Novel autoantibodies in rheumatoid arthritis.

Rheumatoid factor and antibodies against cyclic citrullinated peptides represent a diagnostic hallmark in rheumatoid arthritis (RA). However, over the last decades many other autoantibodies have been identified. Several proteins can trigger an aberrant autoimmune response in their native form while others acquire this feature after post-translational modifications such as citrullination, carbamylation or acetylation. It is of interest that also the enzymes catalyzing such post-translational modifications (e.g. the protein arginine deiminases) can transform themselves into autoantibodies in RA. The purpose of this review article is to provide an overview of relevant literature published over the last years regarding novel autoantibodies and their possible diagnostic and prognostic significance in RA.

Performance of the Multidimensional Geriatric Assessment and Multidimensional Prognostic Index in predicting negative outcomes in older adults with cancer.

The Multidimensional Geriatric Assessment (MGA) is currently used for assessing geriatric oncological patients, but a new prognostic index - the Multidimensional Prognostic Index (MPI) - has a demonstrated prognostic value in cancer patients too. The present work was designed to compare the MPI and MGA as predictors of 12-month mortality. 160 patients ≥70 years old with locally-advanced or metastatic solid cancers consecutively joining our Geriatric Oncology Program were administered a Comprehensive Geriatric Assessment to calculate their MGA and MPI scores. SETTINGS: Geriatric Clinic, Geriatric Surgery Clinic, Medical Oncology Unit, Padova Hospital, Italy. Using Cohen's Kappa coefficient, there was a poor concordance between the MPI and MGA. Severe MPI being associated with a higher mortality risk than Frail in the MGA. The ROC curves indicated that the MPI had a greater discriminatory power for 12-month mortality than the MGA. In our population of elderly cancer patients, the MPI performed better than the MGA in predicting mortality. Further evidence from larger prospective trials is needed to establish whether other geriatric scales, such as the GDS and CIRS-SI, could enhance the value of prognostic indexes applied to elderly cancer patients.

Extra-articular rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic inflammatory disease that mainly affects the joints, though a consistent proportion of patients may also display extra articular manifestations (EAMs). From rheumatoid nodules to interstitial lung disease, from cardiovascular events to vasculitis, the spectrum of EAMs encompasses various conditions with different prognoses. EAMs may also occur as first RA manifestation, therefore the coordination with other health professionals, including general practitioners, is needed. The aim of this article is to provide an overview on EAMs in RA with particular focus on the recognised risk factors and the available recommendations for managing them, as well as comorbidities in RA patients.

TET2 gene expression and 5-hydroxymethylcytosine level in multiple sclerosis peripheral blood cells.

Aberrant DNA methylation can lead to genome destabilization and to deregulated gene expression. Recently, 5-hydroxymethylcytosine (5hmC), derived from oxidation of 5-methylcytosine (5mC) by the Ten-Eleven Translocation (TET) enzymes, has been detected. 5hmC is now considered as a new epigenetic DNA modification with relevant roles in cell homeostasis regulating DNA demethylation and transcription. Our aim was to investigate possible changes in the DNA methylation/demethylation machinery in MS. We assessed the expression of enzymes involved in DNA methylation/demethylation in peripheral blood mononuclear cells (PBMCs) from 40 subjects with MS and 40 matched healthy controls. We performed also, DNA methylation analysis of specific promoters and analysis of global levels of 5mC and 5hmC. We show that TET2 and DNMT1 expression is significantly down-regulated in MS PBMCs and it is associated with aberrant methylation of their promoters. Furthermore, 5hmC is decreased in MS PBMCs, probably as a result of the diminished TET2 level.

Intracortical modulation, and not spinal inhibition, mediates placebo analgesia.

Suppression of spinal responses to noxious stimulation has been detected using spinal fMRI during placebo analgesia, which is therefore increasingly considered a phenomenon caused by descending inhibition of spinal activity. However, spinal fMRI is technically challenging and prone to false-positive results. Here we recorded laser-evoked potentials (LEPs) during placebo analgesia in humans. LEPs allow neural activity to be measured directly and with high enough temporal resolution to capture the sequence of cortical areas activated by nociceptive stimuli. If placebo analgesia is mediated by inhibition at spinal level, this would result in a general suppression of LEPs rather than in a selective reduction of their late components. LEPs and subjective pain ratings were obtained in two groups of healthy volunteers - one was conditioned for placebo analgesia while the other served as unconditioned control. Laser stimuli at three suprathreshold energies were delivered to the right hand dorsum. Placebo analgesia was associated with a significant reduction of the amplitude of the late P2 component. In contrast, the early N1 component, reflecting the arrival of the nociceptive input to the primary somatosensory cortex (SI), was only affected by stimulus energy. This selective suppression of late LEPs indicates that placebo analgesia is mediated by direct intracortical modulation rather than inhibition of the nociceptive input at spinal level. The observed cortical modulation occurs after the responses elicited by the nociceptive stimulus in the SI, suggesting that higher order sensory processes are modulated during placebo analgesia.

