Osteoarticular Infections: Younger Children With Septic Arthritis and Low Inflammatory Patterns Have a Better Prognosis in a European Cohort

BACKGROUND

Osteoarticular infections (OAI) are associated with complications and sequelae in children, whose prediction are of great importance in improving outcomes. We aimed to design risk prediction models to identify early complications and sequelae in children with OAI.

METHODS

This observational study included children (>3 months-17 years old) with acute OAI admitted to a tertiary-care pediatric hospital between 2008 and 2018. Clinical treatment, complications and sequelae were recorded. We developed a multivariable logistic predictive model for an acute complicated course (ACC) and another for sequelae.

RESULTS

A total of 240 children were identified, 17.5% with ACC and 6.0% and 3.6% with sequelae at 6 and 12 months of follow-up, respectively. In the multivariable logistic predictive model for ACC, predictors were fever at admission [adjusted odds ratio (aOR): 2.98; 95% confidence interval (CI): 1.10-8.12], C-reactive protein ≥100 mg/L (aOR: 2.37; 95% CI: 1.05-5.35), osteomyelitis (aOR: 4.39; 95% CI: 2.04-9.46) and Staphylococcus aureus infection (aOR: 3.50; 95% CI: 1.39-8.77), with an area under the ROC curve of 0.831 (95% CI: 0.767-0.895). For sequelae at 6 months, predictors were age ≥4 years (aOR: 4.08; 95% CI: 1.00-16.53), C-reactive protein ≥110 mg/L (aOR: 4.59; 95% CI: 1.25-16.90), disseminated disease (aOR: 9.21; 95% CI: 1.82-46.73) and bone abscess (OR: 5.46; 95% CI: 1.23-24.21), with an area under the ROC curve of 0.887 (95% CI: 0.815-0.959).

CONCLUSIONS

In our model we could identify patients at low risk for complications and sequelae, probably requiring a less aggressive approach.

Osteoarticular infections in infants under 3 months of age

BACKGROUND

Acute osteoarticular infections (OAI) in infants under 3 months of age (≤3M) are rare and remain a diagnostic challenge. Orthopedic complications and functional sequelae have been less well described in this age group. Our aims were to evaluate trends in aetiology, management, and outcomes of OAI ≤ 3M, and to compare these younger children who have OAI with older children.

METHODS

A longitudinal observational study was conducted of OAI cases admitted to tertiary care pediatric hospital from 2008 to 2018. OAI ≤ 3M was compared with children above 3 months. Clinical, microbiological, imaging, and outcome data were analyzed.

RESULTS

We identified 24 (9.1%) of the 263 OAI in children under 3 months. Analyzing OAI ≤ 3M there was a twofold increase since 2014; 54% were males with a median age of 28 days (IQR: 13.5-60.0), 10 (41.7%) were premature and nine (37.5%) had healthcare-associated infections. Microbiological causes were identified in 87.5%, mostly Staphylococcus aureus (57.1%) and Group B Streptococcus (23.8%), and 25% were multidrug-resistant (5 methicillin-resistant S. aureus and 1 Enterobacter cloacae). Bacteremia (100% vs 36.8%, P = 0.037), multidrug resistant bacteria (75% vs 16, P = 0.04), and healthcare-associated infections (100% vs 26.3%, P = 0.014) were associated with sequelae. Comparing OAI ≤ 3M with older children, OAI ≤ 3M were treated with longer antibiotic courses, had more complications and sequelae (17.4% vs 3.2%, P = 0.002).

CONCLUSIONS

S. aureus is still the most common cause of OAI ≤ 3M, and 25% of causative bacteria were multidrug-resistant bacteria. Complications and sequelae were more frequent in OAI ≤ 3M when compared with older children.

P–119 The correlation between sperm chromatin fragmentation and intrauterine insemination outcome

Study question

Does sperm genomic integrity affect the intrauterine insemination (IUI) outcomes in couples with unexplained infertility and young maternal age?

Summary answer

Spermatozoa with higher genomic integrity are correlated with higher clinical pregnancy rates in couples with unexplained infertility undergoing IUI.

What is known already

It is known that elevated sperm chromatin fragmentation (SCF) on the male gamete affects embryo development and implantation. This is particularly relevant in IVF as well as programmed intercourse and IUI. By complementing the standard semen analysis with an SCF assay, we can assess the competence of the male gamete and its ability to generate euploid embryos and healthy offspring. Elevated SCF has been used as a way to identify subtle male factor infertility in couples undergoing IUI with poor pregnancy outcomes in order to plan for further treatments.

