Does asymmetric dimethylarginine (ADMA) plasma concentration predict esophageal varices in patients with cirrhosis?

BACKGROUND: In previous studies elevated Asymmetric NG, NG - dimethylarginine (ADMA) plasma levels, an endogenous nitric oxide synthase inhibitor, correlated with the severity of hepatic venous pressure gradient measurement, both in peripheral and in hepatic veins. The aim of this study was to explore whether elevated ADMA plasma levels were able to predict the presence of esophageal varices (EV) and/or large EV in patients with cirrhosis. METHODS: 74 cirrhotic patients who had undergone elective upper gastrointestinal endoscopy in order to assess the presence of portal hypertension and predictors of EV and/or large EV. ADMA levels were assayed by an ELISA test (Immundiagnostik AG, Germany). RESULTS: 53 patients had EV (26/53 had large EV). Univariate analysis of low hemoglobin (p = 0.045), PT-INR (p = 0.003), albumin (p = 0.024), bilirubin (p = 0.036), Child-Pugh score (p = 0.026), and ascites (p = 0.036) predicted the presence of EV. Multivariate analysis predicted EV for only PT-INR. The presence of large EV was predicted with univariate analysis of ADMA plasma levels (p = 0.013), low hemoglobin (p < 0.001), PT-INR (p = 0.001), albumin (p = 0.001), bilirubin (p = 0.026), Child-Pugh score (p < 0.001), ascites (p = 0.004). Sensitivity, specificity, predictive positive and negative values of ADMA plasma level > 0.5 micromol/L(-1) in predicting large EV were 0.69 (95% CI 0.53 - 0.82), 0.51 (95% CI 0.40 - 0.62), 0.43 (95% CI 0.31 - 0.56), 0.76 (95% CI 0.62 - 0.86), while the area under the ROC curve was 0.65 (95% CI 0.51 - 0.79). CONCLUSIONS: ADMA plasma levels were increased in cirrhotics with more advanced liver failure but did not prove to be a useful clinical tool for predicting the presence of esophageal varices or large esophageal varices.

Chlamydia pneumoniae infection as a risk factor for accelerated atherosclerosis in hemodialysis patients.

Atherosclerotic cardiovascular disease is the main cause of morbidity and mortality for end-stage renal disease patients undergoing chronic haemodialysis (HD). Several studies in recent years have identified Chlamydia pneumoniae, a respiratory pathogen, as risk factor for cardiovascular diseases in the general population. The aim of our study is to evaluate chlamydial load, in peripheral blood mononuclear cells (PBMC) of HD patients. Furthermore, the correlation between DNA chlamydial load and markers of inflammation was also examined. PBMC specimens isolated from 49 HD patients and 46 blood donors were analyzed for the presence of C. pneumoniae DNA by real-time PCR and ompA nested touchdown PCR. In HD patients, plasma levels of several inflammatory markers were also determined. A significantly higher rate of C. pneumoniae DNA was found in HD patients (44.9 percent) than in blood donors (19.6 percent) (p=0.016); HD patients were also more likely to have a significantly high chlamydial load (p=0.0004). HD patients with atherosclerotic cardiovascular diseases have a significantly greater chlamydial load than HD patients without cardiovascular diseases (p= 0.006). A significantly higher value of C-reactive protein, IL-6 and advanced oxidative protein products was found in HD patients with a greater chlamydial load (p less than 0.05). Likewise, a significantly lower monocyte HLA-DR percentage (p=0.011) as well as a lower monocyte HLA-DR expression were found in such patients (p= 0.007). In conclusion, our results show that HD patients are at high risk of C. pneumoniae infection correlated with chronic inflammatory response which in turn can lead to accelerated atherosclerosis and other long-term clinical complications such as myocardial infarction and stroke.

Detection of different Borrelia burgdorferi genospecies in serum of people with different occupational risks: short report.

This study is aimed at applying a previously described PCR-based method to detect B. burgdorferi sensu lato and different Borrelia genospecies in total DNA preparations of serum samples collected from people with different occupational risks for tick bite and with serological evidence of borreliosis. Among the seropositive samples, the PCR for B. burgdorferi confirmed the positivity in 65 percent of the forestry workers and in 60 percent of the subjects living in the same area. None of the seronegative subjects belonging to the control group showed the presence of B. burgdorferi sensu lato DNA. Results on genospecies distribution show that B. afzelii was the predominant species, followed by B. garinii and finally by B. valaisiana.

