Myocarditis: A Clinical Overview.

PURPOSE OF REVIEW: In this paper we will review the modern diagnostic approach to patients with clinically suspected myocarditis as well as the treatment modalities and strategy in light of up-to-date clinical experience and scientific evidence. RECENT FINDINGS: Rapidly expanding evidence suggests that myocardial inflammation is frequently underdiagnosed or overlooked in clinical practice, although new therapeutic options have been validated. Moreover, the available evidence suggests that subclinical cardiac involvement has negative prognostic impact on morbidity and mortality and should be actively investigated and adequately treated. Myocarditis represents a growing challenge for physicians, due to increased referral of patients for endomyocardial biopsy (EMB) or cardiac magnetic resonance (CMR), and requires a highly integrated management by a team of caring physicians.

Myocarditis and inflammatory bowel diseases: A single-center experience and a systematic literature review.

BACKGROUND: Myocarditis and inflammatory bowel diseases (IBD) are rare conditions, but may coexist. Myocarditis in IBD may be infective, immune-mediated, or due to mesalamine toxicity. A gap of knowledge exists on the clinical features of patients that present myocarditis in association with IBD, especially for endomyocardial biopsy-proven cases. Our aims are: 1) to describe the clinical characteristics of patients with an associated diagnosis of myocarditis and IBD in a single-center hospital, 2) to perform a systematic review of the literature of analogous cases. METHODS: We retrospectively analyzed data of patients followed up at the outpatient Cardio-immunology and Gastroenterology Clinic of Padua University Hospital, to identify those with an associated diagnosis of myocarditis and IBD. In addition, a systematic review of the literature was conducted. We performed a qualitative analysis of the overall study population. RESULTS: The study included 104 patients (21 from our single center cohort, 83 from the literature review). Myocarditis in IBD more frequently affects young (median age 31 years) males (72%), predominantly with infarct-like presentation (58%), within an acute phase of the IBD (67%) and with an overall benign clinical course (87%). Nevertheless, a not negligible quote of patients may present giant cell myocarditis, deserve immunosuppression and have a chronic, or even fatal course. Histological evidence of mesalamine hypersensitivity is scarce and its incidence may be overestimated. CONCLUSIONS: Our study shows that myocarditis in association with IBD, if correctly managed, may have a spontaneous benign course, but predictors of worse prognosis must be promptly recognized.

Low levels of endothelial progenitor cells correlate with disease duration and activity in patients with Behçet's disease.

OBJECTIVES: We tested whether Behçet's disease (BD) is characterized by alterations of circulating endothelial progenitor cells (EPCs),which are involved in vascular homeostasis and repair. METHODS: We enrolled 30 BD patients and 27 matched healthy controls. EPCs were defined and measured by flow cytometry according to the expression of CD34, CD133 and KDR. RESULTS: We show that BD patients had significantly lower levels of CD34+KDR+ and CD34+CD133+KDR+ EPCs than controls. We found significant negative correlations between EPC phenotypes and BD duration, while there were positive correlations between CD34+KDR+ EPCs and both BD activity scores and C-reactive protein. The lower EPC levels with increasing disease duration was shown in univariate analysis and in multivariable analysis adjusted for possible confounders. CONCLUSION: This is the first report that BD is associated with progressive EPC decline. Reduction of EPCs may represent a mechanism of induction and/or progression of vascular injury in these patients.

Inhibitory effect of synthetic cannabinoids on cytokine production in rheumatoid fibroblast-like synoviocytes.

OBJECTIVE: To verify whether synthetic cannabinoids (CP55,940 and WIN55,212-2) are able to exert an anti-inflammatory effect on rheumatoid fibroblast-like synoviocytes (FLS) by down-regulating cytokine production, and determine whether this effect could be mediated by CB1/CB2 cannabinoid receptors. METHODS: Interleukin-6 (IL-6) and interleukin-8 (IL-8) were assayed in the supernatant from cultured FLS by ELISA method before and after 3 hours of incubation with CP55,940 (10 microM) and WIN55,212-2 (10 microM). Co-stimulation of cells with the cannabinoid receptor antagonists was performed to evaluate receptor involvement in cytokine modulation. All the experiments were conducted in basal conditions and after 1 hour pre-incubation with 0.1 ng/ml IL-1beta. FLS expression of CB1 and CB2 receptor was studied by Western Blot analyses. RESULTS: Both CP55,940 and WIN55,212-2 induced a potent and significant reduction in IL-6 and IL-8 secretion from IL-1beta. stimulated FLS. Although FLS express CB1 and CB2 receptor, cannabinoid receptor antagonists did not significantly modify the inhibition of cytokines secretion induced by CP55,940 and WIN55,212-2. CONCLUSIONS: In vitro, CP55,940 and WIN55,212-2 exert a potent anti-inflammatory effect on rheumatoid FLS via a non-CB1/CB2 receptor mediated mechanism.