Study design, size, duration

This is a retrospective cohort study of IUI outcomes of couples with young maternal age and a negative infertility workup treated at our center from 2016–2020. Terminal deoxynucleotidyl dUTP transferase nick-end labeling (TUNEL) assay was used to assess sperm genomic integrity. Couples were grouped based on SCF level: normal (≤15%) or abnormal (>15%). Rates of clinical pregnancy, defined as the presence of a fetal heartbeat, were compared between the groups following IUI.

Participants/materials, setting, methods

A total of 189 consenting couples, in which the female partner had a normal uterine cavity and patent fallopian tubes, underwent 454 IUI attempts. Only women ≤37 years old were included to control for age-related confounding factors. At least 500 spermatozoa were assessed per patient, and a threshold of ≤ 15% was considered normal. Women were either untreated for natural cycle IUI or stimulated with clomiphene citrate, gonadotropins, or Letrozole.

Main results and the role of chance

A total of 454 IUI cycles were reported at our center; 302 of these were carried out in 132 couples in which the male partner had normal SCF averaged at 9.29%. The average maternal age was 34.1±3 years, and the average paternal age was 37.1±5 years. These men had the following semen parameters: a concentration of 46.2±5x106/mL, 43.8±3% motility, and an average SCF of 9.3±3%. There were 45 documented clinical pregnancies (45/302, 14.9%) as confirmed by the presence of at least one fetal heartbeat detected by ultrasound; 26 delivered, 9 are ongoing, 5 were spontaneous abortions, and 5 were lost to follow-up. A total of 57 couples in which the male partner (37.2±5.9 years) had abnormal SCF underwent 152 IUI cycles (maternal age, 34.0±2.7 years). The men had the following semen parameters: an average SCF of 23.8±10 (p < 0.0001), a concentration of 26.0±10 x106/ml, and 40.1±4% motility. These IUI attempts yielded a clinical pregnancy rate of only 4.6% (7/152; P < 0.0001); 4 delivered and 3 were spontaneous abortions.

Limitations, reasons for caution

This study is a retrospective cohort analysis of a relatively small number of patients. Furthermore, most patients were screened for SCF due to at least one prior IUI failure. A prospective, randomized trial, in which men are concurrently screened for SCF levels at the first IUI attempt, would be ideal.

Wider implications of the findings: Assessment of SCF at the initial male infertility screening can be a useful tool to investigate the competence of the male gamete. Screening couples with idiopathic infertility for a subtle male factor would guide those with higher SCF toward alternative reproductive treatments to avoid unnecessary IUI treatments.

Trial registration number

Not applicable

P–118 A sperm selection technique to mitigate paternal contributions to embryo aneuploidy

Study question

Can microfluidic sperm selection (MFSS) select male gametes without sperm chromatin fragmentation (SCF) and double-stranded DNA breaks (dsDNA) in order to generate euploid conceptuses?

Summary answer

Couples treated by ICSI with MFSS had significantly improved embryo ploidy rates and pregnancy outcomes, demonstrating the efficacy of this novel selection method.

What is known already

SCF has been linked to infertility, specifically to embryo developmental and implantation failure. This damage can be both single-stranded (ssDNA) or double-stranded (dsDNA). Recent studies have shown that dsDNA in particular causes chromosomal aberrations and contributes to embryo aneuploidy, which leads to implantation failure.

Study design, size, duration

Consenting couples treated at our center by intracytoplasmic sperm injection (ICSI) with spermatozoa selected by MFSS were included. The majority of these couples had a medical history significant for elevated SCF, recurrent implantation failure, and embryo aneuploidy. ICSI clinical outcome, as well as preimplantation genetic testing for aneuploidy (PGT-A) and frozen embryo transfer (FET), was recorded and compared to the couples’ historical treatments following sperm selection by density gradient centrifugation (DGC).

Participants/materials, setting, methods

From 2016 to 2020, 51 consenting men had their ejaculates screened for SCF levels by terminal deoxynucleotidyl dUTP transferase nick-end labeling (TUNEL) using a commercially available kit. At least 500 spermatozoa were assessed per patient, with a normal threshold of ≤ 15%.

To screen for dsDNA, neutral Comet using a modified in-house protocol was also performed in a pilot study. At least 200 spermatozoa were assessed per patient, with a normal threshold of ≤ 3%.