Chlamydia pneumoniae and atherosclerosis: current state and future prospectives.

Chlamydia pneumoniae, an intracellular bacterial pathogen, is known as a leading cause of human respiratory tract infections worldwide. Over the last decade, several reports in the literature have suggested that infection with C. pneumoniae may contribute to the pathogenesis of atherosclerosis. In order to play a causative role in chronic disease, C. pneumoniae would need to persist within infected tissue for extended periods of time, thereby stimulating a chronic inflammatory response. C. pneumoniae has been shown to disseminate systemically from the lungs through infected peripheral blood mononuclear cells and to localize in arteries where it may infect endothelial cells, vascular smooth muscle cells, monocytes/macrophages and promote inflammatory atherogenous process. The involvement of C. pneumoniae in atherosclerosis was investigated by seroepidemiological and pathological studies, in vivo and in vitro studies, and in clinical antibiotic treatment trials. This review will provide an update on the role of C. pneumoniae in atherosclerosis focusing on the recent insights and suggesting areas for future research.

Chlamydia pneumoniae induces T cell apoptosis through glutathione redox imbalance and secretion of TNF-alpha.

Chlamydia pneumoniae persistent infection has been implicated in the pathogenesis of several chronic inflammatory diseases including atherosclerosis, and we hypothesized that modulation of the apoptosis of macrophages and/or T cells by C. pneumoniae infection may contribute to the development of such diseases. We therefore evaluated apoptosis, cytokine response, and redox status in human primary T cells and macrophages infected with C. pneumoniae. In addition, co-cultures of T cells and macrophages infected with C. pneumoniae were also carried out. Apoptosis, and levels of glutathione (GSH), glutathione disulfide (GSSG), and tumour necrosis factor (TNF)-alpha were measured by flow cytometry, high performance liquid chromatography and enzyme-linked immunosorbent assay. C. pneumoniae induced apoptosis in T cells as well as in co-cultures of T cells and infected macrophages by marked decrease in GSH/GSSG ratio and increased production of TNF-alpha, respectively. The results demonstrate that interaction of C. pneumoniae with T cells and/or macrophages characterized by interference with redox status, and secretion of tumour necrosis factor-alpha culminates in the induction of T cell apoptosis and survival of infected macrophages. In conclusion, the inappropriate T cell response against C. pneumoniae and survival of infected macrophages could explain the persistence of this intracellular obligate pathogen in the host-organism; it may contribute to the development of chronic inflammatory diseases, although further studies are needed to clarify such a complex mechanism.

Chlamydia pneumoniae and atherosclerosis: the role of mast cells.

Chlamydia pneumoniae (C. pneumoniae), a respiratory pathogen, has been implicated in the pathogenesis of atherosclerosis, an inflammatory progressive disease, characterized by the formation of atherosclerotic plaques. Among several types of inflammatory cells involved in the atherogenesis process, recently particular attention has been directed toward the mast cells. Experimental studies have provided several mechanisms by which C. pneumoniae and mast cells could play a role in all stages of atherosclerosis, from initial inflammatory lesions to plaque rupture. C. pneumoniae, as well as mast cells, may actively participate both through the production of cytokines and matrix-degrading metalloproteinases and by provoking apoptosis of atheroma-associated vascular cells, key events in plaque rupture. This mini-review provides a brief overview on adventitial inflammatory effects of C. pneumoniae and mast cells and their potential role in plaque instability. In addition, in this paper we review the role of mast cells in innate immunity.

No evidence of involvement of Chlamydia pneumoniae in lung cancer by means of quantitative real-time polymerase chain reaction.

Chlamydia pneumoniae, an obligate intracellular pathogen, is well-known as etiological agent of acute respiratory infections; the repeated or prolonged exposure to chlamydial antigens may promote the persistence of C. pneumoniae in the respiratory tract leading to chronic diseases, such as chronic obstructive pulmonary disease and asthma. The predilection of C. pneumoniae to cause respiratory tract infections combined with its persistent nature suggest that it might play a role in lung cancer. The aim of our study is to evaluate the involvement of C. pneumoniae in pathogenesis of lung cancer. We therefore investigated the presence of C. pneumoniae DNA in tumor lung tissues by using real-time PCR assay. Simultaneously, tumor and healthy tissues from the same patient with primary carcinoma lung were analyzed. C. pneumoniae DNA was not detected in a single lung tumor tissue by means of an highly sensitive, and specific real-time PCR assay based on FRET hybridization probes. In conclusion, this study does not support the involvement of C. pneumoniae in the pathogenesis of lung cancer, suggesting that further investigations are needed to clarify other potential causative factors for the development of this malignancy.