The primary somatosensory cortex contributes to the latest part of the cortical response elicited by nociceptive somatosensory stimuli in humans.

Nociceptive laser pulses elicit temporally-distinct cortical responses (the N1, N2 and P2 waves of laser-evoked potentials, LEPs) mainly reflecting the activity of the primary somatosensory cortex (S1) contralateral to the stimulated side, and of the bilateral operculoinsular and cingulate cortices. Here, by performing two different EEG experiments and applying a range of analysis approaches (microstate analysis, scalp topography, single-trial estimation), we describe a distinct component in the last part of the human LEP response (P4 wave). We obtained three main results. First, the LEP is reliably decomposed in four main and distinct functional microstates, corresponding to the N1, N2, P2, and P4 waves, regardless of stimulus territory. Second, the scalp and source configurations of the P4 wave follow a clear somatotopical organization, indicating that this response is likely to be partly generated in contralateral S1. Third, single-trial latencies and amplitudes of the P4 are tightly coupled with those of the N1, and are similarly sensitive to experimental manipulations (e.g., to crossing the hands over the body midline), suggesting that the P4 and N1 may have common neural sources. These results indicate that the P4 wave is a clear and distinct LEP component, which should be considered in LEP studies to achieve a comprehensive understanding of the brain response to nociceptive stimulation.

Novelty is not enough: laser-evoked potentials are determined by stimulus saliency, not absolute novelty.

Event-related potentials (ERPs) elicited by transient nociceptive stimuli in humans are largely sensitive to bottom-up novelty induced, for example, by changes in stimulus attributes (e.g., modality or spatial location) within a stream of repeated stimuli. Here we aimed 1) to test the contribution of a selective change of the intensity of a repeated stimulus in determining the magnitude of nociceptive ERPs, and 2) to dissect the effect of this change of intensity in terms of "novelty" and "saliency" (an increase of stimulus intensity is more salient than a decrease of stimulus intensity). Nociceptive ERPs were elicited by trains of three consecutive laser stimuli (S1-S2-S3) delivered to the hand dorsum at a constant 1-s interstimulus interval. Three, equally spaced intensities were used: low (L), medium (M), and high (H). While the intensities of S1 and S2 were always identical (L, M, or H), the intensity of S3 was either identical (e.g., HHH) or different (e.g., MMH) from the intensity of S1 and S2. Introducing a selective change in stimulus intensity elicited significantly larger N1 and N2 waves of the S3-ERP but only when the change consisted in an increase in stimulus intensity. This observation indicates that nociceptive ERPs do not simply reflect processes involved in the detection of novelty but, instead, are mainly determined by stimulus saliency.

The primary somatosensory cortex largely contributes to the early part of the cortical response elicited by nociceptive stimuli.

Research on the cortical sources of nociceptive laser-evoked brain potentials (LEPs) began almost two decades ago (Tarkka and Treede, 1993). Whereas there is a large consensus on the sources of the late part of the LEP waveform (N2 and P2 waves), the relative contribution of the primary somatosensory cortex (S1) to the early part of the LEP waveform (N1 wave) is still debated. To address this issue we recorded LEPs elicited by the stimulation of four limbs in a large population (n=35). Early LEP generators were estimated both at single-subject and group level, using three different approaches: distributed source analysis, dipolar source modeling, and probabilistic independent component analysis (ICA). We show that the scalp distribution of the earliest LEP response to hand stimulation was maximal over the central-parietal electrodes contralateral to the stimulated side, while that of the earliest LEP response to foot stimulation was maximal over the central-parietal midline electrodes. Crucially, all three approaches indicated hand and foot S1 areas as generators of the earliest LEP response. Altogether, these findings indicate that the earliest part of the scalp response elicited by a selective nociceptive stimulus is largely explained by activity in the contralateral S1, with negligible contribution from the secondary somatosensory cortex (S2).

Dishabituation of laser-evoked EEG responses: dissecting the effect of certain and uncertain changes in stimulus spatial location.