Paradoxical experience of hypnotic analgesia in low hypnotizable fibromyalgic patients.

The study investigated the differences in pain perception in highly (Highs) and low (Lows) hypnotizable patients with chronic benign pain undergoing hypnotic suggestions of analgesia. Self reports of pain intensity were collected in different groups of fibromyalgic patients: (1) Highs and Lows during pre-hypnosis, neutral hypnosis, suggestions for analgesia, posthypnotic conditions; (2) Lows during suggestions for analgesia administered after a mental stress instead of neutral hypnosis; (3) healthy Lows receiving nociceptive stimulation during hypnotic relaxation and suggestions of analgesia. The results showed that Highs and Lows differed in their response to suggestions, but significant analgesia was reported also by Lows. These individuals did not report any difference in pain perception between the sessions including mental stress and hypnotic relaxation. No change in pain perception was observed in healthy Lows during nociceptive stimulation associated with relaxation and suggestions for analgesia. In conclusion, the presence of chronic pain seems to be responsible for the paradoxical response of non hypnotizable patients to hypnotic suggestions.

Anti-TNF-alpha therapy in seven patients with Behcet's uveitis: advantages and controversial aspects.

Behcet's disease (BD) is a chronic, relapsing, multisystem disease. In some patients, ocular involvement can lead to severe vision impairment despite immunosuppressive therapy. Since high levels of circulating TNF-alpha have been found both in peripheral blood and aqueous humor of patients with active BD, we evaluated the efficacy of anti-TNF-alpha therapy in seven patients with severe ocular involvement resistant to previous treatment. Seven patients with sight-threatening relapsing uveitis refractory to immunosuppressive regimens received intravenously infliximab, at a dose of 3-5 mg/kg, on week 0-2-4 and then every 6-8 weeks, in combination with low-dose prednisone and methotrexate or azathioprine. Efficacy was assessed in terms of number and severity of relapses of posterior uveitis, visual acuity, and reduction of corticosteroids and immunosuppressive drugs. After a mean follow-up period of 23 months, the total number of relapses dropped to 6, compared to the 21 observed in an equivalent period of time before treatment. The visual acuity improved in 4 eyes, while it remained stable in 9. Therapy with infliximab considerably reduced the required daily dose of both corticosteroids and immunosuppressive drugs. In our experience infliximab proved to be safe and effective in controlling both the number and intensity of cases of posterior uveitis and the extraocular manifestations of BD. It also allowed a reduction of corticosteroids and immunosuppressive drugs required to control the disease. However, ocular and systemic manifestations tended to recur after drug withdrawal or when the interval between infliximab courses was longer than 8 weeks. Moreover, infliximab administration is costly and requires hospital admission.

Simvastatin inhibits cytokine production and nuclear factor-kB activation in interleukin 1beta-stimulated synoviocytes from rheumatoid arthritis patients.

