7 times more likely to be smokers and to smoke before the practice session compared to swimmers.

CONCLUSION

Smoking prevalence in all athletes was lower than that observed in youths. However, athletes of team sports were three times more likely to smoke than athletes of sprint and resistance sports. The reason is likely to be psychological: these sports, not focusing on the individual physical performance, allow athletes to feel less responsible for successes of their teams. It is essential to ensure a specific alliance for prevention between Health and Sport authorities, such as Federations and sporting societies, in order to develop interventions to inform athletes of team sports about the health and physical risks associated to smoking.

Long-Term Therapy with Corticosteroids in Nasal Polyposis: A Bone Metabolism Assessment

Chronic rhinosinusitis associated with nasal polyposis (RSCwNP) affects 4% of the general population. As chronic condition, it requires chronic pharmacological treatment, whereas the surgical approach becomes necessary in obstructive and/or complicated cases. Intranasal and systemic corticosteroids (CS) represent the "Gold Standard" treatment for RSCwNP. The present study aimed to evaluate the side effects of prednisone in a group of patients with RSCwNP treated with long-term CS. In particular, attention was focused on bone disorders (osteopenia and osteoporosis) and prospective fracture risk increase. Forty patients (26 females, mean age 55.70 ± 14.03 years) affected by RSCwNP have been enrolled. Control group included 40 healthy subjects (17 females, mean age 56.37 ± 13.03 years). Nasal endoscopy, skin prick tests, nasal cytology, and bone densitometry were evaluated in all subjects. The likelihood of impaired bone metabolism (osteopenia or osteoporosis) was superimposable in both groups. Within RSCwNP group, no parameter was statistically significant in predicting a metabolism alteration.

Three-trocar laparoscopic cholecystectomy under spinal anesthesia in a patient with asthma

INTRODUCTION

Laparoscopy is perceived as the state-of-the-art technique for a wide variety of operations but is contraindicated by comorbidities such as respiratory diseases. We present the case of a patient affected by asthma who underwent a successful three-trocar low-pressure pneumoperitoneum under spinal anesthesia.

CASE REPORT

A 58 year-old male with symptomatic gallstones had partly-controlled asthma and respiratory allergies. Potential bronchospasm was avoided by a less invasive laparoscopic technique. Under spinal anesthesia open pneumoperitoneum was achieved at the umbilicus. Two more trocars were inserted. A cholecystectomy was performed in 90 minutes keeping the patient in a supine position and the pneumopneumoperitoneum at 8 mmHg. The post-operative course was uneventful. Discharge to home occurred on day two.

DISCUSSION

Laparoscopy is contraindicated in the presence of hemodynamic instability and inability of the patient to tolerate laparoscopic surgery. Asthma is caused by bronchoconstriction from a myriad possible stimuli requiring a specific anesthetic plan. Spinal anesthesia under low pressure pneumoperitoneum is a safe alternative to general anesthesia in high risk candidates. In experienced hand, a three-trocar cholecystectomy is safe and feasible.

CONCLUSION

Our patient represented a challenging case due to a partly-controlled asthma. Bronchospasm under general anesthesia was prevented by spinal anesthesia to keep a spontaneous physiologic respiration, irrigation of the right subdiaphragmatic surface with lidocaine to control right shoulder pain, safe dissection by three trocars, a pneumoperitoneum at 8 mmHg, the supine position to prevent significant physiologic changes and minimize diaphragmatic irritation.

Extracorporeal shockwave therapy versus exercise program in patients with low back pain: short-term results of a randomised controlled trial

The physiotherapy treatment of low back pain (LBP) with physical stimulation offers different possibilities of application. Until now, the physical therapies used in LBP are laser therapy, ultrasonotherapy and currents. We conducted a clinical trial in order to verify whether shockwave therapy, which is very effective in treating tendinopathies and fracture consolidation delays, leads to clinical and electromyographic improvement in patients affected by LBP. We randomized thirty patients affected by LBP treated with shock waves (shockwave group) or a standard protocol characterized by rehabilitative exercises (control group). At one and three months, the patients treated with shockwave therapy showed clinical improvement measured by VAS scales (p=0.002; p= 0.02), and disability evaluated with Roland scales (p=0.002; p=0.002) and Oswestry (p=0.002; p=0.002). At three months, the patients treated with shock waves, showed a significant improvement in terms of values of amplitude of the sensory nerve conduction velocity (SNCV) of the plantar medialis nerve (left: p=0.007; right: p=0.04), the motor nerve muscular conduction (MNCV) of the deep peroneal nerve (left: p=0.28; right: p=0.01) and recruitment of motor units of finger brevis extensor (left: p = 0.02; right: p=0.006). In the control group, there was a trend to increase the clinical and electromyographic results without statistical significance. The preliminary results suggest a good applicability of shockwave therapy in the treatment of LBP, in accordance with the antiinflammatory, antalgic, decontracting effects and remodeling of the nerve fiber damage verified in previous studies conducted on other pathological models. Future research will allow us to verify the integration of this therapy into a rehabilitation protocol combined with other physical therapies.

