Night time blood pressure and cardiovascular structure in a middle-aged general population in northern Italy: the Vobarno Study

The aim was to determine, in a cross-sectional study, the relation between structural alterations in the heart and carotid arteries, and blood pressure (BP) changes from day to night time, measured by ambulatory BP (ABP). In 225 untreated subjects (107 F, 118 M, age range 48-64 years) and 59 treated subjects (24 M, 35 F, age range 50-64), living in a small town of northern Italy (Vobarno, Brescia) carotid intima media thickness as well as the occurrence of plaque, were evaluated by ultrasound. Echocardiographic left ventricular (LV) mass was measured according to the Penn Convention. BP was determined by clinic measurement and by 24-h non-invasive ABP monitoring. Subjects were divided in two groups, according to the decrease of night time systolic BP (SBP) "dippers" (SBP decreased by at least 10% during night time) and "non-dippers" (decrease of night time SBP <10%). The intima-media thickness in the common carotid, in the carotid bifurcation, in the internal carotid artery and average intima-media thickness were significantly greater in untreated non-dippers as compared with dipper subjects (ANOVA P < 0.05). A significantly higher prevalence of plaque was observed in untreated non-dippers as compared with dippers (P = 0.002). After adjusting for age, sex, 24-h SBP, and smoking, IMT in the carotid bifurcation and average intima-media thickness remained significantly greater in non-dipper subjects (P < 0.05 for all comparisons). No significant differences in LV mass were observed between dippers and non-dipper subjects. In conclusion, in a general population of unselected middle-aged subjects, night time BP values, among other risk factors, seem to represent an important determinant of carotid wall structure.

Factors affecting the efficacy of intraarticular corticosteroid injection of knees in juvenile idiopathic arthritis

OBJECTIVE

To determine in a prospective analysis whether baseline demographic, clinical, and laboratory variables predict the outcome of intraarticular corticosteroid (IAC) injection of the knees in children with juvenile idiopathic arthritis (JIA).

METHODS

We studied consecutive patients who met the criteria for the diagnosis of JIA and received their initial injection of triamcinolone hexacetonide in one or both knees. Predictor variables included sex, age, age at onset of JIA, onset subtype, disease duration, drug therapy at the time of IAC injection, physician and parent global assessment of disease status, Childhood Health Assessment Questionnaire disability index, erythrocyte sedimentation rate (ESR), C-reactive protein, involvement of other joints besides knees, amount of fluid aspirated, and dose of IAC injected. The primary outcome measure was persistence of complete clinical response at 6 months, i.e., no evidence of synovitis clinically.

RESULTS

Ninety-four patients were available for analysis. At 6 months after the IAC injection, 65 (69%) patients showed a sustained complete clinical response, whereas 29 (31%) had had a recurrence of joint inflammation. Univariate statistical analyses showed that patients who had a sustained clinical response had a significantly higher ESR than those who did not (p = 0.023). The ESR was the only variable that remained in the best-fit model from multivariate logistic regression analysis (OR 2.61, p = 0.049).

CONCLUSION

Our findings indicate that patients with JIA who have a higher ESR are more likely to benefit from IAC injection of the knees.

Discordance between proxy-reported and observed assessment of functional ability of children with juvenile idiopathic arthritis

OBJECTIVE

To determine the level of agreement between parents and clinicians in rating dysfunction in children with juvenile idiopathic arthritis (JIA).

METHODS

A parent of each patient completed the Italian version of the Childhood Health Assessment Questionnaire (CHAQ). Subsequently, an examiner assessed, in a specially equipped room, the child's performance of tasks as described by the CHAQ. Demographic and clinical variables were recorded for all patients.

RESULTS

Seventy consecutive JIA patients and their parents were included. The mean proxy-reported and observed CHAQ score was 0.64+/-0.53 and 0.47+/-0.62 respectively, the difference ranging from -1.75 to 1.5. There were 30 cases (43%) of agreement (difference < or =0.25 CHAQ units) between the parent's and clinician's ratings, whereas in 40 cases (57%) there was discordance (difference >0.25 CHAQ units). In 30 cases the parent rated the child's functional ability as worse than that observed by the clinician (i.e. the parent underestimated the child's function), whereas in 10 cases the parent rated the child's functional ability as better than that observed by the clinician (i.e. overestimated the child's function). Multivariate regression analysis showed that children's functional ability was overestimated by parents with increasing erythrocyte sedimentation rate and global articular severity score and underestimated with increasing level of pain. Among the functional areas of the CHAQ, the level of agreement was poorest in the areas of eating and hygiene and was best for activities.

CONCLUSIONS

Discordance between proxy-reported and observed functional ability was frequent in our patients with JIA. The children's functional ability was overestimated by parents as the severity of arthritis increased and underestimated as the level of pain increased.