The repetition of nociceptive stimuli of identical modality, intensity and location at short (1 s) and constant inter-stimulus interval (ISI) determines a strong habituation of the corresponding electroencephalographic (EEG) responses. To understand what determines this response habituation, we (1) examined the effect of introducing a selective change in the spatial location of the repeated stimulus (i.e., without altering its modality, intensity and timing), and (2) dissected the relative contribution of bottom-up, stimulus-driven spatial changes and top-down, cognitive expectations of such a change. Multichannel EEG was recorded while participants received a triplet of stimuli (S1-S2-S3) delivered to the hand dorsum at 1-s ISI. S3 was delivered either to the same hand as S1 and S2 or to the other hand, and participants were either explicitly informed or not informed of the location of S3. We found that, unlike the introduction of a change in the sensory modality of the repeated stimulus (Valentini et al. in J Cogn Neurosci 23:2822-2837, 2011), introducing a change in its spatial location did not produce a significant dishabituation of the laser-evoked N1, N2 and P2 peaks, but only a small amplitude increase following the P2 peak, maximal on the hemisphere contralateral to the stimulated hand. Furthermore, the magnitude of the elicited responses was not significantly affected by cognitive expectations. Altogether, these results indicate that bottom-up, stimulus-driven novelty resulting from a change in stimulus spatial location does not revert the habituation caused by repetition suppression, but determines a small increase of neural activity over the contralateral central-parietal cortex, likely reflecting shifts in spatial attention.

Traumatic diaphragmatic rupture in pediatric age: review of the literature.

PURPOSE: Traumatic diaphragm rupture (TDR) is a rare complication of trauma in pediatric age and may be easily missed by the severity of associated injuries so that delayed emergent presentation can occur with increased rate of morbidity and mortality. No review has been available to guide clinicians through the pitfalls and the initial diagnostic approach to pediatric TDR. METHODS: A Medline thorough search on TDR was conducted using different queries. English language citations were identified during the period of January 2000 through December 2014 limiting the search to pediatric age (0-18 years). Abstracts were reviewed to determine eligibility and texts were obtained for further review. Differences were resolved by consensus and only reliable data were included. RESULTS: Most frequently reported presenting symptoms of TDR are respiratory and abdominal. While respiratory symptoms are among the most frequently described at the onset in pediatric and adult series, abdominal symptoms result to be more frequent in adult than pediatric patients. Chest X-ray (CXR) is the first-line imaging exam which is reported to show pathognomonic or suspect findings in 85 %. CT was the second main radiological technique used, in particular to confirm the suspicion of TDR. CONCLUSIONS: A high clinical index of suspicion is needed to diagnose and effectively manage diaphragmatic rupture. TDR should be kept in mind while dealing with patients assessed for abdominal or respiratory symptoms whenever there is history of trauma or blunt injury especially in children as the increasing of non-operative management of blunt abdominal trauma could result in missing important injuries as TDR.

Psychomotor performance is not influenced by brief repeated exposures to mobile phones.

The present study investigated the presence of a cumulative effect of brief and repeated exposures to a GSM mobile phone (902.40 MHz, 217 Hz modulated; peak power of 2 W; average power of 0.25 W; SAR = 0.5 W/kg) on psychomotor functions. To this end, after each of 3 15-min exposures, both an acoustic simple reaction time task (SRTT) and a sequential finger tapping task (SFTT) were administered to 24 subjects. The present study was unable to detect the cumulative effects of brief and repeated EMF exposure on human psychomotor performance, although there was a non-statistical trend to shorter reaction times. In summary, these data show an absence of effects with these particular exposure conditions; however, possible cognitive effects induced by different signal characteristics cannot be excluded.

Attention to pain! A neurocognitive perspective on attentional modulation of pain in neuroimaging studies.

Several studies have used neuroimaging techniques to investigate brain correlates of the attentional modulation of pain. Although these studies have advanced the knowledge in the field, important confounding factors such as imprecise theoretical definitions of attention, incomplete operationalization of the construct under exam, and limitations of techniques relying on measuring regional changes in cerebral blood flow have hampered the potential relevance of the conclusions. Here, we first provide an overview of the major theories of attention and of attention in the study of pain to bridge theory and experimental results. We conclude that load and motivational/affective theories are particularly relevant to study the attentional modulation of pain and should be carefully integrated in functional neuroimaging studies. Then, we summarize previous findings and discuss the possible neural correlates of the attentional modulation of pain. We discuss whether classical functional neuroimaging techniques are suitable to measure the effect of a fluctuating process like attention, and in which circumstances functional neuroimaging can be reliably used to measure the attentional modulation of pain. Finally, we argue that the analysis of brain networks and spontaneous oscillations may be a crucial future development in the study of attentional modulation of pain, and why the interplay between attention and pain, as examined so far, may rely on neural mechanisms shared with other sensory modalities.