Extracorporeal shockwave therapy on muscle tissue: the effects on healthy athletes

The aim of this study is to investigate the effects of extracorporeal shock wave therapy (ESWT) on muscle rheological and functional properties in a population of young athletes. Thirty-two football and basketball players were recruited and randomized into two groups. The athletes underwent three sessions of therapy administered every five days to the thigh muscles. The treatment consisted of ESWT (electromagnetic generator, Energy Flux Density=0.03 mJ/mm2) or a placebo treatment bilaterally on the quadricep and femoral bicep muscles. Monitoring was carried out at recruitment (T0), at the end of treatment (15 days, T1) and at 30 days (T2) with myometric evaluation (measuring elasticity, stiffness and muscular tone) and electromiography exam (recording the Motor Unit Amplitude Potential values). The results showed a significant increase in the treated athletes in the elasticity (lateral vastus muscle, p=0.007), in muscular tone (femoral rectus, p=0.031) and in muscular recruitment (the lateral vastus, p<0.005; medial vastus muscle, p=0.055). These results could represent a translational interpretation of the known biological effect on connective tissue: an increase in blood flow, oxygenation, metabolic process activation and proliferative effect. The effects found may represent the justification for verifying the usefulness of using of shockwave therapy to reduce muscular fatigue and improve performance during the sport season.

Baropodometry on patients after total knee arthroplasty

PURPOSE

It is well known that total knee replacement surgery decreases pain and improves function, but the effect on postural assessment needs to be studied better with the use of new technological devices. Total knee arthroplasty (TKA) improves motor coordination and stability of the knee. On the other hand, changing joint functionality can modify the balance. The aim of this trial is to record and analyze the static and dynamic baropodometric data of patients in the first few months following joint replacement. For the physiatrist, this tool can be useful to check if the rehabilitation treatment protocols and times are correct.

METHODS

We designed a prospective observation longitudinal study to assess postural stability following TKA. Between December 2014 and May 2015, sixty consecutive patients were recruited through local orthopedic physician offices and hospitals. The patients scheduled to undergo TKA were recruited and were monitored before surgery (T0) and at 1 (T1), 3 (T2) and 6 months (T3) after knee surgery. The correction of varus/valgus deviation at X-ray and the Knee Society Score were performed to verify the functional recovery. We used static and dynamic baropodometric analysis to evaluate postural assessment.

RESULTS

After surgery, there was a significant improvement in physiological alignment of knee axes (p < 0.0001) and of Knee and Function Scores (excellent, mean values 80.5 and 80.7, respectively, p < 0.0001). The static analysis showed that the center of gravity and the pressure on the foot of the operated limb were corrected toward the physiological center (p < 0.0001) and the body weight displaced to the forefeet and to the hindfeet reduced bilaterally (p < 0.0001). The type of footprint did not change. The dynamic analysis confirmed the significant normalization of the pressure on the foot of the operated limb at all follow-ups (p < 0.0001). The percentage of load was reduced on the operated limb (p = 0.0096) and speed of step, cadence and semi-step length increased (p < 0.0001).

CONCLUSION

These data show the progressive recovery of stability after TKA from the immediate postoperative to the subsequent months. The clinical and functional improvement correlated with a load redistribution between the two limbs. The baropodometry could be an excellent noninvasive method for monitoring effects of rehabilitation treatment.