Apolipoprotein B Arg3500Gln mutation prevalence in children with hypercholesterolemia: a French multicenter study

BACKGROUND

Familial defective apolipoprotein B-100, a dominantly inherited form of hypercholesterolemia caused by a single Arg3500Gln mutation, is silent in childhood but may confer a high risk of cardiovascular disease in adulthood. The objective was to determine the prevalence of familial defective apolipoprotein B-100 in hypercholesterolemic French children and to provide a basis for targeting screening efforts in this population.

METHODS

One hundred ninety children attending 13 pediatric clinics distributed throughout France were included based on the presence of type IIa hypercholesterolemia with a plasma low-density lipoprotein-cholesterol level of more than 130 mg/dL. The Arg3500Gln mutation was detected in dried blood spots using a polymerase chain reaction assay combined with enzymatic restriction.

RESULTS

Three hyperlipidemia phenotypes were found: monogenic dominant pure hypercholesterolemia (n = 117), polygenic hypercholesterolemia (n = 43), and combined hyperlipidemia (n = 11). Three unrelated children were heterozygous for the Arg3500Gln mutation; all three had monogenic dominant pure hypercholesterolemia (3/94 families; 3.2%), yielding a prevalence of 1.83% (3/164) in hypercholesterolemic children, which is similar to prevalences reported in European adults.

CONCLUSIONS

The familial defective apolipoprotein B-100 mutation was common (1/31) in children with a phenotype of familial hypercholesterolemia, supporting screening in this population with the goal of preventing premature cardiovascular events.

The Italian version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report herein the results of the cross-cultural adaptation and validation into the Italian language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Italian CHAQ was already published in the literature and was therefore revalidated while the Italian CHQ was fully cross culturally adapted with 3 forward and 3 backward translations, and than validated. A total of 1,192 subjects were enrolled: 404 patients with JIA (16% systemic onset, 31% polyarticular onset, 21% extended oligoarticular subtype, and 32% persistent oligoarticular subtype) and 788 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Italian version of the CHAQ-CHQ are reliable, and valid tools for the functional, physical and psychosocial assessment of children with JIA.

[Alkaline phosphatase level and bone density in Scheuermann's disease and in adolescent idiopathic scoliosis]

Authors made a comparison between 167 suffers from Scheuermann's disease (SD), 70 adolescence idiopathic scoliosis (AIS) and 132 age, sex, height, weight, pubertal developmental stages (Tanner stages) matched controls. The height percentile in 130 cases was also determined. The bone mineral density (BMD) was measured by pQCT on the non dominate sided radial bone. The alkaline phosphatase (AP) level increased at the beginning of puberty and in the puberty in SD. In SD the trabecular Z-score of BMD was significantly decreased in Tanner stage 1 to 4 in both boys and girls. It was not found any significance difference, however, in Tanner stage 5, while in AIS girl no significance decrease of BMD was found. In SD good correlation could be demonstrated between increase in AP and decrease in trabecular Z score r = 0.2, while did not correlate with height percentile. The AP level's increase, and radiomorphometric data of SD severity (intervertebral space narrowing and antero-posterior diameter increase of vertebral body) shows a significant correlation with decreased trabecular Z-score in the period of prepuberty.

The extended oligoarticular subtype is the best predictor of methotrexate efficacy in juvenile idiopathic arthritis

OBJECTIVE

To determine whether demographic, clinical, and laboratory variables measurable at baseline predict the clinical efficacy or major toxic effects of methotrexate (MTX) therapy in children with chronic arthritis.

STUDY DESIGN

Patient eligibility criteria: (1) monitored in our unit between 1986 and 1996 with a diagnosis of chronic arthritis and (2) treatment with MTX as the sole second-line agent and for at least 6 months. Outcomes investigated: (1) short-term (6-month) clinical response, (2) complete disease control, (3) disease relapse after MTX discontinuation after complete disease control, (4) aminotransferase elevation, (5) gastrointestinal toxicity. Independent variables that showed significant results with univariate tests or were clinically relevant for each outcome underwent multiple logistic or Poisson regression analyses.

RESULTS

Eighty patients were available for analysis. The disease onset subtype was systemic in 37 patients, polyarticular in 20 patients, and oligoarticular in 23 patients (all with polyarticular course: extended oligoarticular subtype). The extended oligoarticular subtype was the best predictor for both the short-term clinical response (odds ratio 6.80, P =.02) and, together with a better functional ability, the complete disease control (rate ratio 3.85, P =.03 and rate ratio 3.29, P =.006, respectively). Patients with this subtype of chronic arthritis tended to have earlier, and more frequently, a disease relapse after MTX discontinuation. Thrombocytosis was the only significant risk factor for liver biochemical abnormalities (rate ratio 2.94, P =.008), whereas no variable yielded significant results for gastrointestinal toxicity.

CONCLUSION

Patients with extended oligoarticular chronic arthritis were more likely to benefit from MTX therapy and to have a relapse after treatment discontinuation, suggesting that MTX is distinctly more effective in this subset of chronic arthritis.