Role of Inflammatory Diseases in Hypertension.

Chronic inflammatory diseases (CID) are characterized by an increased risk of cardiovascular (CV) morbidity and mortality. Several mechanisms, including early acceleration of subclinical atherosclerotic damage, inflammatory markers and immune system deregulation factors, have been demonstrated to strictly interplay for development and progression of atherosclerosis. Moreover, traditional CV risk factors are likely to explain at least some of the excess of CV risk in these patients. Among traditional CV risk factors, compelling evidence suggests a higher incidence and prevalence of hypertension in patients with CID in comparison to the general population. Moreover, hypertension represents an important predictor of CV events in these patients. Pathogenic mechanisms underlying the rise of blood pressure in CID are multifactorial and still poorly investigated. Indeed, multiple disease-related factors may affect blood pressure control in these patients and hypertension may affect disease prognosis and increase CV risk. Better knowledge of the complex interplay between hypertension and CID will be important to elucidate pathogenic mechanisms and to improve CV outcome in these patients. Aim of this review is to highlight available evidence on the relationship between hypertension and CID and to elucidate the multiple factors that may affect blood pressure control in these disorders.

Clinical and serological studies of tuberculosis patients in Argentina receiving immunotherapy with Mycobacterium vaccae (SRL 172).

Two small, placebo-controlled studies of immunotherapy with heat killed Mycobacterium vaccae added to routine chemotherapy for pulmonary tuberculosis, together involving 40 HIV seronegative patients, were carried out in Argentina. The immunotherapy was associated with reduced sputum smear positivity of AFB at 1 month and a greater reduction in ESR at 2 months. In the first study radiological improvement was better (P < 0.05) among immunotherapy recipients. In the second study, weight regain and time to become apyrexial were measured and were found to be improved amongst immunotherapy recipients (P < 0.05). In the first month of treatment the levels of IgG to the 65 kDa and 70 kDa heat-shock proteins showed greater falls following immunotherapy (P < 0.05 and P < 0.001, respectively). On admission serum cytokine levels of interleukins 4 and 10 (IL-4, IL-10), interferon gamma (IFN-gamma) and tumour necrosis factor alpha (TNF-alpha) were grossly raised in comparison with a matched control group (P < 0.001). After 1 month. Levels of IL-4, IL-10 and TNF-alpha fell (P < 0.001, P < 0.01 and P < 0.01, respectively) and levels of IFN-gamma rose more (P = 0.005) in immunotherapy recipients than in those receiving chemotherapy alone. The results are in accord with a switch towards a TH1 immunological status and clinical benefit for immunotherapy recipients.

Circulating immune complexes in patients with advanced tuberculosis and their association with autoantibodies and reduced CD4+ lymphocytes.

We investigated the presence of circulating immune complexes (CICs) in serum from tuberculosis (TB) patients with different degrees of pulmonary involvement. Patients were classified into four groups according to the extent of lung involvement: mild (N = 9), moderate (N = 12), moderate plus (N = 16), and severe cases (N = 10). A search for CICs by the 3.5% PEG precipitation test showed that the CIC values of patients with the moderate plus or severe form of pulmonary TB were significantly higher compared to healthy controls and to mild and moderate cases (P < 0.01 and P < 0.001, respectively). Further analysis demonstrated that increased CIC levels were associated with increased autoantibody production, since this abnormality was more prevalent in patients with advanced disease (P < 0.01), who also showed a significant reduction of CD4+ T lymphocytes. The immunoregulatory and pathogenetic implications of these findings are discussed.

Preparation of human rabies vaccine in VERO cell culture using a microcarrier system.

1. The rabies virus (Pasteur PV strain) was propagated in VERO cells attached to microcarriers in a 3.7-1 bioreactor. Virus titers of about 10(6) LD50/ml were obtained regularly. 2. Ultrafiltration was efficient for concentrating the virus suspensions, and the sucrose gradient reduced the residual VERO cell DNA to acceptable levels (less than 50 pg/dose). The remaining cell DNA content was evaluated by dot-blot hybridization with a probe prepared with VERO cell DNA. 3. The final virus preparations were inactivated by B-propiolactone treatment, showed a potency higher than 2.5 IU/dose and protected mice experimentally infected intracerebrally with rabies virus (CVS-13.2). 4. This methodology for the production of a rabies vaccine for human use should be of interest to countries where high technology facilities are not available.