DPEJ placement in cases of PEG insertion failure.

BACKGROUND AND STUDY AIMS: PEG placement is routinely used for enteral feeding; in some cases PEG is not feasible or indicated due to technical difficulties, such as gastric herniation, organ interposition, or presence of gastroparesis. In these cases, surgical gastrostomy or jejunostomy are possible alternatives; more recently, direct percutaneous jejunostomy (DPEJ) has been proposed to avoid surgical intervention. The aim of the study was to evaluate the necessity, technical feasibility and outcome of DPEJ in a group of patients consecutively proposed for PEG placement. PATIENTS AND METHODS: In each patient proposed for PEG placement, an upper gastrointestinal endoscopy was performed, and then a pull traction removal gastrostomy tube (18-20 F) was inserted. When PEG was not feasible or contraindicated, a variable stiffness pediatric videocolonscope was used to reach the jejunum: then DPEJ was performed with the same technique and materials as PEG. In both groups enteral feeding was started 24h after the endoscopic procedure, using an enteral feeding pump and the same nutritional schedules. RESULTS: In a 1-year period 90 patients were proposed for PEG placement; PEG could not be performed for technical reasons in 8 (gastric herniation in 1; organ interposition in 7) and gastroparesis in 1. In one patient both PEG and DPEJ were not feasible for organ interposition. The duration of the endoscopic procedure was slightly longer in DPEJ (mean 20 min versus 15 min). No complications related to the endoscopic procedure were observed in both DPEJ and PEG patients. No nutritional complication were observed in the DPEJ group. CONCLUSION: In our experience, PEG was not feasible or contraindicated in about 10% of patients proposed for. In these patients, DPEJ was placed: the procedure resulted to be feasible and safe with the use of a pediatric videocolonscope to easily reach the jejunum. The insertion of DPEJ did not change the nutritional management of enteral feeding. However, long-term effects or complications remain to be evaluated in larger studies.

In vitro susceptibility of isolates of Borrelia burgdorferi s.l. to antimicrobial agents.

In the present study, we investigate the in vitro antimicrobial activity of macrolides, beta-lactams and tetracycline against Borrelia burgdorferi s.l. clinical and tick isolates. Minimal inhibitory concentrations (MICs) were determined in normal growth condition and after pre-exposure of the strains to sub-MIC of the founder of each drug family. All the classes of tested antibiotics showed good antibacterial activity against all the borreliae isolates and there were no significant susceptibility differences among clinical and tick isolates. After pre-exposure of the strains to sub-MIC of erythromycin, cefoxitin and tetracycline, we observed that some strains of B. burgdorferi s.l. showed higher MIC values to both the pre-exposed drug and drugs of the same family. The less susceptibility of borreliae, in the last growth condition in vitro, could be one of the justifications of clinical results indicating the limited efficacy of these antibiotics in treatment of B. burgdoferi infections.

Genotype and phenotype relationship in MLSb resistance in Streptococcus pyogenes and Streptococcus agalactiae isolated in central Italy.

The aim of this work is to study a correlation between phenotype and genotype in clinical isolates of erythromycin-resistant Streptococcus spp. Among the 25 erythromycin-resistant S. pyogenes, we detected six strains with iMLSB, nine with cMLSB and two with M phenotypes. Among 14 erythromycin-resistant S. agalactiae, we detected five strains with iMLSB, seven with cMLSB and none with an M phenotype. Moreover, 8 S. pyogenes and 2 S. agalactiae showed a phenotype not matching the known ones described in literature, defining an unknown phenotype. Upon examination, the genetic profiles, erm(A), erm(B) and mef(A), of the clinical isolates did not easily correlate with a specific phenotype. Our findings highlighted that the whole matter of phenotypic diversity in macrolide-resistant S. pyogenes and S. agalactiae strains and the correlation with their genetic profiles should be submitted to a more careful analysis of phenotypic and genotypic characterization.