Main results and the role of chance

A total of 51 men (average age, 41.0±8 years) had mean sperm concentrations of 39.0±33x106/mL, 38.4±12% motility, and 2.1±1% normal morphology. Following DGC and MFSS, the concentrations were 4.7±8 and 4.3±8x106/mL and the motility was 64.0±33 and 98.0±3%, respectively (P < 0.0001). The average SCF decreased from 20.1±18% in the ejaculate to 16±3% following DGC, but was 2.9±4% after MFSS. The dsDNA fell from 3.4±3% in raw specimens to 2.9±1% after DGC, and to only 0.5±0.7% following MFSS (P < 0.0001).

These men underwent ICSI with their female partners (average age, 37.3±4 years), with sperm selected by DGC; they achieved a fertilization rate of 56.4% (337/597) with 26.0% euploid embryos (36/139). FET cycles from these embryos yielded an implantation rate of 8.3% (2/24) and a clinical pregnancy rate (CPR) of 15.4% (2/13), but both miscarried.

These couples then underwent ICSI with MFSS, with a fertilization rate of 78.0% (588/754; P < 0.0001) and 50.0% (172/344; P < 0.0001) euploid embryos after PGT-A. A total of 37 embryos have been replaced, with an implantation rate of 67.6% (25/37; P < 0.0001) and a CPR of 73.5% (25/34; P < 0.001), with an ongoing/delivery rate of 70.6% (24/34; P < 0.0001).

Limitations, reasons for caution

While the oocyte contribution cannot be discounted, MFSS was able to yield spermatozoa that had the highest motility and ability to produce euploid embryos following ICSI.

Wider implications of the findings: The genome and epigenome of the spermatozoon, and their contribution to reproductive outcomes, are being vigorously explored and scrutinized. Alternative approaches to gamete selection, such as MFSS, in couples with elevated SCF and dsDNA provide the best chances for future pregnancies by mitigating embryo aneuploidy.

Trial registration number

Not applicable

P–120 Selecting spermatozoa with the highest genomic integrity in order to enhance clinical outcomes in men with high DNA fragmentation levels

Study question

What are the best methods of selecting spermatozoa with the highest genomic integrity in order to improve embryo implantation and term pregnancy rates with ICSI?

Summary answer

Testicular or ejaculate spermatozoa isolated by microfluidic sperm selection (MFSS) were characterized by superior genomic integrity with improved clinical pregnancy and delivery rates.

What is known already

In couples with unexplained infertility, a subtle male factor can often be identified. Both single-strand (ss) and double-strand (ds) DNA nicks and breaks hinder the ability of the male gamete to support embryonic development. Surgical retrieval of spermatozoa from the proximal male genital tract can prevent their exposure to oxidative stress. Moreover, use of membrane-based microfluidics chips has been shown to allow for selection of the most progressively motile spermatozoa with higher genomic integrity.

Study design, size, duration

Over the course of 48 months, 86 consenting men presenting with high sperm chromatin fragmentation (SCF) in their ejaculate with prior ART failure underwent a subsequent cycle with specimens retrieved by testicular biopsy or ejaculate processed by MFSS. A concurrent TUNEL assay was performed on samples collected or selected by each method. Sperm specimens of both origins were utilized for ICSI cycles. Semen parameters, chromatin integrity, and pregnancy outcomes were compared between the two methods.

Participants/materials, setting, methods

Fresh ejaculates from consenting men were collected for standard semen analysis (WHO 2010). Testicular biopsy and MFSS were used to isolate spermatozoa with a higher genomic integrity after previous ART failure. SCF was assessed by terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) on at least 500 spermatozoa under a fluorescent microscope with a threshold of ≥ 15%. MFSS was carried out by Zymot® chips. ICSI was performed in the standard fashion.

Main results and the role of chance

A total of 86 men (36.5±5 years) had the following semen parameters: volume of 2.6 ±1mL, concentration of 27.0±33 x 106/mL, 35.6±15% motility, and high SCF (24.1±10%). They underwent 146 ICSI cycles with their partners (maternal age, 33.7±3) resulting in a high incidence of pregnancy loss (100%; 13/13). Of those who failed to conceive, 22 couples used surgically retrieved spermatozoa (SRS) with a concentration of 1.8 ± 4 x 106/mL (P < 0.01), 5.0±11% motility (P < 0.01), and an SCF of 12.6 ± 6% (P < 0.0001). SRS was used in 37 ICSI cycles, yielding a fertilization rate of 61.6% (204/331, P < 0.01), an implantation rate of 10.6% (9/85, P < 0.01), a CPR of 23.5% (8/34, P < 0.01), and a delivery rate of 17.6% (6/34, P < 0.01). Another 24 couples underwent ICSI cycles with ejaculated spermatozoa processed by MFSS with a concentration of 1.8±3 x 106/mL (P < 0.01), but an increased motility of 99±1% (P < 0.01) and an SCF of 1.2 ±1%, lower than both the raw and testicular specimens (P < 0.0001). MFSS-processed specimens resulted in a fertilization rate of 76% (335/441, P < 0.01), an implantation rate of 26.3% (15/57, P < 0.05), and a CPR of 67.9% (19/28, P < 0.01), of which 15 patients delivered and 2 pregnancies are ongoing (89.5%; P < 0.01).