OBJECTIVES: Recent studies demonstrated in vivo the effectiveness of statins in reducing the inflammatory response in rheumatic diseases, and still more recently, simvastatin has been reported to inhibit in vitro IL-6 and IL-8 production by unstimulated fibroblast-like-synoviocytes (FLS) from rheumatoid arthritis (RA) patients. However, no data are available on the effect of statins on the production of these cytokines induced by IL-1, which plays a crucial role in joint inflammation in the course of active RA in vivo. METHODS: In 12 RA patients, synovial tissue specimens were taken to obtain cultures of FLS. Cultures were incubated with IL-1 +/- simvastatin (5-50 micromol/l), and IL-6 and IL-8 production was evaluated (ELISA), also following the addition of mevalonate and its isoprenoid derivatives. Moreover, nuclear factor-kB (NF-kB) activation (immunocytochemistry and Western Blot analysis) were also evaluated. RESULTS: Culture incubation with IL-1 produced a dramatic increase (up to 40-fold) in cytokine production with respect to unstimulated cells. Simvastatin significantly inhibited (about 20%) IL-6 and IL-8 production from IL-1-stimulated FLS. This effect was completely reverted by the concomitant incubation with mevalonate or geranylgeraniol (but not farnesol or squalene). Moreover, simvastatin produced a clear-cut inhibition of IL-1-induced NF-kB activation. CONCLUSION: Simvastatin significantly inhibits the production of IL-6 and IL-8 also in IL-1-stimulated FLS, even though to a lesser extent than in unstimulated cells, via a HMG-CoA-reductase block with an interference in prenylation process and NF-kB activation. Our results further support the rationale for the use of statins in the treatment of rheumatoid synovitis.

Antiprothrombin antibodies: a comparative analysis of homemade and commercial methods. A collaborative study by the Forum Interdisciplinare per la Ricerca nelle Malattie Autoimmuni (FIRMA).

OBJECTIVE: Prothrombin (PT) is a target for antibodies with lupus anticoagulant (LA) activity, suggesting the possible application of anti-prothrombin antibody (aPT) assays in patients with antiphospholipid syndrome (APS). Different methods - both homemade and commercial - for the detection of aPT are available, but they seem to produce conflicting results. The purpose of this study was to compare the performance of different assays on a set of well-characterized serum samples. PATIENTS AND METHODS: Sera were gathered from 4 FIRMA institutions, and distributed to 15 participating centres. Forty-five samples were from patients positive for LA and/or anticardiolipin antibodies (aCL) with or without APS, and 15 were from rheumatoid arthritis (RA) patients negative for antiphospholipid antibodies. The samples were evaluated for IgG and IgM antibodies using a homemade direct aPT assay (method 1), a homemade phosphatidylserine-dependent aPT assay (aPS/PT, method 2), and two different commercial kits (methods 3 and 4). In addition, a commercial kit for the detection of IgG-A-M aPT (method 5) was used. RESULTS: Inter-laboratory results for the 5 methods were not always comparable when different methods were used. Good inter-assay concordance was found for IgG antibodies evaluated using methods 1, 3, and 4 (Cohen k > 0.4), while the IgM results were discordant between assays. In patients with thrombosis and pregnancy losses, method 5 performed better than the others. CONCLUSION: While aPT and aPS/PT assays could be of interest from a clinical perspective, their routine performance cannot yet be recommended because of problems connected with the reproducibility and interpretation of the results.

[Dante's Inferno and the McGill Pain Questionnaire]. / Dante, l'Inferno e il McGill Pain Questionnaire.

AIMS OF THE STUDY: To study the images which depict the damned's sufferings in Dante's Inferno, in their expression of the several meanings of "pain", the semantics of "pain" in the poem has been analyzed, eventually trying to determine whether the organization of punishments of Inferno may somehow mirror a disability scale. METHODS: A detailed analysis of the text was carried out, which proved a valuable tool for interpreting the organization of punishments as a possible disability scale. The semantics of pain in the Divine Comedy was studied through all the forms of the pain descriptors (included the archaic terminological forms) from the Italian version of the McGill Pain Questionnaire (MGPQ) by Maiani and Sanavio. RESULTS AND CONCLUSIONS: In Dante's Inferno a classification of pain is provided, based on the experience of sufferings; Dante's images seem not only instrumental to investigating the sensorial but also the affective and intellectual spheres by introducing a number of characters and describing the impact of punishment onto their souls. Our research highlighted that 46 out of 78 terms from the MGPQ are present in Inferno, though with different forms; the Groups the MGPQ is divided into are also represented with the exception of Group XII, the most frequently detected being Groups XIII-which studies the fear-related sensations in the emotional sphere - XIV, XIX and XX. The great attention emerges that Dante devoted to describing simple sensorial experiences as well as the way punishments affected the soul. As a whole, the terms pertaining to the sensorial sphere are the most frequently encountered. The lack of motion which increases circle after circle in Hell, well matches the progressing physical and psychological impairment caused by some invalidating diseases. Noticeably, Dante created such a complex system centuries before the studies were released on the impact of pain and its quantitative and mostly qualitative definition. In conclusion, this interpretation suggests that the writing on the door to Hell which leads Dante into the inaccessible world of "the miserable race, those who have lost the good of intellect", may well be the title of a precise and incredibly up to date classification of painful sensations which are wonderfully described with simple and suggestive examples each time transforming into powerful images. ..."Through me road to the city of desolation, / Through me the road to sorrows diuturnal, / Through me the road among the lost creation".