Irisin levels correlate with bone mineral density in soccer players

Irisin, a novel myokine produced in response to physical exercise by skeletal muscle, displays anabolic effect on bone and can improve the bone-loss-induced osteoporosis in hind limb suspended mice. It is well known that muscles positively impact the skeleton and in different sports, including soccer, total body bone mineral density (TB-BMD) is elevated. Therefore, we have investigated the correlation between irisin serum levels and total and bone sub-regional BMD in soccer players never studied before. In this study, Caucasian football players of Bari team have been enrolled. Their sera were collected to measure by ELISA kit irisin levels and by dual-energy X-ray absorptiometry (DEXA) analysis measurements of BMD (g • cm−2) in the whole body and different bone sub-regions (head, arms, legs, ribs, dorsal vertebrae, lumbar vertebrae, pelvis) were performed. The BMC (g) was measured in the whole body. By means of Pearson’s (R) and Cohen’s (d) coefficient we investigated the linear association between the irisin serum levels and BMD. In soccer players, we have found a positive correlation between irisin and TB-BMD as demonstrated by the values of Pearson and Cohen’s (d) coefficient. Furthermore, linear association was detected between irisin and BMD of different bone-site such as right arm, lumbar vertebrae and head. A positive trend was also observed analyzing circulating levels of irisin and bone mineral content as well as total Z-score. In conclusion, we have demonstrated the correlation between irisin and total or bone sub-regional BMD in soccer players for the first time, an additional systemic effect of the “sport-hormone” defined myokine.

Autologous lipotransfer versus stromal vascular fraction enriched lipoinjection for diabetic foot wounds healing: a pilot study

Chronic ulcers of the lower limbs represent a significant social and economic burden. Diabetes is a strong risk factor for development of chronic lesions. Adult stem cells and growth factors derived from the adipose tissue are among the most promising therapeutic strategies for hard to heal wounds. Fat grafts have been used for several decades to treat soft tissue deformities, but despite its excellent characteristics, the outcome was unpredictable, due to partial necrosis and resorption of the graft. Stem cells’ enrichment of these grafts or their injection into the edges of the ulcers have shown encouraging results in various experimental settings. In this pilot study, we compared the standard of care to autologous lipotransfer and stromal vascular fraction (SVF) enriched lipoinjection in 30 patients with diabetic foot ulcers, showing clear superiority of SVF enriched lipoinjection in terms of percentage of reduction of ulcers size and healing time.

Short-term effect of shockwave therapy, temperature controlled high energy adjustable multi-mode emission laser or stretching in Dupuytren’s disease: a prospective randomized clinical trial

Dupuytren’s disease is a debilitating disease of the hand characterized by nodules on the surface of the palm with progressive loss of finger extension. The chosen forms of treatment are infiltrative and surgical. Conservative treatment could be useful but few studies have been carried out and these regarded mainly stretching exercises and thermo-therapy. To date, no study has analyzed the effects of biostimulation with shock-waves (SW) and high energy laser therapy [Temperature controlled High Energy Adjustable multi-mode emission Laser (THEAL)]. We recruited 45 patients, 32 males and 13 females (average age 63.4 years) affected by early or late stage Dupuytren’s disease [33 metacarpophalangeal (MCP) joints, 12 proximal interphalangeal (PIP) joints]. We randomized the patients into three treatment groups: extracorporeal shockwave therapy (ESWT), THEAL and stretching exercises. Follow-ups were at the end of treatment (T1), after 1 month (T2), and after 3 months (T3). The three forms of treatment determined a progressive clinical-functional improvement. The pain relief was statistically significant for SW and THEAL at all follow-ups (FUs) (p</=0.01). The functional recovery was statistically significant in the SW group at all FUs and in the THEAL and Stretching groups at T1 and T2 (p<0.01). Patient satisfaction level was higher for SW at T2 and T3 and for THEAL at T2 (p</=0.01). The extension deficit recovery as regards the MCP and PIP joints was statistically significant in the SW group at T1 and T2 (p</= 0.01) and in the stretching group at T1 (p<0.01). The SW and THEAL treatments appear safe, have good efficacy and are associated with good patient satisfaction in the short and medium terms. Further studies may verify the possibility of repeated cycles and/or combined therapies to improve results.

Short term efficacy of capacitive-resistive diathermy therapy in patients with low back pain: a prospective randomized controlled trial

To compare the effectiveness of Doctor Tecar TherapyTM with that of laser therapy in the management of low back pain (LBP), a total of 60 patients with LBP were enrolled. The participants were randomly divided into two groups: a Tecar group (experimental group, 30 subjects), and a laser group (control group, 30 subjects). All the subjects received 10 sessions of therapy: one each day from Monday to Friday and the same again the following week. All the subjects were evaluated for pain (VAS) and disability (Roland and Morris score and Oswestry score) at baseline (T0), and 2 weeks (T1), 1 month (T2) and 2 months (T3) after the end of treatment. The pain and disability presented a trend to improvement over time in both groups. This improvement was statistically significant at all follow-ups (FUs) in the Tecar group but only at T1 for the Laser group (p less than 0.01). Comparing the two methods, there emerged a significant difference in favour of the Tecar group at T2 and T3 (p less than 0.01). The results show that Tecar therapy determined significant improvement already by the end of the treatment. Moreover, at the first and second month FUs, the Tecar therapy showed statistically better results than laser therapy.