Limitations, reasons for caution

This is a preliminary study on a small number of subjects. A randomized prospective study conducted on a larger cohort would be required to confirm our findings.

Wider implications of the findings: SCF severely affects pregnancy by impairing embryonic development, consequently promoting implantation failure. While retrieving spermatozoa from the germinal epithelium is a viable option, MFSS provides an alternative. Although MFSS requires an adequate number of sperm with good kinetic characteristics, it provides a more palatable option, reducing surgical risk and costs.

Trial registration number

Not applicable

Kingella kingae Displaced S. aureus as the Most Common Cause of Acute Septic Arthritis in Children of All Ages

BACKGROUND

Acute septic arthritis (SA) still remains a challenge with significant worldwide morbidity. In recent years, Kingella kingae has emerged and treatment regimens have become shorter. We aim to analyze trends in SA etiology and management and to identify risk factors for complications.

METHODS

Longitudinal observational, single center study of children (<18 years old) with SA admitted to a tertiary care pediatric hospital, from 2003 to 2018, in 2 cohorts, before and after implementation of nucleic acid amplification assays (2014). Clinical, treatment and disease progression data were obtained.

RESULTS

A total of 247 children were identified, with an average annual incidence of 24.9/100,000, 57.9% males with a median age of 2 (1-6) years. In the last 5 years, a 1.7-fold increase in the annual incidence, a lower median age at diagnosis and an improved microbiologic yield (49%) was noticed. K. kingae became the most frequent bacteria (51.9%) followed by MSSA (19.2%) and S. pyogenes (9.6%). Children were more often treated for fewer intravenous days (10.7 vs. 13.2 days, P = 0.01) but had more complications (20.6% vs. 11.4%, P = 0.049) with a similar sequelae rate (3.7%). Risk factors for complications were C-reactive protein ≥80 mg/L and Staphylococcus aureus infection, and for sequelae at 6 months, age ≥4 years and CRP ≥ 80 mg/L.

CONCLUSIONS

The present study confirms that K. kingae was the most common causative organism of acute SA. There was a trend, although small, for decreasing antibiotic duration. Older children with high inflammatory parameters might be at higher risk of sequelae.

[Acute haematogenous osteomyelitis in Lisbon: An unexpectedly high association with myositis and arthritis]

INTRODUCTION

Despite the current trend towards less aggressive therapeutic approaches, acute haematogenous osteomyelitis (AHO) continues to be a challenge and is associated with significant morbidity worldwide. Our aim was to determine if 80% compliance with current protocol was achieved, identify complications and associated risk factors and analyse trends in aetiology and management of AHO in children.

METHODS

We conducted a longitudinal, observational, single-centre study in patients with AHO aged less than 18 years admitted to a paediatric hospital, between 2008 and 2018, divided into 2 cohorts (before and after 2014). Demographic, clinical data and disease progression were analysed.

RESULTS

The study included 71 children with AHO, 56% male, with a median age of 3 years (interquartile range, 1-11). We found a 1.8-fold increase of cases in the last 5 years. The causative agent was identified in 37% of cases: MSSA (54%), MRSA (4%), Streptococcus pyogenes (19%), Kingella kingae (12%), Streptococcus pneumoniae (8%), and Neisseria meningitidis (4%). Complications were identified in 45% of patients and sequelae in 3.6%. In recent years, there was an increase in myositis (30% vs. 7%; p=0.02), septic arthritis (68% vs. 37.2%; p=0.012) and in the proportion of patients treated for less than 4 weeks (37% vs. 3.5%; p=0.012), with a similar sequelae rates. The risk factors for complications were age 3 or more years, CRP levels of 20mg/l or higher, time elapsed between onset and admission of 5 or more days and positive culture, although on multivariate analysis only positive culture was significant. The presence of complications was a risk factor for sequelae at 6 months.

CONCLUSIONS

Our study confirms that AHO can be aggressive. The identification of risk factors for complications may be fundamental for management.