[Efficacy of Cellfood's therapy (deutrosulfazyme) in fibromyalgia]. / Efficacia del trattamento con Cellfood (deutrosulfazyme) nella fibromialgia.

OBJECTIVE: To assess the efficacy of Cellfood's therapy in the treatment of fibromyalgia. METHODS: This study was a single-blind, cross-over, randomized placebo-controlled trial. Forty female were selected from 320 cases investigated in the period 2003-2005 of June. To be included in this study, it was required that the diagnosis of fibromyalgia was made by a specialist in according to the ACR classification criteria of 1990. The patient's age was between 35-47 years, the choice of criteria were the absence of improvements with the conventional therapy and the normality of medical check-up. The patients were divided into two different-groups of thirty-one and nine subjects, each-one (group A) treated with Cellfood for six months in according to the Eurodream's scheme, and each-other (group B) treated with placebo for three months and successively with Cellfood for three months. Besides we have estimated the tender points with algometer and the health status of women with the Fibromyalgia Impact Questionnaire (FIQ) at the baseline (T0) and at three (T1) and six month (T2). RESULT: The group A had an appreciable improvement of the parameters at T1 statistically significant compared to the group B, while we observed a stability of they at T2 on the group A and an improvement of the parameters of the group B statistically non significant compared to each-one. CONCLUSION: Our result suggest that the Cellfood's therapy improve fibromyalgia symptoms and health-related quality of life.

[The hand: a reflection of arthritis]. / La mano: lo specchio dell'artrite.

Hand joint involvement in rheumatic diseases is often precocious and predominant as compared to other skeleton-muscular regions. Clinical examination not always allows for easy detection of fluid outpouring and synovial involvement, and undoubtedly does not allow to diagnose pathognomonic bone alterations of several rheumatic conditions. Articular ultrasonography is an innocuous methodology, easily reproducible and directly applied by a rheumatologist. The aim of this vignette is to present ultrasonography elementary lesions of the hand for a prompt diagnosis.

Homocysteine enhances cytokine production in cultured synoviocytes from rheumatoid arthritis patients.

OBJECTIVE: Hyperhomocysteinemia is commonly observed in Rheumatoid Arthritis (RA) patients, thus putatively accounting in part for the high rate of cardiovascular events in these subjects. Homocysteine (Hcy) is known to exert a pro-inflammatory effect putatively contributing to the progression of atherosclerotic lesions by cytokine production from several vascular cell-types. In order to evaluate the possibility that Hcy may play a direct pro-inflammatory activity also in the joints of RA patients, we investigated: (i) the joint concentration of Hcy, and (ii) the effect of Hcy on cytokine production by unstimulated and IL-1beta-stimulated human RA cultured synoviocytes. METHODS: In 5 RA and 5 controls subjects, Hcy was measured in the blood and knee synovial fluid, and specimens of synovial tissue were taken to obtain cell cultures. Cultures were incubated with Hcy (10-100 micromol/l) +/- IL-1beta, and IL-6 and IL-8 concentrations were evaluated in the supernatants (ELISA) together with the activation of nuclear factor-kB (NF-kB) (immunocytochemistry). RESULTS: Hcy was present in synovial fluids, with a mean concentration significantly higher in RA patients than in controls (9.0 +/- 1.1 vs 5.9 +/- 1.2 micromol/l). Hcy enhanced IL-6 and IL-8 production in RA synoviocytes only (up to 35%). Moreover, Hcy produced a clear-cut activation of NF-kB in rheumatoid cells only. CONCLUSION: Hcy enhances IL-1-dependent cytokine production by rheumatoid synoviocytes at a concentration measurable in RA joints in vivo. Thus, in RA patients, Hcy may not only represent an important risk factor for the progression of cardiovascular diseases, but it may also contribute to the joint damage.