Efficacy of folinic acid in reducing methotrexate toxicity in juvenile idiopathic arthritis

OBJECTIVE

To investigate the efficacy of folinic acid in reducing the side effects associated with methotrexate (MTX) therapy in children with juvenile idiopathic arthritis (JIA) and to determine whether folate supplementation may reduce the benefit of MTX administration.

METHODS

This was a retrospective, non-controlled study. Inclusion criteria were: 1) diagnosis of JIA according to the Durban 1997 criteria; 2) treatment with low to intermediate doses of MTX (10-20 mg/m2/week) as the sole second-line agent for at least 6 mos.; and 3) supplementation with folinic acid (2.5-7.5 mg) in a single weekly dose 24 hrs after MTX administration. All patients were started on folinic acid only after the development of a side effect. Exclusion criteria were: treatment with higher doses of MTX (> 20 mg/m2/week). The outcomes investigated were: hepatotoxicity (liver transaminase increase), gastrointestinal toxicity, disease flare, and clinical remission. The number of episodes per patient-year of MTX treatment of each outcome before and after folinic acid supplementation was compared by the Wilcoxon matched pairs test.

RESULTS

A total of 43 children with JIA were included in the study. The mean duration of treatment before and after folinic acid supplementation was 1.1 years and 1.8 years, respectively. After the start of folinic acid supplementation, the mean number of episodes per patient-year of hepatotoxicity and gastrointestinal toxicity decreased from 2.30 to 0.32 (p < 0.001) and from 1.09 to 0.29 (p = 0.002), respectively. The mean number of disease flares and clinical remissions per patient-year did not change significantly.

CONCLUSION

In our JIA patients, folinic acid supplementation resulted in a significant reduction in the most common side effects of MTX, without affecting the clinical efficacy of the drug.

Responsiveness of clinical measures in children with oligoarticular juvenile chronic arthritis

OBJECTIVE

To compare the relative responsiveness of outcome measures in children with oligoarticular course juvenile chronic arthritis (JCA).

METHODS

Twenty-six consecutive children with JCA and < or =4 joints involved were assessed at admission and after 3 months of followup. Outcome measures included physician and parent global assessments, functional ability as measured by the Childhood Health Assessment Questionnaire (CHAQ), articular variables, and laboratory indicators of systemic inflammation. Responsiveness was calculated with the standardized response median, the effect size, and the Guyatt method.

RESULTS

The physician global assessment of disease activity, the active joint count, the global articular severity score, and the number and score of swollen joints proved consistently more responsive with either responsiveness measure used. The parent global assessment of the child's well being, the scores of joints with pain/tenderness and limited range of motion, and the number of joints with limited range of motion showed intermediate responsiveness. The CHAQ, morning stiffness, and laboratory indicators of systemic inflammation were the least responsive measures.

CONCLUSION

The subjective estimation of disease activity by the physician and the articular variables were the more responsive outcome measures in children with oligoarticular JCA. The assessment of functional ability as measured by the CHAQ showed a poor sensitivity to clinical change in this subset of patients with JCA.

Ischemic necrosis of bile ducts complicating Schönlein-Henoch purpura

Gastrointestinal complications of Schönlein-Henoch purpura are frequent and sometimes severe. However, there seem to be no reports of liver involvement. A child is described in whom Schönlein-Henoch purpura was complicated by bile duct lesions, resulting in biliary cirrhosis and requiring liver transplantation. At surgical removal, the liver had lesions of bile ducts and of adjacent small blood vessels in the hilum, very similar to those complicating hepatic artery thrombosis after liver transplantation. These findings suggest that Schönlein-Henoch purpura can be complicated by vasculitis of the peribiliary vessels resulting in ischemic necrosis of the bile ducts. Schönlein-Henoch purpura can be added to the list of causes of ischemic cholangiopathies.

Marked and sustained improvement two years after autologous stem cell transplantation in a girl with systemic sclerosis

Autologous transplantation of hematopoietic stem cells has recently been proposed as a possible treatment for autoimmune diseases that are associated with a very severe prognosis. A 12-year-old girl who, since 4 years of age, had systemic sclerosis with progressive pulmonary involvement underwent autologous peripheral blood-derived stem cell transplantation (aPBSCT) using CD34+ selection, cyclophosphamide, and the infusion of the monoclonal antibody CAMPATH-1G. Following transplantation, in the absence of any treatment other than symptomatic therapy, the patient's exertional dyspnea and alveolitis disappeared and she experienced a marked improvement in skin score, height velocity, and general well-being that has persisted 2 years after the transplantation procedure. Autologous PBSCT associated with the infusion of the monoclonal antibody CAMPATH-1G appears to be a useful therapy for otherwise intractable forms of progressive systemic sclerosis.

Responsiveness of outcome measures in juvenile chronic arthritis. Italian Pediatric Rheumatology Study Group

OBJECTIVE

To examine the responsiveness of the disease activity measures more commonly used in juvenile chronic arthritis (JCA) clinical trials.