Crude extract of cyanobacteria (Radiocystis fernandoi, strain R28) induces liver impairments in fish

Radiocystis fernandoi R28 strain is a cyanobacterium which produces mostly the RR and YR microcystin variants (MC-RR and MC-YR, respectively). The effects of crude extract of the R. fernandoi strain R28 were evaluated on the protein phosphatases and on the structure and ultrastructure of the liver of the Neotropical fish, Hoplias malabaricus, after acute and subchronic exposure. Concomitantly, the accumulation of the majority of MCs was determined in the liver and muscle. The fish were exposed to 120.60 MC-RR+MC-LR kg-fish^-1 (=100μg MC-LReq kg-fish^-1) for 12 and 96h (one single dose, acute exposure) and 30days (one similar dose every 72h, subchronic exposure). MCs did not accumulate in the muscle but, in the liver, MC-YR accumulated after acute exposure and MC-RR and MC-YR accumulation occurred after subchronic exposure. Protein phosphatase 2A (PP2A) activity was inhibited only after subchronic exposure. Acute exposure induced liver hyperemia, hemorrhage, changes in hepatocytes and cord-like disorganization. At the ultrastructural level, the decreasing of glycogen and lipid levels, the swelling of mitochondria and whirling of endoplasmic reticulum suggested hepatocyte necrosis. Subchronic exposure resulted in a complete disarrangement of cord-like hepatocytes, some recovery of mitochondria and whirling endoplasmic reticulum and extensive connective tissues containing fibrous materials in the liver parenchyma. Despite microcystin toxicity and liver alterations, no tumor was induced by MCs. In conclusion, the increased algal mass of R. fernandoi in tropical freshwater, producing mainly MC-RR and MC-YR variants, results in fish liver impairments.

Therapeutic Vaccine against Streptococcus sobrinus-induced Caries

Streptococcus sobrinus produces a virulence-associated immunomodulatory protein (VIP) which suppresses the host-specific immune response and induces the early production of IL-10. In this study, we evaluated the effects of therapeutic immunization with this VIP on the incidence of caries in S. sobrinus-infected rats. Groups of Wistar rats were orally infected with S. sobrinus and fed with sucrose-sweetened drinking water ad libitum. Five days later, rats were immunized intranasally with active or heat-inactivated VIP plus alum as adjuvant or PBS plus adjuvant (sham-immunized). After 3 wks, all rats were re-immunized as above. Evaluation of dental caries showed that VIP-immunized animals had significantly fewer enamel sulcal and proximal caries lesions than did the sham-immunized animals (p < 0.001). The protective effects following therapeutic VIP immunization were attributed to the induced salivary immunoglobulin A specific to the VIP. These results offer a promising and safe strategy for the development of a vaccine against dental caries.

Testing single extraction methods and in vitro tests to assess the geochemical reactivity and human bioaccessibility of silver in urban soils amended with silver nanoparticles

To assess if the geochemical reactivity and human bioaccessibility of silver nanoparticles (AgNPs) in soils can be determined by routine soil tests commonly applied to other metals in soil, colloidal Ag was introduced to five pots containing urban soils (equivalent to 6.8 mg Ag kg(-1) soil). Following a 45 days stabilization period, the geochemical reactivity was determined by extraction using 0.43 M and 2 M HNO3. The bioaccessibility of AgNPs was evaluated using the Simplified Bioaccessibility Extraction Test (SBET) the "Unified BARGE Method" (UBM), and two simulated lung fluids (modified Gamble's solution (MGS) and artificial lysosomal fluid (ALF)). The amount of Ag extracted by 0.43 M and 2 M HNO3 soil tests was <8% and <50%, respectively of the total amount of Ag added to soils suggesting that the reactivity of Ag present in the soil can be relatively low. The bioaccessibility of Ag as determined by the four in vitro tests ranged from 17% (ALF extraction) to 99% (SBET) indicating that almost all Ag can be released from soil due to specific interactions with the organic ligands present in the simulated body fluids. This study shows that to develop sound soil risk evaluations regarding soil contamination with AgNPs, aspects of Ag biochemistry need to be considered, particularly when linking commonly applied soil tests to human risk assessment.

Challenges in orthopaedic management of Parkes-Weber syndrome

A 16-year-old boy with a diagnosis of Parkes-Weber syndrome presented with a lower leg discrepancy of 3 cm for orthopaedic management. He had the triad of red skin lesion, lymphoedema and overgrowth of the right leg and multiple arteriovenous fistulae confirmed by angiography. Considering the risk of aggravating the vascular lesion, we decided conservative management of unequal limb lengths as long as this is well tolerated.

