Functional genomic and serological analysis of the protective immune response resulting from vaccination of macaques with an NS1-truncated influenza virus.

We are still inadequately prepared for an influenza pandemic due to the lack of a vaccine effective for subtypes to which the majority of the human population has no prior immunity and which could be produced rapidly in sufficient quantities. There is therefore an urgent need to investigate novel vaccination approaches. Using a combination of genomic and traditional tools, this study compares the protective efficacy in macaques of an intrarespiratory live influenza virus vaccine produced by truncating NS1 in the human influenza A/Texas/36/91 (H1N1) virus with that of a conventional vaccine based on formalin-killed whole virus. After homologous challenge, animals in the live-vaccine group had greatly reduced viral replication and pathology in lungs and reduced upper respiratory inflammation. They also had lesser induction of innate immune pathways in lungs and of interferon-sensitive genes in bronchial epithelium. This postchallenge response contrasted with that shortly after vaccination, when more expression of interferon-sensitive genes was observed in bronchial cells from the live-vaccine group. This suggested induction of a strong innate immune response shortly after vaccination with the NS1-truncated virus, followed by greater maturity of the postchallenge immune response, as demonstrated with robust influenza virus-specific CD4+ T-cell proliferation, immunoglobulin G production, and transcriptional induction of T- and B-cell pathways in lung tissue. In conclusion, a single respiratory tract inoculation with an NS1-truncated influenza virus was effective in protecting nonhuman primates from homologous challenge. This protection was achieved in the absence of significant or long-lasting adverse effects and through induction of a robust adaptive immune response.

Integrated molecular signature of disease: analysis of influenza virus-infected macaques through functional genomics and proteomics.

Recent outbreaks of avian influenza in humans have stressed the need for an improved nonhuman primate model of influenza pathogenesis. In order to further develop a macaque model, we expanded our previous in vivo genomics experiments with influenza virus-infected macaques by focusing on the innate immune response at day 2 postinoculation and on gene expression in affected lung tissue with viral genetic material present. Finally, we sought to identify signature genes for early infection in whole blood. For these purposes, we infected six pigtailed macaques (Macaca nemestrina) with reconstructed influenza A/Texas/36/91 virus and three control animals with a sham inoculate. We sacrificed one control and two experimental animals at days 2, 4, and 7 postinfection. Lung tissue was harvested for pathology, gene expression profiling, and proteomics. Blood was collected for genomics every other day from each animal until the experimental endpoint. Gross and microscopic pathology, immunohistochemistry, viral gene expression by arrays, and/or quantitative real-time reverse transcription-PCR confirmed successful yet mild infections in all experimental animals. Genomic experiments were performed using macaque-specific oligonucleotide arrays, and high-throughput proteomics revealed the host response to infection at the mRNA and protein levels. Our data showed dramatic differences in gene expression within regions in influenza virus-induced lesions based on the presence or absence of viral mRNA. We also identified genes tightly coregulated in peripheral white blood cells and in lung tissue at day 2 postinoculation. This latter finding opens the possibility of using gene expression arrays on whole blood to detect infection after exposure but prior to onset of symptoms or shedding.

Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures.

OBJECTIVE: To determine whether the procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing. DESIGN: Prospective randomized. SETTING/PARTICIPANTS: One hundred femoral shaft fractures without significant concomitant injuries admitted to an academic Level 1 urban trauma center. INTERVENTION: Stabilization of the femoral shaft fracture using a reamed or unreamed technique. OUTCOME MEASUREMENTS: The surgical time, estimated blood loss, fluoroscopy time, and perioperative complications were prospectively recorded. RESULTS: One hundred patients with 100 femoral shaft fractures were correctly prospectively randomized to the study. Thirty-seven patients received reamed and sixty-three patients received unreamed nails. All nails were interlocked proximally and distally. The average surgical time for the reamed nail group was 138 minutes and for unreamed nail group was 108 minutes (p = 0.012). The estimated blood loss for the reamed nail group was 278 milliliters and for the unreamed nail group 186 milliliters (p = 0.034). Reamed intramedullary nailing required an average of 4.72 minutes, whereas unreamed nailing required 4.29 minutes of fluoroscopy time. Seven perioperative complications occurred in the reamed nail group and eighteen in the unreamed nail group. Two patients in the unreamed group required an early secondary procedure. Iatrogenic comminution of the fracture site occurred during three reamed and six unreamed intramedullary nailings. Reaming of the canal was required before the successful placement of three nails in the unreamed group because of canal/nail diameter mismatch. CONCLUSIONS: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. The unreamed technique, however, was associated with a higher incidence of perioperative complications, although the difference was not statistically significant (p = 0.5).