Increased titres of IgM anti-heparan sulfate antibody in Behçet's disease.

OBJECTIVE: Endothelial dysfunction is crucial in Behçet's disease (BD) pathogenesis, and measures of endothelial damage are potential markers of BD activity. Heparan sulfate (HS) is the most abundant proteoglycan in the endothelial cells, and anti-HS antibodies have been reported in subjects with vascular damage, due to vasculitis/vasculopathy. The aim of our study was to measure serum anti-HS antibodies in patients with BD and to determine whether their presence correlates with disease activity or clinical manifestations. METHODS: Thirty-two patients with BD (21 men, 11 women) (median age 36.81+/-12.0 years) were considered. Of these, 13 had clinically active disease at the time of study. The mean disease duration was 7.31+/- 8.2 years (median 6 years). Anti-HS antibodies were measured by ELISA. As controls, sera from 40 sex- and age-matched healthy subjects, and 78 age-matched patients with systemic lupus erythematosus (SLE) were studied. RESULTS: Anti-HS IgM antibody titres were significantly higher in BD patients compared to healthy subjects (p=0.016) and SLE controls (p=0.0008). No differences in anti-HS IgG antibody titres were observed among the 3 groups. Using categorical data, increased titres of IgM anti-HS antibodies were significantly more frequent in patients with BD vs patients with SLE (p=0.02). The presence of the antibodies, of either isotype, did not correlate with disease duration, disease activity or clinical manifestations. CONCLUSIONS: BD patients have increased IgM anti-HS antibody titres compared to healthy and SLE controls. These antibodies did not correlate with disease activity or discrete clinical features, but might be relevant for pathogenic mechanisms of the disease.

[Anabolic effects and inhibition of interleukin 6 production induced by neridronate on human osteoblasts]. / Effetti anabolici e di inibizione della produzione di interleuchina 6 indotti dal neridronato in colture di osteoblasti umani.

UNLABELLED: Bisphosphonates (BPs) are pharmacological compounds widely used in the treatment of a variety of bone-related diseases, particularly where the bone-turnover is skewed in favour of osteolysis. The mechanisms by which BPs reduce bone-resorption directly acting on osteoclasts (OCs) are now largely clarified even at molecular level. The researches concerning the BPs effects on osteoblasts (OBs) have instead shown variable results. OBJECTIVES: We have investigated the efficacy of neridronate (NER), an amino-BP, as anabolic agent on human OBs. Moreover, we have tried to verify if NER is able to negatively modulate the production of IL-6 on OBs stimulated or not by the pro-inflammatory cytokine IL-1beta. METHODS: We have tested if different concentrations of NER (from 10-11 M to 10-3 M), added to primary human OB cultures, could affect the cells number, the endogenous cellular alkaline phosphatase (ALP) activity, the collagen I (COL-I) synthesis, the formation of mineralized nodules and the IL-6 production. Our experimental approach was performed testing a wide range of NER concentrations because, under physiological conditions, OBs seems to be exposed to variable and transient levels of the drug. RESULTS: Our results show that NER doesn't negatively affect in vitro the viability, proliferation and cellular activity of human OBs, even after 20 days of exposure to concentrations < or =10-5 M (therapeutic dose). In addition, NER seems to enhance the differentiation of cultured OBs in mature bone-forming cells. A maximum increase of COL-I synthesis (+25% after 4 days; p < 0.05), ALP activity (+50% after 10 days; p < 0.01) and mineralized nodules (+48% after 20 days; p < 0.05) was observed in cultures treated with NER 10-8 M. A maximal reduction of IL-6 secretion (-24% on IL-1beta stimulated cultures and -29% on unstimulated cultures) was observed for NER 10-9 M. CONCLUSIONS: These results encourage the use of neridronate in therapy of demineralizing metabolic bone disorders.

Immunosuppressive therapy prevents recurrent pericarditis.