Study of mural paintings using in situ XRF, confocal synchrotron-μ-XRF, μ-XRD, optical microscopy, and SEM-EDS--the case of the frescoes from Misericordia Church of Odemira

In this work, we present the results of an analytical method developed for detailed pigment identification, stratigraphy, and degradation of the paint layers of mural paintings applied in the study of the 17th century frescoes from the Misericordia Church of Odemira (Southwest Portugal). In situ X-ray fluorescence spectrometry analyses were performed on three panels of the mural paintings and complemented by colorimetric measurements. The different color areas were also sampled as microfragments (approx. 1 mm2) that were studied as taken or mounted in epoxy resin to expose the different paint layers. The microfragments of paint layers and their cross sections were characterized by optical microscopy and scanning electron microscopy coupled with energy dispersive X-ray spectrometry. Furthermore, elemental analysis was obtained with spatially resolved confocal synchrotron radiation μ-X-ray fluorescence spectrometry performed at ANKA synchrotron FLUO beamline. Occasionally, phase analysis by μ-X-ray diffraction was also performed. Results from the different techniques allowed pigment identification and, in some cases, the evaluation of color changes due to degradation processes and, considering the Southern Portugal geology, the identification of their possible provenance. The pigments used were essentially yellow, brown and red ochres, smalt blue, copper green, and black earths, probably from local sources.

rEnolase maternal immunization confers caries protection on offspring

Therapeutic vaccination with Streptococcus sobrinus recombinant enolase (rEnolase) protects rats from dental caries. Here, we investigated the effect that maternal rEnolase vaccination before pregnancy had on the offspring's immune response to S. sobrinus oral infection and dental caries progression. Female Wistar rats were immunized by intranasal and subcutaneous routes with rEnolase adsorbed onto aluminum hydroxide as adjuvant or similarly treated with the adjuvant alone (sham-immunized). Ten days after the last administration, the immunized females were paired with a male rat. The oral immune responses to S. sobrinus infection and dental caries in the offspring were evaluated. The results showed that pups born from rEnolase-immunized mothers had higher levels of rEnolase-specific salivary IgA and IgG antibodies (indicating a placental antibody transfer) and lower sulcal and proximal enamel caries scores than rats born from sham-immunized mothers. In conclusion, rEnolase maternal immunization before pregnancy provides offspring with protection against S. sobrinus-induced dental caries.

Ponseti method: does age at the beginning of treatment make a difference?

The Ponseti method is reportedly effective for treating clubfoot in children up to 9 years of age. However, whether age at the beginning of treatment influences the rate of successful correction and the rate of relapse is unknown. We therefore retrospectively reviewed 68 consecutive children with 102 idiopathic clubfeet treated by the Ponseti technique in four Portuguese hospitals. We followed patients a minimum of 30 months (mean, 41.4 months; range, 30-61 months). The patients were divided into two groups according to their age at the beginning of treatment; Group I was younger than 6 months and Group II was older than 6 months. All feet (100%) were initially corrected and no feet required extensive surgery regardless of age at the beginning of treatment. There were no differences between Groups I and II in the number of casts, tenotomies, success in terms of rate of initial correction, rate of recurrence, and rate of tibialis anterior transference. The rate of the Ponseti method in avoiding extensive surgery was 100% in Groups I and II; relapses occurred in 8% of the feet in younger and older children.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Effect of genetic modificationsby selection for immunological toleranceon fungus infection in mice

Two strains of mice genetically selected for extreme phenotypes of immunological tolerance to ovalbumin, susceptible (TS) and resistant (TR), were experimentally infected with Sporothrix schenckii. The objective was to observe whether the genetic modifications produced by the selection might be associated with interstrain differences in adaptive immune and innate responses to infection. Therefore, we evaluated the LD(50), CFU, phagocytic index, fungicidal activity, pro-inflammatory cytokines, specific antibody titres, and the delayed-type hypersensitivity reactivity. TR mice were tenfold more susceptible to infection than TS mice, as shown by LD(50) (5 x 10(6) conidia i.v.). In TS mice, the resistance was a consequence of the tissue fungal load reduction, consistent specific T-cell-mediated immunity, and tumour necrosis factor (TNF)-alpha activity at onset of infection. In TR mice, these responses were not precociously detected. Therefore, the absence of CD4(+) T-cell response in the first week of infection might explain the non-clearance of pathogen in TR mice. However, TR mice did show an increase in TNF level and delayed-type hypersensitivity response after the first week post-infection; there was also expansion and increase in granulomatous foci and CFU in the spleen. The expansion of granulomatous foci and the increase in TNF-alpha and tissue fungal load to damaging levels induced severe tissue destruction, general failure of the organs, cachexy and death in TR mice. The results show that genetic selection for extreme phenotypes of immunological tolerance also modified the responses to S. schenckii infection.