Chlamydia pneumoniae in asymptomatic carotid atherosclerosis.

We evaluated, in 415 patients with asymptomatic carotid atherosclerosis: (i) the prevalence of C. pneumoniae DNA in atherosclerotic carotid plaques and peripheral blood mononuclear cells (PBMC); (ii) the distribution of C. pneumoniae in atherosclerotic carotid plaques and PBMC from the same patients; (iii) the correlation between circulating anti-chlamydial antibodies and the presence of C. pneumoniae DNA. Overall, 160 atherosclerotic carotid plaques and 174 PBMC specimens from patients with asymptomatic carotid atherosclerosis were examined by ompA nested touchdown PCR for presence of C. pneumoniae. In addition, C. pneumoniae DNA was detected in 81 specimens of atherosclerotic carotid plaque and PBMC obtained from the same patients. C. pneumoniae DNA was found in 36.9% of atherosclerotic carotid plaques and in 40.2% of PBMC specimens examined (P=NS). With regard to 81 patients, C. pneumoniae DNA was detected in 27.2% of atherosclerotic carotid plaques and in 44.4% of PBMC specimens(P=0.05). In 18 patients, the presence of C. pneumoniae DNA in PBMC specimens and atherosclerotic carotid plaques coincided (P=0.005). No statistically significant association was found between anti-C. pneumoniae antibodies (IgG and IgA) and positive PCR results. In conclusion, our results suggest that the detection of C. pneumoniae DNA in PBMC specimens seems to be a first-choice method to identify the patients at risk for endovascular chlamydial infection.

Chlamydia pneumoniae in PBMC: reproducibility of the OMPA nested touchdown PCR.

The aim of our study was to evaluate whether the replicate PCR testing may provide more accurate estimates of C. pneumoniae DNA prevalence in PBMC of patients undergoing carotid endarterectomy. Clinical sensitivity and reproducibility of ompA nested touchdown PCR was also performed. Clinical sensitivity and reproducibility was examined by testing C. pneumoniae-negative PBMC spiked with serial dilutions of semipurified C. pneumoniae elementary bodies (from 8 to 0.002 IFU/ml). Detection of C. pneumoniae DNA was performed by ompA nested touchdown PCR. Each clinical and spiked PBMC DNA specimen was analyzed in replicates of 1, 3, 5 and 10. PCR results of serial dilutions of C. pneumoniae DNA performed in replicates of 10 were analysed by probit analysis. C. pneumoniae DNA was detected in 14 of the 30 (46.7 %) PBMC clinical specimens examined when 10 replicates were tested. When we analyzed 1, 3 and 5 replicates, 4 (13.3 %), 7(23.3 %), 12(40 %) of the 30 specimens were positive, respectively. The limit of detection of ompA nested PCR touchdown was 0.008 IFU/ml when 10 replicates were tested. The ompA nested PCR had reproducibility scores of 10 for 10 from 8 to 4 IFU/ml concentration, but scores decreased for smaller numbers of IFU/ml. Our results showed that repeat testing of the same specimen increased clinical sensitivity as well as reproducibility of the ompA nested touchdown PCR. In conclusion the replicate PCR testing improves the performance of ompA nested touchdown PCR and provides a more accurate estimates of the prevalence of C. pneumoniae in PBMC of patients with atherosclerotic cardiovascular disease.

Prevalence of Chlamydia pneumoniae in peripheral blood mononuclear cells in Italian patients with acute ischaemic heart disease.

Chlamydia pneumoniae infection generally starts in the respiratory tract and probably disseminates systemically in the blood stream within alveolar macrophages. We investigated the prevalence of C. pneumoniae DNA in peripheral blood mononuclear cells (PBMC) in patients with acute ischaemic heart disease. Samples of blood were obtained from 93 consecutive patients with acute ischaemic heart disease and from 42 healthy subjects, for detection of C. pneumoniae DNA in PBMC by polymerase chain reaction (PCR) and for serology. C. pneumoniae DNA in PBMC was detected in 25.8% (24/93) of the patients with acute ischaemic heart disease and in 4.8% (2/42) of the healthy subjects (P=0.008). C. pneumoniae IgG was found in 76.3% of patients and in 45.2% of healthy subjects (P=0.0008) while C. pneumoniae IgA was found in 59.1% and in 33.3%, respectively (P=0.01). No correlation was found between anti-C. pneumoniae antibody titers and positive PCR results. The detection of C. pneumoniae DNA in PBMC may aid in selecting patients who may benefit from antibiotic treatment; however, to support this contention, longitudinal studies on patients treated with antibiotics would also be necessary.