METHODS

Data were obtained from an open-label, non-controlled, multicentre trial designed to investigate the efficacy of methotrexate (MTX) in children with JCA. Outcome measures, including physician and parent global assessments, functional ability measures, articular variables, and laboratory indicators of systemic inflammation, were assessed at baseline and after 6 months of MTX treatment in 132 patients. Responsiveness of endpoint variables was evaluated by assessing the effect size (ES) and the standardized response median (SRM).

RESULTS

Physician and parent global assessments were the more responsive instruments, showing ES and SRM above 1.0. Erythrocyte sedimentation rate, C-reactive protein, functional status measures and articular variables showed intermediate responsiveness. Morning stiffness, haemoglobin and platelet count were the least responsive instruments.

CONCLUSION

The results of our analysis indicate that subjective estimations of the disease activity, either by the physician or parents, are the most responsive instruments in the assessment of the therapeutic response in children with JCA. The responsiveness of outcome measures in JCA should be further investigated in prospective controlled studies.

Motor representation of the hand in the human cortex: an f-MRI study with a conventional 1.5 T clinical unit

The purpose of this study was to show a gradient of possible bilateral activation for movements of the non-dominant vs. dominant hand, as well as for areas involved in complex vs. simple hand movements. A standard 1.5 T magnetic resonance imaging (MRI) system has been utilized to localize the cortical motor hand areas, using the blood oxygen level dependent contrast (BOLDc) technique and single-section fast low-angle shot (FLASH) imaging. Ten normal right-handed subjects volunteered for the study. The motor tasks consisted of simple (flexion-extension) finger movements of either hand, and complex movements (finger-to-thumb opposition in a repeating, pre-planned sequence) of the non-dominant hand. Simple movements caused contralateral activation of the primary motor area (MA); ipsilateral activation was observed for the non-dominant hand only. Supplementary motor area (SMA) was also activated, with a clear contralateral prevalence. The ratio of bilateral activation of MA did not change with complex movements of the non-dominant hand, while SMA as well as lateral premotor area were largely bilaterally activated in this task. In conclusion, the ipsilateral MA is activated for movements--even simple--performed with the non-dominant hand. There is widespread functional activity, involving both contralateral and ipsilateral SMA, for complex movements.

Radiologic progression in patients with juvenile chronic arthritis treated with methotrexate

We investigated the rate of radiologic progression, as measured by carpal length, in 26 children with juvenile chronic arthritis who were treated with methotrexate. After 2 years of treatment, the carpal length was significantly more deteriorated in nonresponders in both the "better" wrist (P = .001) and the "worse" wrist (P = .005). These results show that methotrexate may have a "disease modifying" potential in juvenile chronic arthritis.

Methotrexate therapy in refractory pediatric onset systemic lupus erythematosus

OBJECTIVE

To evaluate the efficacy, safety, and corticosteroid sparing potential of methotrexate (MTX) in patients with pediatric onset systemic lupus erythematosus (SLE).

METHODS

The medical records of 11 patients with SLE with onset before age 16 years were reviewed. Details of clinical features, previous therapy, indications for MTX, efficacy, toxicity, and corticosteroid reduction during MTX therapy were recorded.

RESULTS

At the start of MTX treatment, 7 patients had nephritis, 3 malar rash, 3 arthritis, 2 skin vasculitis, and 2 thrombocytopenia. All patients were given MTX (12.5-17.0 mg/m2/week) as the sole drug therapy along with prednisone. Although many patients showed initial improvement and/or were able to reduce the prednisone dose, after 7 to 23 months 8 patients had a flare of SLE requiring increased doses of prednisone, one patient had unchanged SLE activity, and 2 patients were permanently discontinued from MTX because of toxicity. Side effects were observed in 8 (73%) patients, but only 2 (18%) discontinued MTX due to toxicity.

CONCLUSION

MTX given as the sole drug therapy along with prednisone did not show a major corticosteroid sparing potential in our patients with pediatric onset SLE.

Performance of the preliminary definition of improvement in juvenile chronic arthritis patients treated with methotrexate. Italian Pediatric Rheumatology Study Group

OBJECTIVE

To investigate the performance of the core set of outcome measures and the preliminary definition of improvement (PDI) in the assessment of response to methotrexate (MTX) treatment in children with juvenile chronic arthritis (JCA).

METHODS

Data were obtained from an open label, non-controlled trial designed to investigate the efficacy of MTX in children with JCA. All patients had the core set of variables assessed at baseline and after six months of treatment. Variables in the core set are: (1) physician global assessment of disease activity; (2) parent or patient (if appropriate in age) global assessment of overall well being; (3) functional ability; (4) number of joints with active arthritis; (5) number of joints with limited range of motion; (6) erythrocyte sedimentation rate. The PDI specifies that to be classified as improved, a patient must show at least 30% improvement from baseline in three of any six variables in the core set, with no more than one of the remaining variables worsening by more than 30%.