ACTN3/ACE genotypes and mitochondrial genome in professional soccer players’ performance

Two nuclear genes, ACTN3, encoding for the α-actinin skeletal muscle isoform 3, and ACE encoding the angiotensin-converting enzyme, have both been associated with quantitative physical performance traits in the general population. The purpose of our study was to assess the association between the two nuclear gene variants, R577X (rs1815739) in ACTN3 and I/D (rs4340) in ACE, with elite athletes’ performance and the effect of training on the mitochondrial DNA (mtDNA) content in peripheral blood. We evaluated the genotypes and frequencies of ACTN3 R577X and ACE I/D polymorphisms between soccer players (n = 43) and healthy non-athletic controls (n = 128). Total DNA was extracted from peripheral blood samples using the standard procedure. The genotypes were assessed by PCR-RFLP analysis and mtDNA cellular content by RT-PCR. The soccer players showed a tendency to a prevalence of ACTN3RR and ACEDD genotypes both independently and in co-occurrence. The effect of physical training on the mitochondrial DNA content in the athletic population was reflected strikingly in its increase in peripheral blood. Based on our results, we suggest that the analysis of ACTN3 and ACE genotypes could predict talent in the soccer field and that knowledge of the genetic variants could determine types and training times for soccer players. In addition, the novelty of this work, never before described in the sports literature, is that the increase of mitochondrial content can be correlated with the training load, suggesting that the mtDNA copy number may be considered a viable bioenergetics biomarker.

Cardiopathy and osteoporosis: the epidemiology in a region of Italy

Cardiopathies and osteoporosis are inter-related due to pathogenetic, hormonal, genetic features as well as an increased risk of fragility. An important feature is attributed to the process of atherosclerosis, which is responsible for an osteopenia effect and degeneration of vascular walls. To date the study populations have been limited. To verify the incidence of cardio-vascular disease in a larger osteoporotic population, we designed a retrospective clinical study analyzing the “Hospital Discharge Data” (HDD) in Apulia between 2006 and 2010. All patients over 55 years with a hospitalization for a fragility fracture and/or drugs prescription for osteoporosis were crossed with the diagnosis and/or drugs prescription for cardiovascular disease. We observed that between 2006 and 2010, in Apulia, 177,639 patients were hospitalized and diagnosed as having fragility fractures, 66.3% had a diagnosis of cardiopathy, with a higher prevalence in males and in patients over 80 years. The incidence of fractures were as follows: femur (51.9%), spine (20.2%), humerus (10.6%), forearm (9%), tibial pilon (7.2%) and tarsus and metatarsus (1.1%). Cerebrovascular diseases were the most frequent, followed by arrhythmias, heart failure and cardiomyopathies. In these patients, the most prescribed drugs were anti-coagulants, ACE inhibitors and diuretics. In patients affected by cerebral circulation disorder there is a greater propensity to fall and thus have a fragility fracture, particularly of the femur. The vertebral fracture, misdiagnosed in 60-70% of patients, may compromise the cardio-respiratory function of these patients. We verified a higher incidence of fragility fractures in patients who were prescribed certain categories of drugs for the treatment of cardio-vascular disease. This hypothesis is not supported by the literature, where contradictory results on the potential effects of these drugs on bone have been published. The high incidence of heart disease found in patients with fragility fractures supports the need for specific screening for osteoporosis in the population with cardio-circulatory pathology.

Single-row and transosseous sutures for supraspinatus tendon tears: a retrospective comparative clinical and strength outcome at 2-year follow-up

INTRODUCTION

Rotator cuff tears commonly necessitate surgical repair; however, the optimal technique for repair continues to be investigated. Recently, double-row repairs have been considered an alternative to single-row repair, allowing a greater coverage area for healing and a possibly stronger repair.

AIM

We performed a study to compare single-row repair and suture-bridge (SB) technique (a TOE technique) in terms of the recovery of the strength and functional outcome.