Controlled trial of oral 5-aminosalicylic acid for the prevention of early relapse in Crohn's disease.

BACKGROUND: Recent data indicate that 5-aminosalicylic acid (5-ASA) is most effective in preventing relapse of Crohn's disease in patients with a short duration of remission before enrollment. AIM: To evaluate the efficacy of oral 5-ASA treatment, started immediately after achieving steroid-induced remission, in preventing clinical relapses of Crohn's disease. METHODS: Patients with active Crohn's disease, achieving remission on steroids, were randomized to oral 5-ASA 3 g/day or placebo, while steroids were tapered over 6 weeks. The trial was terminated after interim analysis showed a slightly higher relapse rate in the 5-ASA group, and the calculated probability of seeing a statistically significant difference by completing the study was minimal. RESULTS: Final analysis included 117 patients (58 taking 5-ASA and 59 taking placebo; follow-up 9.2 +/- 6.5 months). Cumulative relapse rates at 6 and 12 months were 34% and 58% in 5-ASA patients and 31% and 52% in placebo patients, respectively (rate difference +0.095; 95% CI = -0.085 to +0.274). Subgroups analysis showed that 5-ASA was equally ineffective in patients with ileal, colonic or ileocolonic disease. CONCLUSIONS: Contrary to previous results, in our study early introduction of treatment with oral 5-ASA did not prevent relapse in Crohn's disease patients treated with steroids to induce remission.

Dependability of sensitivity tests in primary culture.

Primary sensitivity tests were done on 90 specimens of infected urine, and the results were compared with those of secondary tests on pure cultures done by three diffusion methods. There was good correlation between the four methods. In a second study, the reliability of primary tests prepared in the clinical laboratory on specimens of pus was assessed, and the frequency with which a definitive result was obtained with different types of specimen was determined. Recommendations are made for the economic use of these tests.

Borrelia burgdorferi s.l. and Ehrlichia chaffeensis in the National Park of Abruzzo.

The aims of the present study were (a) to determine the presence of Ixodes ricinus in three different areas of the National Park of Abruzzo; (b) to search for the presence of Borrelia burgdorferi in the collected sample of Ixodes; (c) to determine the seroprevalence of B. burgdorferi antibodies and E. chaffeensis antibodies in inhabitants of the park and in park workers. The presence of B. burgdorferi in Ixodes was checked by PCR. For the detection of antibodies to B. burgdorferi all sera were assayed by ELISA as screening test and by Western blot as confirmatory test. For the detection of antibodies to E. chaffeensis all sera were assayed by IFA. Antibodies to B. burgdorferi were present in 9.1% of the park workers, 4.5% were confirmed positive by the IgG Western blot test. None of the inhabitants of the park was positive. Antibodies against E. chaffeensis were found in 4.5% of the park workers and 8% of the inhabitants of the park. The results obtained in the collecting of the ticks seem to show that the presence of I. ricinus in the park territory is rather discontinuous and small in number, therefore it is not epidemiologically significant for the transmission of B. burgdorferi sensu lato. Serological study for Ehrlichia revealed a high frequency of E. chaffeensis antibodies in the park inhabitants and a lower prevalence in the park workers.

Epidemiology of urogenital infections caused by Chlamydia trachomatis and outline of characteristic features of patients at risk.

A study of Chlamydia trachomatis infection was conducted in two stages on 15,656 subjects at urogenital clinics of the Faculty of Medicine and Surgery at La Sapienza University in Rome, the S. Anna Hospital in Turin, and the Niguarda Hospital in Milan. The overall incidence of the disease was 6.4% in patients examined throughout the whole study period. The rate of positive cases was 5.8% for the 5270 patients examined up to 1990, and 6.7% for the 10,386 patients examined from 1990 to 1992, showing an increasing trend. There was a much higher positivity rate in men (9.8%) than in women (6.0%); the difference was statistically significant. Of all patients, 60%, were asymptomatic. In symptomatic patients, C. trachomatis was present in 18.5% of cases of non-gonococcal urethritis and in 12.8% of cases of salpingitis. The highest incidence of C. trachomatis infection was in women who had begun sexual activity at an early age, (under 25 years in age), had several sexual partners and used intra-uterine contraceptive devices or spermicides or both.