Large-scale monitoring of host cell gene expression during HIV-1 infection using cDNA microarrays.

Human immunodeficiency virus type 1 (HIV-1) infection alters the expression of host cell genes at both the mRNA and protein levels. To obtain a more comprehensive view of the global effects of HIV infection of CD4-positive T-cells at the mRNA level, we performed cDNA microarray analysis on approximately 1500 cellular cDNAs at 2 and 3 days postinfection (p.i.) with HIV-1. Host cell gene expression changed little at 2 days p.i., but at 3 days p.i. 20 cellular genes were identified as differentially expressed. Genes involved in T-cell signaling, subcellular trafficking, and transcriptional regulation, as well as several uncharacterized genes, were among those whose mRNAs were differentially regulated. These results support the hypothesis that HIV-1 infection alters expression of a broad array of cellular genes and provides a framework for future functional studies on the differentially expressed mRNA products.

Wound site as a predictor of complications following deep nail punctures to the foot.

The site of injury, condition of the nail, and type of foot covering were compared in 36 inpatients and 34 outpatients with nail puncture wounds to the foot. Of the 36 inpatients, 34 (94%) had pyarthrosis, osteomyelitis, or both. The plantar surface of the foot was divided into 3 zones. Of the 36 inpatients, 35 (97%) had deep puncture wounds in zone 1. In contrast, only 6 of 34 (18%) outpatients had injury to this area. Tennis shoes were shown to predispose to infection with Pseudomonas aeruginosa. Based on our findings, an early hospital admission should be considered for all patients with deep puncture wounds located in zone 1 and for patients who give a history of bone penetration in zone 2 or 3 at the time of injury. All patients who meet the above criteria and who are not admitted to hospital should be observed closely.

Surgical treatment of tears of the rotator cuff in athletes.

Forty-five athletes with either a partial or a complete tear of the rotator cuff were treated with anterior acromioplasty and repair of the tear. The minimum duration of follow-up was twenty-four months (average, forty-two months). Thirty patients had an incomplete tear and fifteen had a complete tear. Postoperatively, thirty-nine (87 per cent) of the patients stated that they were improved compared with their preoperative status, although only thirty-four patients (76 per cent) felt that they had a significant reduction of pain postoperatively. Objectively, twenty-five (56 per cent) of the patients were rated as having a good result, which allowed them to return to their former competitive level without significant pain. Twelve (41 per cent) of the twenty-nine athletes who had been involved in pitching and throwing returned to their former competitive status. Seven (32 per cent) of the twenty-two pitchers and throwers who had been active at a professional or collegiate level returned to the same competitive level. In our experience, a repair of the rotator cuff combined with an acromioplasty in a young athletic population provides satisfactory relief of pain but does not guarantee that the patient will be able to return to his or her former competitive status in all sports.

Shoulder impingement syndrome in athletes treated by an anterior acromioplasty.

Shoulder pain caused by a impingement syndrome commonly affects an athlete's performance. Thirty-five shoulders in 33 athletes had an impingement syndrome treated by an anterior acromioplasty after failure of conservative treatment. Thirty-one of 35 shoulders (89%) were subjectively judged improved by the patients from their preoperative status. The moderate and severe pain was reduced from 97% of the shoulders preoperation to 20% postoperation. The pain at rest and with activities of daily living was reduced from 71% of the shoulders preoperation to 9% postoperation. However, only 15 of 35 operated shoulders (43%) allowed return to the same preinjury level of competitive athletics, and only four of 18 athletes involved in pitching and throwing returned to their former preinjury status. This operation is satisfactory for pain relief but does not allow an athlete to return to his former competitive status. A prolonged rehabilitation program may improve the results.

The coracoid transfer for recurrent anterior instability of the shoulder in adolescents.