MATERIAL AND METHOD

The purpose of the retrospective study was to compare 44 patients treated for a rotator cuff repair with the single-row (24) or suture-bridge techniques (20). At 24-month FU, there were not statistically significant differences for the UCLA score, Individual Constant Score, pain, ROM, and strength on the treated and contra-lateral arm. Comparing the mean values of the differences in strength obtained between the treated arm and the contra lateral in each group, the final results appeared significantly different in favor of SB (p = 0.03).

CONCLUSION

Patients treated with DR could expect to regain the same strength of the contra-lateral side, while patients treated with SR could expect globally good results, overall in terms of pain relief and functionality, but lower strength.

Risk of infectious mononucleosis among agonistic swimmers: a cross-sectional study

BACKGROUND

The risk of infectious mononucleosis among athletes is quite debated. Some personal observations seem to suggest an increase risk of mononucleosis among athletes, because they attend always close settings with an high probability of respiratory pathogens transmission; overtraining has been also proposed as risk factor.

STUDY DESIGN

Cross-sectional study in a group of swimmers (aged 11-14 years) of the University Sport Centre of Bari.

METHODS

40 swimmers were interviewed by healthcare personnel at the end of training courses; demographic characteristics, personal habits, information about sport training and diagnosis of mononucleosis were analysed.

RESULTS

The life-time incidence of mononucleosis was around 40%; multivariate analysis showed the association between mononucleosis and use of bottles of other persons (aOR=8.2; 95% CI=1.4-49.2; z=2.32; p=0.021) and average duration of training session was longer among subjects who reported mononucleosis than in subjects who did not indicate this disease.

CONCLUSIONS

Future multi-centric studies are needed to better define the epidemiology of the mononucleosis in sport settings and to formulate appropriate recommendations to prevent the spreading of this disease.

High level laser therapy for the treatment of lower back pain: clinical efficacy and comparison of different wavelengths

High energy laser therapy (HELT) could be a new alternative treatment for lower back pain (LBP), which is a significant public health problem. Nevertheless, differences between the various light waves of HELT have not yet been fully researched. Sixty-six patients with lower back pain were treated using a high energy laser therapy. They were randomized into three different protocols which differed according to wave length (650 nm, 810 nm and TRIAX, which is simultaneous emission of 810 nm, 980 nm e 1064 nm). The other parameters remained constant (5 W and 50 J/cm2 for ten daily sessions). The visual analogue scale (VAS), the Roland Scale, and the Oswestry Score were measured before treatment (T0), and at end of the treatment session (T1) and 1 month (T1), 2 months (T2) and 4 months of follow-up (T4). In each group we verified a statistically significant improvement over time and that there was a relationship between the time and treatment (p less than 0.01). At T1 for all wavelengths we found a statistically significant improvement of three scores (p less than 0.01), which was maintained up to T4. The group treated with 810 nm HELT, showed a better remission of pain on the VAS scale, and disability on the Oswestry Scale at T4 (p=0.01). Comparing T0-T1 the variation in the Roland Score was significant in the patients treated with 810 nm (p less than 0.01). All the wavelengths analyzed proved to be efficacious for LBP. The greater efficacy of 810 nm in promoting nerve regeneration and in modulating the nociception transmission could explain the better outcomes.

Tendonitis of the rotator cuff treated with extracorporeal shock wave therapy: radiographic monitoring to identify prognostic factors for disintegration

Extracorporeal shock wave therapy (ESWT) is widely used for calcific tendonitis of the shoulder. The initial rationale for this therapy was to break the calcification, but this effect does not always occur. To date, we do not know how calcifications evolve or why they may be less responsive to the action of the shock waves. One hundred and seventy-four shoulders with calcific tendinitis were prospectively evaluated before and after ESWT, using the radiographic classifications according to Gartner and Heyer, to Bosworth and to Molè. Three months after ESWT therapy, we observed the disappearance of calcification in 36.8% of the shoulders, a reduction in size in 21.8% and no change in 41.4%. The calcifications that disappeared were large according to Bosworth (p=0.004). The probability of disappearance of calcification increased with increasing age (p=0.011), for medium calcifications according to Bosworth (p=0.001), and calcifications of type A according to Molè (p=0.043). The results of our study suggest that the radiographic aspects of calcific tendonitis of the rotator cuff could influence the disruptive effects after ESWT. With this knowledge we could define the timing of treatment and therapeutic choice for each patient.