Percutaneous endoscopic gastrostomy and enteral nutrition in amyotrophic lateral sclerosis.

Bulbar involvement in amyotrophic lateral sclerosis (ALS) is often related to a worse prognosis on account of the higher risk of pulmonary aspiration and undernutrition due to dysphagia. The aim of our study was to assess the effects of enteral feeding by percutaneous endoscopic gastrostomy (PEG) in a long-term follow-up of ALS patients. We report the results of PEG in 31 ALS patients with bulbar involvement. The patients were observed at 3-monthly intervals over a period of 2 years after PEG. All the data were compared with those obtained from a control group of 35 ALS patients who refused PEG. Mortality did not differ significantly between the two groups of patients during the first 6 months of observation, whereas after this period it was lower in the PEG group. In the patients who had had PEG, the body mass index showed a mild but statistically significant improvement after tube insertion while in the control group it decreased significantly. The findings of this study demonstrate that PEG can improve survival in elderly and young ALS patients with bulbar involvement; it enhances their quality of life and helps their integration in their social and family surroundings. We think that PEG should be included symptomatic treatment of all ALS patients with bulbar involvement from the onset of symptoms.

Prevalence of Borrelia Burgdorferi sensu lato genomospecies and of the human granulocytic ehrlichiosis (HGE) agent in Ixodes ricinus ticks collected in the area of Monti Lepini, Italy.

Ticks are obligate hematophagous arthropods that are parasites in every class of vertebrates in most regions of the world. They are also considered to be important vectors for the transmission of human infectious diseases. In the present study we used polymer chain reaction (PCR) amplification analysis to determine the prevalence of Borrelia burgdorferi and Ehrlichia phagocytophila, the agents of, respectively, Lyme borreliosis and human granulocytic ehrlichiosis, among ticks inhabiting the area of Monti Lepini, a wild area located in the Latium Region of Italy. A total of 141 I. ricinus ticks (125 nymphs and 16 adults) were collected in the studied area. Total DNAs were extracted from I. ricinus nymphs (pooled in groups of five) and from individual adults. The DNA samples were examined for the presence of B. burgdorferi sensu lato and E. phagocytophila by PCR using two specific pairs of oligonucleotides that specifically amplify distinct DNA regions of the 16S rRNA genes of the two species. The prevalence of vectors infected with B. burgdorferi s. l. was 16% in pooled nymphs samples, and 12.5% in adult ticks, while E. phagocytophila was found only in pooled nymphs samples (8%). Three genomospecies were identified, namely Borrelia afzelii, Borrelia garinii, and Borrelia valaisiana, in samples found positive for B. burgdorferi s. l. No sample was found positive for Borrelia burgdorferi sensu stricto.

Detection of Chlamydia pneumoniae in atherosclerotic coronary arteries.

Chlamydia pneumoniae has recently been associated with the development of coronary heart diseases by sero-epidemiological studies and by direct detection of the organism in atherosclerotic tissues. The aim of our study was to employ a semi-nested PCR approach to investigate the presence of C. pneumoniae in both normal and atherosclerotic coronary arteries of humans obtained at autopsy. Moreover, we have evaluated the role of infection with C. pneumoniae in relation to the extent of coronary atherosclerosis. One hundred and eighty coronary artery specimens were collected at autopsy from 60 consecutive subjects (three arterial segments from each subject). Atherosclerosis in each arterial segment was graded histologically by the Stary classification. Thirty normal coronary arteries were also taken at autopsy as control. PCR results evidenced the presence of C. pneumoniae DNA in atherosclerotic coronary arteries in 19 (31.7%) of 60 subjects examined, while none of the 30 subjects with non-atherosclerotic tissues was positive (p=0.001). Moreover, of the 180 atherosclerotic specimens examined, C. pneumoniae DNA was detected in 3.4% (2/59) of mild atherosclerotic lesions, and in 14.0% (17/121) of advanced atherosclerotic lesions (p=0.05). Our results demonstrate that the presence of C. pneumoniae DNA may be associated with the severity of coronary atherosclerosis.