Increased resistance to systemic candidiasis in athymic or interleukin-10-depleted mice

Candida albicans produces a virulence-associated immunomodulatory protein (p43), which activates lymphocytes polyclonally, suppresses specific antibody responses to Candida antigens, and potentiates systemic growth of C. albicans. In this study, athymic, unlike euthymic, C57BL/6 mice were resistant to systemic candidiasis and produced lower serum levels of interleukin (IL)-4 and IL-10. Pretreatment with p43 stimulated the production of both cytokines. Depletion of IL-10, but not of IL-4, in euthymic animals reestablished resistance and abrogated p43-dependent suppression of the specific antibody response and facilitated C. albicans growth. In agreement with these results, both immunosuppression and p43-mediated facilitation of the fungus growth were abolished in IL-10 knockout mice. These observations demonstrate the relevance of IL-10 in facilitating systemic candidiasis and suggest a critical role for the immunosuppressive virulence factor p43 in the process.

Sequences required for induction of neurotensin receptor gene expression during neuronal differentiation of N1E-115 neuroblastoma cells

The promoter region of the mouse high affinity neurotensin receptor (Ntr-1) gene was characterized, and sequences required for expression in neuroblastoma cell lines that express high affinity NT-binding sites were characterized. Me(2)SO-induced neuronal differentiation of N1E-115 neuroblastoma cells increased both the expression of the endogenous Ntr-1 gene and reporter genes driven by NTR-1 promoter sequences by 3-4-fold. Deletion analysis revealed that an 83-base pair promoter region containing the transcriptional start site is required for Me(2)SO activation. Detailed mutational analysis of this region revealed that a CACCC box and the central region of a large GC-rich palindrome are the crucial cis-regulatory elements required for Me(2)SO induction. The CACCC box is bound by at least one factor that is induced upon Me(2)SO treatment of N1E-115 cells. The Me(2)SO effect was found to be both selective and cell type-restricted. Basal expression in the neuroblastoma cell lines required a distinct set of sequences, including an Sp1-like sequence, and a sequence resembling an NGFI-A-binding site; however, a more distal 5' sequence was found to repress basal activity in N1E-115 cells. These results provide evidence that Ntr-1 gene regulation involves both positive and negative regulatory elements located in the 5'-flanking region and that Ntr-1 gene activation involves the coordinate activation or induction of several factors, including a CACCC box binding complex.

Purification, and biochemical and biological characterization of an immunosuppressive and lymphocyte mitogenic protein secreted by Streptococcus sobrinus

An immunosuppressive/mitogenic (ISM) protein was purified from the supernatants of cultures of Streptococcus sobrinus with an isoelectric point of 4.75 and a relative molecular mass of 38 kDa (p38). Treatment of C57BL/6 mice with p38 induced an increase in the numbers of non-specific splenic Ig-secreting plaque-forming cells (PFC) with peak responses on day 3 for IgM-secreting PFC and on day 5 for IgG-secreting PFC, with an isotype pattern consisting predominantly of IgG2a and IgG2b. This increase was accompanied by a lymphocyte blastogenic response of both T and B lymphocytes. The in vitro effects of p38 on pure B, T and total splenic lymphocytes indicated that this ISM protein was primarily a B cell mitogen, being T cells activated subsequently by the generation of B blasts. Suppression of the murine primary immune response against sheep red blood cells was observed in C57BL/6 mice treated 4 days before with p38. The amino acid sequence of the N-terminus of p38 has a significant similarity with several enolases, particularly with rabbit enolase. However, the biological effects ascribed to p38 have not been detected after in vivo treatment with that enolase. The immunosuppressive effect of p38 was abrogated by depletion of IL-10 but not of IL-4. In agreement with this observation IL-10 was the only cytokine detected in serum of C57BL/6 mice after p38 treatment and the peak of serum levels was observed as soon as 2 h after treatment.

Evidence for circulating hemocyte proliferation in the shrimp Penaeus japonicus

We have observed by flow cytometric analysis that a small but consistent percentage of circulating hemocytes in phases S, G2 and M of the cell cycle can be detected in Penaeus japonicus. Significantly increased percentages of proliferating hemocytes (approximately three-fold increase) were observed after stimulation by lipopolysaccharide (LPS), p43 (an immunosuppressive lymphocyte mitogenic protein produced by Candida albicans) and a combination of LPS and p43. Moreover, an approximately six-fold increase in the percentage of proliferating hemocytes was also observed in animals infected with Fusarlum opp., as compared to non-infected shrimps. Furthermore, [3H] thymidine uptake in circulating hemocytes was 26 times greater in LPS stimulated than in non-stimulated shrimps. The present study suggests that circulating hemocytes of the shrimp P. japonicus can divide in vivo and that proliferation can be increased significantly after mitogenic or infectious stimulation.