Extracorporeal shock waves induce osteogenic differentiation of human bone-marrow stromal cells

The effects of treatment with shock waves (SW) on osteoblastic cells have already been described. Furthermore, the effects of treatment with SW are also determined by the contextual stimulation of other cell lines, in particular of mesenchymal cells. This is the first experimental study of stimulation of a human mesenchymal stem cell line, taken from bone marrow, using SW (electromagnetic device), with two energy levels. The results showed a significant increase in expression of the main osteoblastic differentiation genes: BMP2, alkaline phosphatase, osteocalcin, COL1A1, RUNX2. The monitoring within 96 hours demonstrated a progressive increase of cell adhesion and an intense cell proliferation at 48 h. The differentiation response and proliferation of stem cells after treatment with SW shows that this therapy is an effective method of regenerative medicine.

Extracorporeal shockwaves as regenerative therapy in orthopedic traumatology: a narrative review from basic research to clinical practice

Extracorporeal Shock Wave Therapy (ESWT), after its first medical application in the urological field for lithotripsy, nowadays represents a valid therapeutical tool also for many musculoskeletal diseases, as well as for regenerative medicine applications. This is possible thanks to its mechanisms of action, which in the non-urological field are not related to mechanical disruption (as for renal stones), but rather to the capacity, by mechanotransduction, to induce neoangiogenesis, osteogenesis and to improve local tissue trophism, regeneration and remodeling, through stem cell stimulation. On the basis of these biological assumptions, it becomes clear that ESWT can represent a valid therapeutic tool also for all those pathological conditions that derive from musculoskeletal trauma, and are characterized by tissue loss and/or delayed healing and regeneration (mainly bone and skin, but not only). As a safe, repeatable and non–invasive therapy, in many cases it can represent a first–line therapeutic option, as an alternative to surgery (for example, in bone and skin healing disorders), or in combination with some other treatment options. It is hoped that with its use in daily practice also the muscle–skeletal field will grow, not only for standard indications, but also in post–traumatic sequelae, in order to improve recovery and shorten healing time, with undoubted advantages for the patients and lower health service expenses.

Epidemiology of diabetes mellitus in the fragility fracture population of a region of Southern Italy

Increased risk of osteoporosis and its clinical significance in patients with diabetes is controversial. This study aims to increase the data which are available regarding the prevalence of diabetes mellitus in patients affected by fragility fracture in Italy. We retrospectively studied Hospital Discharge Data (HDD) in the Apulian database for the period 2006–2010 to identify a fragility fracture diagnosis in males over 65 years of age and in females over 50. The database was then checked for drug prescriptions to identify those persons who had taken at least one osteoporosis drug. Within this latter group, thanks to hospital admission and prescription records, the subjects affected with diabetes mellitus were identified. Between 2006 and 2010 in Apulia 177,639 patients were hospitalized and diagnosed as having fragility fracture. The greatest number of those fragility fractures were found to be in the 70 to 79 age range (64,917 total; females 56,994, males 7,923). The prevalence of diabetes subjects in Apulia in this period was estimated at 6.5%. In the same region and period 21.1% of subjects affected by diabetes experienced a fragility fracture; in particular, this number was 27% for males and for 20.5% females. This is the first study providing data on the prevalence of fragility fractures and diabetes in the Apulian population. The data confirm that diabetes is a risk factor which influences bone density and risk of fractures and therefore the need of osteoporosis screening and treatment in diabetic patients.

Prognostic factors of extracorporeal shock wave therapy for tendinopathies

INTRODUCTION

Extracorporeal shock wave therapy is very widely used for the management of tendinopathies and plantar fasciitis.

AIM

The aim of the study is to determine whether there are prognostic factors that may influence the outcome of extracorporeal shock wave therapy for these diseases.

METHODS

Three hundred fifty-five patients were analyzed 2 months after shock wave treatment for rotator cuff tendinitis, epicondylitis, Achilles tendinopathy, trocanteritis, jumper's knee or plantar fasciitis. We recorded the epidemiological, clinical and treatment protocol, and these data were correlated with treatment outcome.

RESULTS

Clinical improvement was achieved in 45.9 % of these patients. We discovered that laterality different to the dominant limb (p < 0.0001) and repeated shock wave treatments (p = 0.004) are prognostic factors in an unsuccessful therapy, while being male (p = 0.015) and a high body mass index (p = 0.004) are factors for success. We found no differences in relation to age, diet, blood type, work or sport activity, presence of co-morbidities, drugs, type of tendinopathy, density of energy delivered and other physiotherapy treatment. Knowledge of these prognostic factors may lead to improved insight for physicians and physiotherapists to predict the extent of the recovery and adjust rehabilitation and patient expectations accordingly.