[Quality of the reagents used in counterimmunoelectrophoresis technique for the determination of antirabies antibodies]. / Evaluación de la calidad de los reactivos que se utilizan en la tecnica de contrainmunoelectroforesis para la determinación de anticuerpos antirrábicos.

This study demonstrated that the antigens and indicator sera produced by the Butantan Institute may be employed with success in the counterimmunoelectrophoresis technique for the titration of rabies antibodies in sera from immunized individuals. No statistically significant differences were demonstrated between the results obtained in the standardization tests carried out at the Butantan Institute and the reference control tests performed at the Pan American Zoonoses Center. It is proposed that the Butantan Institute be in charge of the production and distribution of these reagents at the national level.

[Immunofluorescence performed in brain of mice, infected with the CVS strain of the rabies virus, in different stages of decomposition]. / Imunofluorescência realizada em cérebros de camundongos infectados com vírus rábico--cepa CVS, em diferentes estágios de decomposição.

The efficiency of the fluorescent antibody (FA) test in detecting rabies virus antigen in decomposed specimens was evaluated in simulated conditions of the safety test recommended for the assessment of residual virus in inactivated rabies vaccines. The CVS-infected mice were submitted to different treatments combining time and temperature in order to cause different stages of carcass decomposition and, the FA test was carried out sequentially at pre-determined time intervals. For the materials stored at 25 degrees C, greater difficulties for prompt recognition of the inclusion bodies were found after 12-18h, whilst the specimens maintained at 4 degrees C, the inclusions were easily visualized for up to 48h. Brain smears of carcasses kept at -20 degrees C were suitable for adequate identification after 720 h of storage. In carcasses that had been maintained at 25 degrees C for 10 h with additional storage at 4 or -20 degrees C, rabies antigenicity could not be detected, respectively after 10 and 24 h, due to tissue decomposition. The authors recommend that the FA test, when applied as an additional tool for the control of the safety test of inactivated rabies vaccine using mice, care must be taken in order to avoid the use of decomposed materials.

Hyperimmune antirabies sera titration by standard mouse neutralization and counterimmunoelectrophoresis tests, comparing results of different laboratories.

To determine the rabies antibody level of twenty-four hyperimmune equine sera, Standard Mouse Neutralization (SMN) and Couterimmunoelectrophoresis (CIE) tests were carried out, both at the Instituto Butantan (IB) and Instituto Panamericano de Proteccíon de Alimentos y Zoonosis (INPPAZ). Statistical analysis has shown a correlation (r) of 0.9317 between the SMN and CIE performed at the IB, while at the INPPAZ it scored 0.974. Comparison of CIE data of both laboratories yielded a correlation of 0.845. The CIE technique has shown to be a sensitive and efficient as the SMN in titrating antirabies hyperimmune equine sera. Based on CIE results, a simple, rapid and inexpensive technique, titers of sera antibody can be rellably estimated in SMN test.

[Thermostability of rabies vaccine, type Fuenzalida & Palacios, for human use]. / Termoestabilidade da vacina contra a raiva, tipo Fuenzalida & Palacios, uso humano.

Ten lots of Fuenzalida & Palacios type antirabies vaccine for human use, produced at the Instituto Butantan (São Paulo, Brazil) were stored at temperatures of 45, 37, 28 and 2-8 degrees C. The potency of each lot was determined in samples taken at varied time intervals using the NIH method and lots presenting antigenic values > or = 0,3 were considered satisfactory for use. After 2 hours at 45 degrees C the antigenic value of one out of 10 lots tested was found to be less than the minimum required value. At 37 degrees C all lots maintained satisfactory antigenic values until the third day of storage, whilst at 28 and 2-8 degrees C the potency was fully maintained, respectively for 10 and 360 days. At the ideal temperature of 2-8 degrees C, 100% of the tested vaccines maintained the minimum required antigenicity for a longer period (16 months) than the expiration time of 6-12 months usually recommended for this type of biological produced in Latin American and Caribbean countries. Thus, the obtained data suggested that in countries still producing Fuenzalida & Palacios type vaccine, the expiration tim could be extended to 16 months, what could prevent the unnecessary discarding of products still in useful condition.