RESULTS

A total of 111 JCA patients were included in the study. According to the PDI, after six months of MTX treatment 73 patients (66%) were classified as improved and 38 (34%) as not improved. Among the core set variables, parent assessment detected the highest percentage of patients improved (72%) and functional assessment the lowest (37%).

CONCLUSION

The PDI identifies about two thirds of patients with JCA treated with low dose MTX as improved. This proportion is similar to that expected to improve based upon a previous controlled study of low dose, oral MTX and provides preliminary evidence of the definition's validity.

[Retroperitoneal hematoma during heparin therapy. Comments on 3 cases]

The authors review the literature during the past ten years relating to the onset of retroperitoneal hemorrhage during heparin treatment. The phenomenon may be attributed to a thrombotic genesis involving the adrenal glands and may or may not be correlated to the presence of heparin-induced immune phenomena. The severity of the phenomenon is readily understood: given that the pathology is heparin-dependent, suspension of heparin treatment is the first main step to be taken; this is evidently a cause of risk in relation to the pathology that imposes the use of heparin. The rarity of this complication means that, according to the authors, it has been undervalued. They report three cases which were brought to their attention over the past three years. On the basis of their experience, the authors underline the importance of knowing the causes that are supposed to be responsible for the complication and the study of blood coagulative status. In order not to overlook the possible adrenal genesis of the phenomenon they also recommend a careful exploration of the adrenal glands when faced with a retroperitoneal hematoma in which the source of hemorrhage cannot be identified.

Correlation between conventional disease activity measures in juvenile chronic arthritis

OBJECTIVE

To estimate in a cross sectional analysis the degree of colinearity among the disease activity measures more commonly used in juvenile chronic arthritis (JCA).

METHODS

This study assessed in a single clinical evaluation three subjective variables, three measures of functional capacity, eight articular indices, and two laboratory indicators of systemic inflammation in 55 consecutive children with JCA. The relation between the clinical measures of JCA activity was determined by Pearson correlation coefficients. An r value of 0.7 or greater was considered evidence of colinearity.

RESULTS

Among the subjective variables, parent global assessment of overall well being and parent assessment of pain were correlated with each other; the physician assessment of disease activity did not show evidence of colinearity with any other variable. The functional status measures were correlated with each other, but not with the indices of articular inflammation. There was a high degree of colinearity among the articular variables, with the number of active joints and the overall severity score being correlated with each other as well as with all the single articular indices. The laboratory variables were correlated with each other, but not with any of the articular, functional or subjective variables.

CONCLUSION

Our results show a high degree of colinearity among the disease activity measures belonging to the same category, whereas this is uncommon for variables that investigate different domains of disease activity. These data underline the need to include the evaluation of each domain in the assessment of JCA activity.

Macrophage activation syndrome in systemic juvenile rheumatoid arthritis successfully treated with cyclosporine

A macrophage activation syndrome, possibly related to methotrexate toxicity, developed in a boy with systemic juvenile rheumatoid arthritis. Corticosteroid administration was ineffective, whereas a prompt response to cyclosporine was observed. Two months later, Pneumocystis carinii pneumonia developed.

Frequency of relapse after discontinuation of methotrexate therapy for clinical remission in juvenile rheumatoid arthritis

OBJECTIVE

To investigate the outcome of children with juvenile rheumatoid arthritis (JRA) who discontinued taking methotrexate (MTX) therapy after the achievement of clinical remission.

METHODS

We conducted a retrospective review of the clinical course of all consecutive patients with JRA treated with MTX at our department.

RESULTS

Seventeen of the 30 patients who responded to treatment entered clinical remission 6 to 30 mo after beginning MTX therapy. All patients were discontinued from MTX within 2 to 5 mo. Five patients relapsed within 9 mo, whereas 12 patients had sustained remission for 12 mo or longer. Four of 5 children with extended pauciarticular JRA relapsed early after MTX discontinuation. These patients were less responsive to a further cycle of MTX, and 3 showed progression of radiographic joint lesions.

CONCLUSION

These findings suggest that MTX should be continued in patients with extended pauciarticular JRA even after the achievement of clinical remission.

Evaluation of response to methotrexate by a functional index in juvenile chronic arthritis

In juvenile chronic arthritis (JCA) the indices of disease activity, such as joint swelling, pain, tenderness, and limitation of motion, may poorly correlate with the degree of functional impairment. Since the improvement of functional capacity is one of the main objectives of treatment, we evaluated the effect of methotrexate (MTX) in 29 children with JCA by assessing both the articular indices and a functional status measure. After 6 months of therapy, 15 of the 29 patients had a significant (> or = 50%) reduction in the number of joints with active arthritis and/or the articular severity score and were then judged as responders, while 14 did not respond to MTX. In the responder group, the median functional index score decreased from 17 (range: 13-27) at baseline to 13 (range: 13-15) at 6 months (p < 0.001); the median score of the non-responder group was 20 both at baseline and at 6 months (ranges: 14-27, and 13-36, respectively). These results show an improvement of functional impairment in those patients who respond to MTX according to the conventional indices of articular inflammation.