OBJECTIVES: This study reviews the clinical outcome of a series of patients with recurrent pericarditis before and after immunosuppressive therapy. BACKGROUND: Despite anti-inflammatory treatment, some patients with acute pericarditis experience repeated relapses of the disease. The use of steroids for the treatment of recurrent pericarditis remains controversial. METHODS: Twelve patients (4 women, 8 men; mean [+/- SD] age 35.9 +/- 17.2 years, range 15 to 65) with recurrent pericarditis unrelated to any systemic disease were selected. All 12 patients previously received ineffective short-term courses of low dose steroids and had a total of 39 relapses during a mean follow-up period of 14.2 months (range 4 to 50). A 3-month course of treatment with prednisone, at an immunosuppressive dosage, was started (1 to 1.5 mg/kg body weight per day for 4 weeks, then gradually withdrawn). When prednisone reduction was undertaken, all patients started a 5-month course of treatment with aspirin (1.6 g/day until steroid suspension, then reduced to 0.8 g/day). RESULTS: During a mean follow-up period of 41.6 months (range 7 to 104), immunosuppressive treatment with high dose prednisone resulted in stable remission in all except one patient, who experienced one relapse. In this patient, the addition of azathioprine to prednisone induced a persistent remission, which remained after 1-year follow-up. During treatment, three patients had severe steroid-related adverse effects that in two patients required replacement of prednisone with azathioprine and cyclophosphamide, respectively. This variation in the immunosuppressive regimen did not modify the favorable clinical outcome. CONCLUSIONS: The dose and duration of steroid treatment are critical factors in preventing recurrent pericarditis. High dose prednisone with aspirin should be considered in the treatment of recurrent pericarditis resistant to anti-inflammatory therapy. Cyclophosphamide or azathioprine should be reserved for patients who do not respond to high dose prednisone or who experience severe complications related to steroid therapy.

Altered thiol pattern in plasma of subjects affected by rheumatoid arthritis.

OBJECTIVE: Rheumatoid arthritis (RA) is a chronic inflammatory disease which involves the synovial membrane of multiple diarthroidal joints causing damage to cartilage and bones. The damage process seems to be related to an overproduction of oxygen reactive species inducing an oxidative perturbation. Since sulfhydryl groups are primary antioxidant factors, we were interested in investigating the balance of plasma sulfhydryl/disulfides in patients with active RA compared to healthy control subjects. METHODS: Twenty-one patients with RA and 15 age-matched controls were studied. Plasmatic sulfhydryl groups and their disulfide form concentrations were measured by spectrophotometry or HPLC. RESULTS: RA patients showed significantly lower levels of plasma protein sulfhydryls and cysteinyl-glycine compared to healthy controls (p < 0.001). Conversely, cystine and homocystine, and protein-bound cysteine and homocysteine were significantly increased (p < 0.005 in disulfides forms and p < 0.05 in protein mixed disulfides forms). There was a significant correlation between some clinical data (ESR, number of tender/swollen joints) and some of the parameters studied. CONCLUSION: The results of this study indicate a biochemical disturbance of plasma sulfhydryl/disulfides balance in patients with RA compared to controls with an increase in some oxidised forms (disulfides and protein mixed disulfides) and a decrease in free thiols. The increase in total homocysteine, correlated to the higher risk of cardiovascular diseases in RA patients, is associated with higher levels of the oxidised forms, disulfides and protein-thiol mixed disulfides.

Effects of 4-year treatment with once-weekly clodronate on prevention of corticosteroid-induced bone loss and fractures in patients with arthritis: evaluation with dual-energy X-ray absorptiometry and quantitative ultrasound.