Thirty-six shoulders with recurrent anterior dislocation or subluxation in thirty-four adolescent patients were treated with a modified Bristow procedure. The average length of follow-up was five years and ten months. Postoperatively, two patients had recurrent anterior subluxation on one occasion and none had recurrent anterior dislocation. The average loss of external rotation was 10 degrees. Despite the fact that young patients have a high rate of recurrence after anterior dislocation or subluxation of the shoulder, the modified Bristow procedure is an effective method of treating recurrent anterior instability of the shoulder in adolescents.

Patellar and quadriceps tendon ruptures--jumper's knee.

We reviewed 13 patients with end stage jumper's knee, 10 with patellar tendon ruptures, and 3 with ruptures of the quadriceps tendon to evaluate our long-term results in treating these tendon ruptures in an athletic population. The focus was on the natural history, the time until return, and the level of return, to athletic activity. Jumper's knee affected all patients to a varying degree prior to rupture. Basketball was the most common sport involved. At followup, averaging 4 1/2 years, patients underwent functional and clinical, as well as Cybex and roentgenographic, evaluations. Results indicated patellar tendon ruptures, where the ruptures are complete, have a more favorable prognosis than those of the quadriceps tendon which are incomplete. All of the latter patients continued to have quadriceps tendinitis following repair. In both groups, the poor results were obtained in patients with chondromalacia and/or patella alta. Cybex testing yielded results of greater than 100% strength in three patients with patellar tendon ruptures, but no patient with quadriceps rupture had comparable test results. There was no apparent relationship between ruptures and cortisone injections. Patellar and quadriceps tendon ruptures from indirect injury in athletes represent the end stage of jumper's knee and result from repetitive microtrauma. Excellent function usually follows repair of patellar tendon ruptures when surgery is performed early and care is taken to restore normal patellar tendon length. Results of quadriceps ruptures are less satisfactory since these ruptures are usually incomplete and all degenerative tissue may not be involved in the healing response.

The modification Bristow-Helfet procedure for recurrent anterior shoulder subluxations and dislocations.

A review of 107 cases in which the Bristow-Helfet procedure was done for recurrent anterior shoulder subluxation and dislocation is presented. The redislocation rate was 2% with very few complications. Eighty-nine percent of the patients were satisfied with the procedure. Mean loss of external rotation was 12.6 degrees. Six of the 41 patients with dominant shoulder surgery were capable of throwing in the same manner as they did prior to injury. Five of 24 patients (21%) with a diagnosis of recurrent anterior subluxation continued to have symptoms of instability following surgery. Associated symptoms of posterior or voluntary subluxation may preclude a satisfactory result.

Staple capsulorrhaphy for recurrent posterior shoulder dislocation.

Recurrent posterior shoulder dislocation or subluxation is uncommon but occurs occasionally in athletes. Ten patients were treated with a posterior shoulder staple capsulorrhaphy. A posterior Bankhart-type-lesion was found in all cases. Eight of the 10 patients had pain relief. The range of motion was usually maintained postoperatively, but no patient returned to his former throwing status. Four patients also had anterior instability. Three patients (30%) had postoperative recurrence of their posterior instability. The two "ligamentous lax" conditions in the series both recurred. The procedure should be supplemented in the "lax" individual. Complications in 4 patients included a painful staple, postoperative adhesions, and symptomatic ectopic bone formation in two patients. Recurrent posterior shoulder dislocation is not a definite indication for operative repair; patients must be carefully selected.

Pes anserinus transplantation without a routine medial meniscectomy: a review of twenty-two cases.

Of 549 pes anserinus transplantations performed at the National Athletic Health Institute, Inglewood, California from 1971 through 1977, only 27 involved the transfer for anteromedial rotational instability in the presence of an intact medial meniscus. The 22 patients reviewed were evaluated with a questionnaire, physical and roentgenogram examinations, and hamstring and quadriceps muscle testing with Cybex II isokinetic dynamometer. Average length of follow-up was one year, four months. Acute anteromedial rotational instability was seen in 16 patients while six had chronic instability. All had an injury to the anterior cruciate ligament, and 12 had associated medial collateral ligament tears. One year postoperatively, 93% of the patients were participating in athletics and 70% rated their knee as above 90% of normal. The Cybex evaluation, however, revealed only 50% of the patients had 90% of normal strength in hamstrings and quadriceps. One patient developed anteromedial rotational instability, and one a torn medial meniscus, two years postsurgery. It was concluded that: I) Routine medial meniscectomy is not necessary with pes anserinus transplantation; 2) Anterolateral rotary instability does not routinely develop after pes anserinus transplantation done without medial meniscectomy; and 3) Hamstring and quadricep muscle strength below 90% of the normal extremity is not indicative of a subjective unsatisfactory functional result.Indexing terms: pes anserinus transplant; medial meniscectomy; anteromedial rotational instability; anterior cruciate ligament; and medial collateral ligament.