Role of monocytes in the up-regulation of the early activation marker CD69 on B and T murine lymphocytes induced by microbial mitogens

CD69 is an early marker of lymphoid cell activation. The authors report on an up-regulation of CD69 in splenic B and T cells of C57Bl/6 mice after administration of lipopolysaccharide (LPS) or microbial immunosuppressive/mitogenic (ISM) proteins produced by C. albicans (p43) and African Swine Fever Virus (p36). This up-regulation of CD69 was observed 6 and 24 h after mitogenic treatments. The same pattern of increased CD69 expression was observed in the lymph nodes of mice treated with p43 or LPS, whereas p36 treatment failed to induce increased CD69 expression in this organ. Intracellular calcium mobilization was induced in splenic B and T lymphocytes after incubation of total spleen cells with LPS, p43 or p36. This increase was higher in B than in T cells. Increased calcium mobilization was also seen in lymph node B cells after incubation with p43 or p36 and in lymph node T cells after p43 stimulation. Up-regulation of CD69 expression on B and T cells was also observed after in vitro stimulation of spleen cells with the three mitogens used. Similar results were obtained with culture supernatants of macrophage/monocyte (M phi) cells activated with LPS (LPS/M phi CS). Stimulation of M phi cells with LPS or with the ISM proteins is demonstrated by the increased production of nitrites by these cells. The increased in vitro expression of CD69 was, however, not abolished by monoclonal antibodies to M phi cytokines such as IL-6, IL-10 or TNF alpha. No increased expression of CD69 was found in vitro on purified B or T cells, even when mixed upon stimulation with p43, p36, LPS or with LPS/M phi CS. However, an increase in the expression of CD69 was observed on B cells co-cultured with M phi cells after treatment with LPS or p36. All three mitogens failed to induce increased CD69 expression on cultured T cells mixed with M phi cells.

Immunoprotection against systemic candidiasis in mice

We have previously described an immunosuppressive B cell mitogenic (ISM) protein, p43, produced by Candida albicans, which plays an important role in the survival of the microorganism in the host. The N-terminal amino acid sequence of p43 was found to be different from all amino acid sequences registered in updated protein databanks. Immunization of BALB/c mice with p43 partially neutralized the biological effects of this protein, namely depletion of bone marrow pre-B and B cells, the increased numbers of total and large B and CD4+ lymphocytes, and the non-specific polyclonal response of splenic IgG2a-, IgG2b- and IgM-secreting plaque forming cells. Immunization of BALB/c mice with p43 fully protected the mice against the fungal infection. In contrast, immunization with C. albicans sonicates (Cs) was not protective. Our data indicated that specific antibodies against p43 protected, whereas those against Cs facilitated C. albicans infection. Thus, the ratio between anti-p43 and anti-Cs antibody titres was much lower in the non-protected mice (Cs-immunized and control non-immunized) than in p43-immunized mice. Moreover, passive administration of specific anti-p43 antibodies significantly protected against fungal infection, whereas passive administration of specific anti-Cs antibodies markedly increased the susceptibility to C. albicans infection. These observations are discussed on the basis of alternative approaches of immunointervention.

Immunological activities of a Candida albicans protein which plays an important role in the survival of the microorganism in the host

A protein with an isoelectric point of 4.3 and a relative molecular mass of 43 kDa (p43) was purified from the supernatants of the cultures of pathogenic Candida albicans but could not be detected in the supernatants of cultures of this fungus with pathogenicity previously attenuated after being repeatedly subcultured in vitro. Treatment of BALB/c and C57BL/6 mice with p43 resulted in (i) marked increases in the numbers of splenic immunoglobulin-secreting plaque-forming cells (PFC) with peak responses of immunoglobulin M (IgM) PFC preceding those of IgG PFC, with an isotype restriction pattern of IgG2a > IgG2b > IgG3 > IgG1 > IgM, and (ii) specific immunosuppression of the murine primary immune response against sheep erythrocytes. Immunosuppressive and B-cell mitogenic properties of p43 were quantitatively associated and inversely correlated with susceptibility to C. albicans infection. C57BL/6 mice treated with p43 2 days before inoculation with C. albicans were considerably more susceptible to the fungal infection than untreated mice. The immunobiological and chemical properties of p43 are compared with previously described immunosuppressive and B-cell mitogenic proteins produced by bacteria and viruses, and strategies for immunointervention are discussed.