Chronic recurrent multifocal osteomyelitis with unusual features

We describe two children with chronic recurrent multifocal osteomyelitis who showed unusual extraskeletal manifestations. The first patient developed an asymptomatic pulmonary consolidation; the second had an atypic localization of the associated pustulosis, which involved the trunk, groin, thighs and buttocks, but spared the palms and soles. We conclude that this disease is clinically more heterogeneous than previously thought.

Spinal mobility and posture: changes during growth with postural defects, structural scoliosis and spinal osteochondrosis

A number of case studies were followed for 10 years. Children suffering from postural defects, structural scoliosis and spinal osteochondrosis were separated from a normal group. Spinal mobility and posture were compared with the mobility of normal, healthy boys and girls aged 5-14 years. In postural defects curves similar to the physiologic one were observed. The range of motion was not physiologic in scoliosis. In this disease, rotation-flexion thoracic hypermobility with decreased lumbar flexion ability was found. A physiologic trend was found in spinal osteochondrosis, although sometimes the rotational mobility of the spine was reduced. An extremely high increase of thoracic kyphosis was found only in children aged 14 years.

Magnetic resonance imaging of the lumbar herniated disc in pregnancy

Lumbosacral pain is a significant complaint in approximately one-half of all pregnancies. In 15%, the pain can be disabling. Although the mechanical and positional stresses of pregnancy have been cited as the primary source of this discomfort, in approximately 1:10,000 cases a herniated lumbar disc (HNP) can be identified as the proximal cause of pain. A 35-yr-old G4AB3PO patient presenting at 10 wk of pregnancy with severe incapacitating lumbar radiculopathy is described. Magnetic resonance imaging, selected by the patient as a diagnostic option, demonstrated a clinically suspected large midline HNP at the L5-S1 level. In the past, visualizing the presence of a HNP during pregnancy by either computerized axial tomography scan or myelography has exposed the fetus to ionizing radiation. However, magnetic resonance imaging now permits a more detailed evaluation without similar x-ray exposure. To date, no recognized biologic effect of MRI on the developing fetus has been reported. Although the long-term effects of an magnetic resonance imaging on the developing fetus have not been conclusively evaluated, its potential for accurate diagnosis and subsequent patient management, as well as planning the delivery, appears to outweigh any recognized hazard to the developing fetus.

[The development of spinal movements and sagittal curves in postural defects, idiopathic scoliosis and Scheuermann disease (results of longitudinal studies on 5, 10 and 14 year old subjects)]

A given population was followed by authors for 10 years. Children suffering from postural defects, structural scoliosis, spinal osteochondrosis were separated from a normal group. Spinal mobility and posture were compared with the mobility of normal, healthy boys and girls aged 5-14 years. In postural defects physiologically curves could be seen. The range of motion hasn't been physiologic in structural scoliosis. The rotation and flexion of the spine were increased while the lumbar flexion was decreased. Physiologic trend was found in Scheuermann disease, however high values of spinal rotation wasn't found. Extremely increased thoracic kyphosis was found only in children aged 14 years. Perhaps the change of motion is an etiologic factor in structural scoliosis.

Acute hemispheric stroke: correlation between three-dimensional transcranial Doppler, MR-angiography, CT and clinical findings

We examined 50 ischemic stroke patients and 67 controls free of vascular disease, intra- or extracranial. We assessed all subjects clinically by neurological examination (quantified on the Canadian Neurological Scale or CNS), by three-dimensional transcranial Doppler sonography (TCD-3D) and by computed tomography (CT) within 24 h of the acute event, repeating CT 15 days later. 15 patients also underwent magnetic resonance angiography (MRA) and digital subtraction angiography (DSA). We used the following Doppler parameters: interhemispheric asymmetry index (AI), mean flow velocity (mV) and pulsatility index (PI) for the middle cerebral artery (MCA). The difference between patients and controls on analysis of the variance (ANOVA) in respect of AI was significant: F = 50.8, p < 0.0001. The CNS-AI correlation was equally valid: r = -0.56, p < 0.001. The CNS-CT correlation proved to be highly significant: r = -0.72, p < 0.0001. TCD-3D allowed quantitative evaluation of the hemodynamic changes and of the collateral blood supply and proved to be a sound method for the investigation of ischemic stroke, correlating well with the clinical findings, MRA and lesion size on CT.

