Subclinical atherosclerosis and endothelial dysfunction in patients with polymyalgia rheumatica: a pilot study.

Objective: The aim of the study was to investigate endothelial function in treatment-naïve polymyalgia rheumatica (PMR) patients and its modification during steroid therapy, in relation to changes in clinical and laboratory parameters.Method: This prospective observational study involved patients with a new diagnosis of PMR according to provisional American College of Rheumatology/European League Against Rheumatism 2012 criteria, who were naïve to steroid therapy, and control subjects matched for age, gender, and comorbidities. All participants underwent clinical and vascular ultrasound evaluations at baseline and after 1, 3, 6, and 12 months of steroid therapy. For the study of endothelial function, we evaluated the brachial artery reactivity, which has emerged as the most well-established technique used in adults, by assessing flow-mediated dilatation (FMD), which measures the endothelium-dependent vasodilatation.Results: Sixteen newly diagnosed PMR patients were compared with a population of 16 matched controls. FMD values in all subjects showed an inverse correlation with the values of erythrocyte sedimentation rate and C-reactive protein. At baseline, the FMD of PMR patients was significantly lower than controls and remained significantly lower with respect to controls until the sixth month of therapy, despite a clinical improvement already being evident after 1 month of therapy.Conclusions: PMR is characterized by an important chronic subclinical inflammatory component. This pilot study demonstrates that affected patients show endothelial dysfunction that slowly responds to steroid therapy. Further studies are needed to investigate the clinical relevance of these observations and, in particular, to monitor the cardiovascular risk profile of PMR patients.

Association between peripheral arterial disease and cardiovascular risk factors: role of ultrasonography versus ankle-brachial index.

OBJECTIVE: Most studies on atherosclerotic processes include peripheral arterial disease diagnosis only if patients report symptoms suggestive of peripheral arterial disease and/or an instrumental demonstration of lower limbs perfusion deficit is provided, rather than the sole presence of atherosclerotic lesions localized at lower limbs, this attitude leading to ignore early stages of the disease. To overcome these limitations, we have proposed a new ultrasonographic semiquantitative score to better identify all disease stages. The aim of this study is to compare ultrasonography versus ankle-brachial index in the association between peripheral arterial disease and cardiovascular risk factors. PATIENTS AND METHODS: This cross-sectional observational study included subjects undergoing lower limbs evaluation through ultrasonography and ankle-brachial index determination because of symptoms suggestive of peripheral arterial disease or presence of known cardiovascular risk factors. Associations between ultrasonography and ankle-brachial index with cardiovascular risk factors were assessed by first fitting logistic regression models and then comparing the respective areas under the Receiver Operating Characteristic and 95% confidence intervals. RESULTS: The areas under the Receiver Operating Characteristic for each cardiovascular risk factors were consistently larger in magnitude for ultrasonography compared with ankle-brachial index, this comparison being statistically significant for age, male gender, smoking status, hypertension, diabetes mellitus and previous cardiovascular events. CONCLUSIONS: Our study demonstrates that ultrasonography is a better method to screen peripheral arterial disease respect to ankle-brachial index in order to identify all disease stages. These findings are useful in particular when including peripheral arterial disease as organ damage marker in cardiovascular risk stratification.

Atherosclerosis and cardiovascular involvement in celiac disease: the role of autoimmunity and inflammation.

OBJECTIVE: The aim of this review is to explore the evidence about the association among celiac disease (CD), atherosclerosis (AS) and cardiovascular (CV) diseases, and the role of inflammation in this connection. MATERIALS AND METHODS: A systematic literature search was conducted using PubMed, EMBASE, and Cochrane Library for the association among CD, AS and CV diseases. RESULTS: Several studies reported the association of CD with accelerated AS, as evidenced by the alterations of a number of parameters indicative of subclinical AS, as increased carotid artery intima-media thickness, endothelial dysfunction and increased arterial stiffness. In addition, recent evidence reported an increase of CV diseases prevalence in CD patients respect to controls, many of which including ischemic diseases as acute myocardial infarction and angina pectoris, as well as death from ischemic heart disease, and, more rarely, stroke for cerebrovascular involvement. Other not-ischemic CV diseases associated with CD are represented by dilated cardiomyopathy, atrial fibrillation, and myocarditis. CONCLUSIONS: On the basis of the reported association among CD, AS and CV diseases, we suggest to perform a more detailed CV risk assessment in all CD patients than what is currently being achieved in clinical practice, in order to scan and treat modifiable CV risk factors in these patients. In particular, we suggest to resort to instrumental techniques to detect AS in the subclinical stage, in order to prevent AS development and CV diseases in CD patients.

Focus on biological identity of endothelial progenitors cells.