The aim of this placebo-controlled study was to determine whether once-weekly clodronate could prevent osteoporosis in patients with arthritis at the start of corticosteroid therapy. One hundred sixty-three patients, 18 to 90 years of age, with rheumatoid or psoriatic arthritis, were randomly assigned to receive either clodronate (100 mg im/week) plus calcium and vitamin D (1000 mg and 800 UI, respectively) or calcium and vitamin D alone. Patients had started therapy with prednisone or its equivalent within the previous 100 days and had bone mineral density <2.5 SD below mean young normal values at the lumbar spine or femoral neck. The primary outcome was the difference between the two treatment groups at months 12, 24, 36, and 48 in the mean percentage change from baseline in the bone mineral density of the lumbar spine, femur (neck and total), and total body. Secondary measurements included changes in the stiffness index evaluated by ultrasound measurements and the rate of new vertebral fractures. The bone density and stiffness did not change significantly in the clodronate plus calcium and vitamin D group, whereas it declined significantly in the calcium plus vitamin D group. The difference between treatment groups at 48 months in the mean change from baseline was 8.78 +/- 1.4% for the lumbar spine (P < 0.01), 7.31 +/- 1.12% for the femoral neck (P < 0.01), 7.92 +/- 1.93% for the trochanter (P < 0.01), 8.39 +/- 1.80% for total femur (P < 0.01), 6.94 +/- 1.09% for total body (P < 0.01), and 9.38 +/- 2.21% for stiffness of os calcis (P < 0.01). Depending on the skeletal regions evaluated, 85 to 98% of patients treated with clodronate had a densitometric change lower than the lowest significant densitometric difference. One hundred percent of patients treated with calcium plus vitamin D had a densitometric decrease greater than the lowest significant difference. The relative risk of vertebral fractures and multiple vertebral fractures in the clodronate group compared to the calcium plus vitamin D group was 0.63 (0.35-0.98, 95% CI) and 0.25 (0.15-0.91, 95% CI), respectively. We concluded that pulsatory administration of im clodronate once weekly is a safe therapy for preventing corticosteroid induced osteoporosis in patients with arthritis.

Dosage and characterization of circulating DNA: present usage and possible applications in systemic autoimmune disorders.

The discovery of extracellular nucleic acids in the circulation was firstly reported in 1948. In the last few years it has been demonstrated that the entire spectrum of genetic changes seen in primary tumors could also be detected in the serum of patients with solid tumors. This observation has also opened up exciting possibilities for tumor detection and monitoring. More recently investigators started looking for other forms of non-host DNA in the plasma/serum so that in 1997 the presence of fetal DNA in the plasma/serum of pregnant women was demonstrated. This finding suggested that maternal plasma fetal DNA would be a very valuable material for noninvasive prenatal diagnosis and monitoring. It has been also postulated that the presence of the two-way trafficking of nucleated cells and free DNA between the mother and fetus may have potential implications for the development of certain autoimmune diseases. Concerning autoimmune disorders, Tan was the first author to describe the presence of high levels of circulating DNA in patients with systemic lupus erythematosus (SLE) in 1986. Later on different authors demonstrated that elevated levels of serum DNA was also present in patients with other diseases including rheumatoid arthritis. We have analyzed both circulating free DNA and DNA extracted from nucleated blood cells in scleroderma and in lupus patients but, by using gel electrophoresis, we were able to define the pattern of the DNA, instead of simply dosing its amount in the circulation. We have found that SLE and SSc have anomalous patterns of DNA both in serum and in the Buffy-coat and that these patterns are typical for each disorder. It is possible that understanding the biological significance of the diversity in DNA pattern exhibition in white blood cells may give new insights into the pathophysiology of autoimmune disorders. It is also conceivable that circulating and immune-competent cellular DNA markers might offer the promise of precise quantitative analysis useful for diagnostic purposes, without the need to establish difficult cutoffs as is necessary for protein markers.

Analysis of HLA DP, DQ, and DR alleles in adult Italian rheumatoid arthritis patients.

We analyzed the distribution of DRB1, DQA1, DQB1, and DPB1 allelic variants in 48 rheumatoid arthritis (RA) patients, compared with 109 Italian random controls, using PCR amplification and hybridization with specific oligonucleotides. We confirm the previously reported increase of DR4 specificity, in comparison with healthy Italian individuals. In particular, we find a statistically significant positive association of DRB1*0401 and DRB1*0404 alleles with RA. However, when we compare the DR4+ groups, none of the DRB1*04 alleles is increased in the RA group. By sequence analysis, performed on 10 patients, we demonstrate that the DRB1*04 genes of RA show no difference from the DRB1*04 sequences previously published. From the molecular analysis of the other DRB1 polymorphic variants, we find a trend of positive association of DRB1*0101 in DR4-negative patients versus DR4-negative healthy controls and, in the group of DR4-negative and/or DR1-negative patients, a similar increase of DRB1*06. Also, we observe in RA patients a statistically significant increase of DQA1*0301 and DQB1*0302 accompanied by a significant decrease of DQA1*0201, DQA1*0501 and DQB1*0201. Finally, from the analysis of DPB1 gene, it can be assessed that the distribution of DPB1 alleles does not differ significantly between RA patients and healthy controls.