Recurrent juvenile dermatomyositis and cutaneous necrotizing arteritis with molecular mimicry between streptococcal type 5 M protein and human skeletal myosin

An adult patient had a syndrome associating the features of juvenile dermatomyositis and cutaneous polyarteritis nodosa that followed a cyclic course from childhood; recurrences were always associated with a rise of serum antistreptococcal antibodies. Regions of homology between streptococcal type 5 M protein and skeletal myosin were found. These findings suggest that streptococcal infection, possibly through a molecular mimicry mechanism, played a role in the pathogenesis of the disease in our patient.

Serum interleukin-6 levels and joint involvement in polyarticular and pauciarticular juvenile chronic arthritis

We measured serum and synovial fluid interleukin 6 (IL-6) levels in patients with polyarticular-onset and pauciarticular-onset juvenile chronic arthritis (JCA), using the hybridoma cell line B9. During active disease, but not during remission, serum IL-6 levels were significantly elevated in patients with polyarticular (p < 0.0001 vs controls) and in patients with pauciarticular JCA (p < 0.01 vs controls). In patients with active polyarticular disease (polyarticular and extended pauciarticular) serum IL-6 levels correlated with the extent and severity of joint involvement (p < 0.05), with erythrocyte sedimentation rate values (p < 0.005) and with C reactive protein concentrations (p < 0.05). In patients with persistent pauciarticular JCA, serum IL-6 levels correlated with the joint swelling score (p < 0.05). Synovial fluid IL-6 levels, measured in 5 patients with pauciarticular JCA, were markedly elevated (range 600-24,000 HGF U/ml). In conclusion, our data suggest that IL-6 is an important pathogenic mediator in polyarticular and pauciarticular JCA.

Three-dimensional transcranial Doppler in acute ischemic stroke in the territory of the middle cerebral artery: clinical and CT correlation

We studied 34 patients with acute ischemic stroke in the territory of the middle cerebral artery (MCA) by three-dimensional transcranial Doppler (TCD-3D). The parameters analyzed were: mean blood flow velocity, systolic and diastolic velocities; indices of pulsatility, hemisphere asymmetry and pulsatility transmission. Of the 34 patients 11 presented marked slowing of flow velocity in the MCA on the infarct side with an asymmetry index (AI) of over 40%, 8 patients with slightly reduced flow velocity in the MCA and an AI of 25-40%, 2 patients in whom there was indirect evidence of collateral circulations in the anterior cerebral artery distribution together with slowing of MCA flow; 5 patients had stenosis of the MCA, 9 patients showed no alterations of the Doppler parameters. The correlation between neurological symptom pattern and AI was significant (r = 0.76). Noninvasive, easy to perform, performable at once and reliable, TCD-3D is a great improvement on traditional transcranial Doppler and is especially useful in assessing the hemodynamics of the cerebral circulation in ischemic stroke.

[Symptoms of spinal osteochondrosis]

Having screened 384 patients suffering from Scheuermann's disease and 2992 eleven-year-old children, the authors conclude that the early and salient symptoms of the disease are mobile thoracic kyphosis associated with the flexious contracture of the hip joint, and occasional anteflexious contracture of the shoulder joint together with a left-curved functional scoliosis. The authors analyse the nature and frequency of scoliosis, excluding other causes of the flexion contracture of the hip joint. Their findings are supported by data processed on computer.

Multiple inhibitors of mitogen-induced proliferation of normal lymphocytes in juvenile chronic arthritis sera

We evaluated the effect of 47 serum samples obtained from 34 children with juvenile chronic arthritis (JCA) on mitogen-induced proliferation of normal peripheral blood lymphocytes (nPBL). We found that sera from patients with active disease, and particularly those with the systemic form, inhibited significantly PHA-induced proliferation of nPBL at all the PHA concentrations tested. This inhibitory activity was independent of the treatment and was correlated with the value of the erythrocyte sedimentation rate. Part of the JCA sera inhibitory effect could be reversed by the addition of exogenous interleukin 2 (IL-2), but not of interleukin 1 (IL-1) or interferon-gamma, moreover, JCA sera were able to partially inhibit the IL-2 dependent proliferation of CTLL. When we tested serum fractions obtained by Sephadex G-200 chromatography for their inhibitory activity, we observed that: a) two major peaks of inhibitory activity on PHA-induced proliferation were present: peak 1 with MW less than 600,000 and peak 2 with MW between 70,000 and 35,000; b) the inhibitory activity present in the high MW peak was in part IL-2 related; and c) both peaks contained elevated levels of acute phase proteins (APP) which are known to inhibit mitogen-induced lymphocyte proliferation. We conclude that sera from patients with active systemic JCA contain inhibitory activity on mitogen-induced lymphocyte proliferation. We conclude that sera from patients with active systemic JCA contain inhibitory activity on mitogen-induced lymphocyte proliferation. This activity is due to the presence of multiple inhibitors, one of which appears to be IL-2 related; at least part of the inhibitory activity may be due to elevated serum levels of APP.