Isolated lateral meniscectomy. A study of twenty-six patients with isolated tears.

To better define the role that the lateral meniscus plays in stabilizing the knee, a study was made of twenty-six patients who had an uncomplicated lateral meniscectomy between 1972 and 1977. Patients with any degree of ligament instability, cruciate or collateral, prior to lateral meniscectomy were eliminated from the study. Also eliminated were any patients with roentgenographic evidence of degenerative arthrits, osteochondritis dissecans, or loose bodies. Only patients whose operative reports stated that the articular cartilage of the lateral compartment was either grossly normal or showed Grade-1 chondromalacia (less than one centimeter in diameter and only softening of the cartilage) at the time of surgery were included in the review. The meniscal lesions included bucket-handle tears, horizontal cleavage tears, and multiple linear defects. No grossly cystic menisci were included in the study. Two menisci demonstrated cystic degenerative changes on histological section. In sixteen patients some degree of ligament instability developed. The longer the interval between injury to the meniscus and its excision, the less satisfactory the result. Only fifteen (54 per cent) of the patients reported satisfactory results, and twenty lost some motion of the knee. We concluded that stability of the knee joint is a multifactorial problem, in which the lateral meniscus certainly plays an important part.

Correctable elbow lesions in professional baseball players: a review of 25 cases.

In a retrospective study, 20 of 25 professional baseball pitchers (mean age, 24 years; range, 19 to 28 years) who had had a reconstructive surgical procedure on the dominant elbow had satisfactory results (able to return to competitive throwing for one full season or more after surgery). Gentle motion wasinitiated 1 week after the operation on each patient. Exercises for mobilization and muscle strengthening of grip, arm, and shoulder were increased until throwing was initiated 10 to 12 weeks postoperatively. Throwing was gradually increased over several weeks from 30 feet at no more than half speed for 15 min to 60 feet at three-quarter speed. Pitchers were instructed to warm up before throwing and warm down and to continue this practice after they began competitive throwing. The longest period of follow-up had been 4 years (mean, 2.8 years). Four of the 25 pitchers had unsatisfactory results (released from their team in less than one full season because of ineffective pitching and were not picked up by another team). The cause of the release of the other patient-player is controversial. This 25-patient group is too small and the follow-up period is too short for definite conclusions. Our evidence does suggest that surgical procedures directed at medial soft tissue and posterior intra-articular changes carry better prognosis for competitive throwers than other procedures. The radiohumeral articular condition should be evaluated at surgery.

The Cybex II evaluation of surgically repaired Achilles tendon ruptures.

Thirty-two patients with 33 complete ruptures of the Achilles tendon with surgical repair were evaluated with the Cybex II isokinetic unit. The evaluations were performed from 6 to 144 months postoperatively. The repaired Achilles tendon had a 16.5% loss of plantarflexion strength and a 17.5% loss of plantarflexion power. The early repairs had a smaller loss of strength and power than late repairs. Twenty-seven of the patients returned to their former level of sports activity.

Analysis of 100 patients with anterolateral rotatory instability of the knee.

Of 100 consecutive patients with anterolateral rotatory instability analyzed, 84 were males and the average age was 27.4 years. Over 50 per cent were injured while participating in athletics and 40 per cent were injured during daily activities. The group averaged 1.2 operations prior to diagnosis. The most frequently performed procedures were medial meniscectomy, pes anserinus transfer and medial capsular reefings. Eighty-four of 100 patients underwent surgery during the study period. Seventy-one had combined rotatory instability and 13 had anterior lateral rotatory instability alone. Sixty-six patients had articular cartilage damage. Before treating the anterolateral rotatory instability, it is necessary to identify and treat other commonly associated abnormalities.