Circulating Endothelial Progenitor Cells (EPCs) were discovered by Asahara et al in 1997 and defined as bone marrow CD34+/KDR+ cells endowed with angiogenic potentialities in vitro and in vivo. The most likely assumption is that EPCs consist of several cell subpopulations with functions targeted at accomplishing the post-natal neovascularization process in a synergic and complementary fashion. Indeed, the subsequent identification of numerous and differentiated hematic populations, characterized by the capacity to develop an endothelial phenotype, has posed a number of questions as to the real identity of EPCs. This concept does not represent a sterile speculation but rather it suggests important implications for the future practice of stem cell therapy. The aim of this report was to explore through a critical analysis the two main experimental methodologies, in vitro culture and flow cytometry, applied to EPCs, followed by a brief revaluation of the endothelial progenitors employing a globally functional approach.

Acetaminophen plus codeine compared to ketorolac in polytrauma patients.

INTRODUCTION: The management of pain in polytrauma patients is mandatory. While non-steroidal anti-inflammatory drugs (NSAIDs) represent the most used drugs in polytrauma patients, their use may be associated with an increased risk of haemorrhage. Opioids may represent a valid alternative to NSAIDs either alone or in combination with acetaminophen. Whether their efficacy is comparable to that produced by NSAIDs in polytrauma patients has never been studied. PATIENTS AND METHODS: 60 polytrauma patients were enrolled for this study. 30 patients were treated with acetaminophen 1000 mg plus codeine 60 mg tid for 24 hours (Group A), while the remaining 30 with ketorolac 10 mg qid for 24 hours (Group B). Pain intensity has been evaluated using an analogical visual scale (VAS) ranging from 0 (no pain) to 10 (very severe pain). The level of pain was valuated at enrolment (TO) as well as after 2 (T2), 12 (T12) and 24 (T24) hours from the starting of the analgesic therapy. Results obtained by the group A were compared with those reported by the group B. RESULTS: T0: Group A mean score was 6.4 +/- 1.5 compared with 6.6 +/- 1.5 of Group B (p= ns); T2: Group A mean score was 3.4 +/- 2.8, compared with 3.5 +/- 2.4 of group B (p = ns); T12: Group A mean score was 3.4 +/- 3.4, compared with 3.5 +/- 3 of Gorup B (p = ns); T24: Group A mean score was 2.9 +/- 1.5, compared to 3.0 +/- 1.6 of Group B (p = ns). All those drugs determined a significant reduction of pain intensity during the course of therapy. CONCLUSIONS: Acetaminophen plus codeine is effective in pain control in polytrauma patients at least in our series. It may represent a valid alternative to NSAIDs, especially in patients with a documented haemorrhage or with a high hemorrhagic risk.

Use of oxycodone in polytrauma patients: the "Gemelli" experience.

INTRODUCTION: This is the first study investigating the effect of oxycodone in polytrauma patients. The management of pain in polytrauma patients has become a very relevant issue. Nonsteroidal anti-inflammatory drugs (NSAIDs) represent the most used drugs in polytrauma patients, even though their use is associated with an increased hemorrhagic risk. Previous studies have demonstrated the efficacy of oxycodone for the treatment of acute pain. The aim of this study was to assess the efficacy of oxycodone administration in polytrauma patients, with minor injuries. PATIENTS AND METHODS: 15 polytrauma patients (10 males, mean age 40 +/- 13 years; 5 females, mean age 49 +/- 26 years) were admitted to the Emergency Department of the Catholic University, A. Gemelli Hospital in Rome, Italy. All patients underwent physical examination, FAST ultrasound, total body CT scanning and blood tests. Three patients had multiple costal fractures, three had pelvic fracture, two had tibial fracture, five had vertebral fractures, one patient had clavicle fracture and ulnar fracture, one patient a severe trauma of the left leg, which required amputation. Five patients also reported minor head trauma, with a Glasgow Coma Score (GCS) 15. All patients reported abdominal trauma, while none of them had severe thoracic or kidney damage. Patients with head trauma also underwent a second CT head scanning 12 hours after admission, which excluded the occurrence of cerebral damage. All patients were then treated with oral administration of oxycodone 10 mg two times per day (bid) for 3 days. Pain intensity, before and after the administration of oxycodone, was evaluated using a scale ranging from 0 to 10. RESULTS: The mean pain score at admission was 8 +/- 0.7. All patients reported significant pain improvement after the administration of oxycodone (8 +/- 0.7 vs 1.8 +/- 0.9; p < 0.0001). A dosage increase of oxycodone from 20 to 40 mg bid was required in only one patient with a clavicle fracture. The main side effects were light-headache (5 patients), constipation (4 patients) and nausea (3 patients). CONCLUSIONS: These data indicate that oxycodone is a safe and effective drug for pain relief in polytrauma patients without severe thoracic, kidney or brain damage.