[Changes in the production of IgM in response to pokeweed mitogen in juvenile rheumatoid arthritis. Correlations with disease activity]

Unstimulated and pokeweed mitogen (PWM)-stimulated "in vitro" IgM synthesis by peripheral blood lymphocytes has been evaluated by an ELISA method in 33 patients with juvenile rheumatoid arthritis (JRA). Lymphocyte PWM responses were significantly reduced in patients with JRA compared with healthy controls. When patients were divided according to disease activity, a significant increase of stimulation index (ratio of IgM synthesis with over that without PWM) has been observed in patients with disease remission compared with those with active disease. These findings confirm the defect in PWM-induced IgM synthesis by peripheral blood lymphocytes of patients with JRA and suggest that these abnormalities may be related to disease activity.

Autoantibodies in juvenile dermatomyositis

Fourteen patients with juvenile dermatomyositis (JDM) have been investigated for the presence of several serum autoantibodies: antinuclear (ANA), anti-single-stranded and double-stranded DNA, anti-histones, anti-Sm, anti-ribonucleoprotein, anti-SSA/SSB, anti-PM-1, anti-Jo-1, anti-mitochondrial, anti-smooth muscle, anti-gastric parietal cells, anti-cardiolipin (ACA) antibodies and rheumatoid factor. Patients were negative for all autoantibodies except for ANA and ACA. ANA were detected in 50% of the patients when tested on rat liver, but the percentage of positivity rose to 86% when HEp-2 cells were used as substrate. This finding suggests that HEp-2 cells represent a more sensitive substrate than rat liver for the detection of ANA in JDM. Three patients were positive for ACA; two of these presented vascular complications, thus suggesting a possible relationship between ACA and vascular involvement in JDM.

Anticardiolipin syndrome in childhood: a report of two cases

We describe two children with an otherwise unexplained deep vein thrombosis associated with high titer anticardiolipin antibodies (ACA) of the IgG class and circulating lupus anticoagulant (LAC). One of these patients had persistent proteinuria but neither had systemic lupus erythematosus. Our observation suggests that ACA and LAC assays should be performed in children with thromboembolic disease even when no underlying autoimmune disease can be found.

Antibody reactivity against single stranded DNA of various species in normal children and in children with diffuse connective tissue diseases

The aim of this work was to study possible differences in the humoral response against autologous and heterologous (bacterial and mammalian) ssDNA in children with diffuse connective tissue diseases (DCTD) compared with age matched controls. We found that IgM anti ssDNA were significantly increased in systemic lupus eritematosus (SLE) and in juvenile arthritis (JA), but not in juvenile dermatomyositis (JDM). IgG anti ssDNA were significantly elevated only in children with SLE. We next evaluated the binding specificity to human and bacterial ssDNA by inhibition assays. We found that SLE and JA sera recognised epitopes shared in common to endogenous and bacterial ssDNA. In contrast, in normal subjects IgG binding to bacterial DNA was not inhibited by human DNA, while IgG anti human ssDNA were cross reactive with the bacterial antigen. These data suggest that natural antibodies (IgM) producing cells are activated in some but not all DCTD, and that normal children have different reactivity against autologous and heterologous ssDNA with respect to SLE and JA patients.

[A new computerized file of juvenile rheumatoid arthritis]

A computerized database for patients with juvenile rheumatoid arthritis (JRA) is presented. The program has been developed using PRIST (Patient Record Information System Tool), a flexible tool specifically oriented to clinical data management. The database consists of three main sections: the fixed record devoted to anamnestic data, the periodic record collecting the clinical, laboratory and instrumental data and the balance record devoted to a periodic balance of the disease course. The major advantages of our database are: time saving data handling, elastic procedures and easy retrospective data collection.

[Ischemic necrosis of femoral condyles in systemic lupus erythematosus]

Avascular necrosis (AN) of bone is a complication of systemic lupus erythematosus (SLE). In the present paper we describe two patients with SLE who presented an AN of femoral condyles 18 months and 2 years respectively after the diagnosis of the disease. In the second case, together with the destructive change of the symptomatic knee, X-ray films showed an initial involvement, still asymptomatic, of the contralateral knee.

Hypergammaglobulinemic purpura in childhood. Report of two cases and review of the literature

Hypergammaglobulinemic purpura is a rare syndrome characterized by long-standing recurrent purpura of the lower limbs, polyclonal hypergammaglobulinemia, increased erythrocyte sedimentation rate and high titer rheumatoid factor positivity. The syndrome can occur isolated or in association with a systemic disease. Few cases have been described in childhood. We report two cases together with a review of the paediatric literature.

[Pro-allergy role of infection. A component of the mode of reacting]

No organism from the cradle lives germ-free or allergen-free. The modalities by which infections facilitate conditions of abnormal reactivity, in particular respiratory asthma and allergy to cow milk proteins, are examined. 216 asthmatic children and 50 infants with rotavirus enteritis have been considered. Infections, besides representing stimuli directly projected on the immune system, also constitute factors which more generally influence the way of reacting.