Oral versus intramuscular methotrexate in juvenile chronic arthritis. Italian Pediatric Rheumatology Study Group

OBJECTIVE

To compare the efficacy and safety of methotrexate (MTX) after oral and intramuscular administration in children with juvenile chronic arthritis (JCA).

METHODS

Pediatric rheumatology centers in Italy participated in this short-term, prospective, open trial. Each investigator was allowed to choose the oral or intramuscular route of administration according to his personal preference in everyday clinical practice. Patients enrolled by each center were given MTX through the same method of administration. All patients received 10 mg/m2 of MTX each week for six months.

RESULTS

A total of 257 patients with JCA (127 treated orally and 130 intramuscularly) were enrolled in the trial by 11 Italian centers. The response rate after 6 months of MTX therapy was 58% in the oral and 61% in the intramuscular cohort. The frequency of adverse side effects did not differ significantly between the two treatment groups.

CONCLUSION

The results of this study suggest that MTX at the conventional dose regimen is equally effective and has a similar safety profile in children with JCA when administered orally or by intramuscular injections.

The use of bovine pericardium for pulmonary valve reconstruction or conduit replacement: long-term clinical follow up

BACKGROUND AND AIMS OF THE STUDY

This study aimed to determine the clinical performance of bovine pericardial aldehyde-treated material alone or in combination with aortic leaflets of porcine origin. These were the porcine aortic stentless pulmonary valved bovine pericardial conduit (PSPVC), and porcine aortic monocusp attached to pericardial patch (PAMC), used to correct right-sided heart lesions.

METHODS

Between November 1985 and October 1995, 33 patients underwent corrective congenital surgery with PSPVC. Mean patient age was 5.7+/-4.3 years (range: 15 days to 18 years). Pulmonary atresia with ventricular septal defect (VSD) was the most frequent disease (16/33, 48%). For PAMC, 45 patients with various congenital heart malformations underwent implantation between June 1989 and April 1996. Mean patient age was 4.8+/-4.7 years (range: 2 weeks to 18 years).

RESULTS

With PSPVC, hospital mortality rate was 18.2% and related to poor preoperative clinical condition in six cases. Four patients were lost to follow up; 23 (85%) were followed for 3 months to 10 years (mean 4.8+/-3.0 years). Distal anastomotic scarring in four patients was probably due to retraction of the pericardial tissue. With PAMC, hospital mortality rate was 11% and related to patients' preoperative clinical condition. Three patients were lost to follow up; 37 survivors have been followed for 6 to 88 months (mean 38.5+/-19.0 months). There were no late deaths. Two patients underwent reoperation; intra-operative observation showed well-preserved monocusps with no signs of tissue degeneration. The remaining 35 patients remain asymptomatic by clinical examination and Doppler echocardiography. The monocusps remained mobile in every case.

CONCLUSION

PSPVCs have shown excellent performance and durability in young patients with a low mean age (5 years). The monocusp graft has remained functional with good leaflet motion for up to seven years.

Altered cardiovascular responsiveness to active tilting in nonalcoholic cirrhosis

BACKGROUND & AIMS

The hyperdynamic circulation of cirrhosis has been related either to plasma volume expansion (increased preload) or peripheral arterial vasodilation (reduced afterload). The aim of this study was to evaluate cardiovascular function in patients with nonalcoholic cirrhosis by echocardiography.

METHODS

Nineteen patients with abnormal sodium handling (11 sodium excretors and 8 sodium retainers) and 15 healthy volunteers underwent echocardiographic evaluation of left ventricular end-diastolic volume index (LVEDVI) and left ventricular end-systolic volume index (LVESVI), left ventricular ejection fraction (LVEF), cardiac index (CI), mean arterial pressure, and systemic vascular resistance (SVR) during supine resting and after 5 minutes of standing.

RESULTS

Supine patients had increased LVEF and CI and reduced LVESVI and SVR. LVEDVI was increased only in sodium excretors. Standing induced a decrease in LVEDVI in all subjects. Healthy volunteers maintained cardiovascular homeostasis by increasing LVEF and heart rate, whereas cirrhotic patients experienced a decrease in SVI and CI despite marked increments in heart rate, plasma renin activity, and plasma norepinephrine level.

CONCLUSIONS

In patients with cirrhosis, the increased LVEF and reduced LVESVI while in a supine position point at reduced afterload as an important determinant of the hyperdynamic circulation. Evidence of an increased preload secondary to increased blood volume, indicated by a high LVEDVI and increased plasma atrial natriuretic peptide levels, was found only in sodium excretors. The altered response to active tilt in cirrhotic patients suggests an impaired myocardial contractility.

1,25-dihydroxyvitamin D3, transforming growth factor beta1, calcium, and ultraviolet B radiation induce apoptosis in cultured human keratinocytes

Apoptosis is a cellular process of self-directed suicide that plays a key role during morphogenesis and in the maintenance of homeostasis in continuously renewing tissues. Currently, apoptosis is detected mainly by gel electrophoresis of fragmented DNA and by typical ultrastructural features such as cell shrinkage and chromatin condensation. Recently, an in situ technique was developed that allows the detection of the apoptotic process in cells and the quantitation of apoptosis in cell populations. We applied this technique to evaluate the apoptotic process in cultured normal human keratinocytes under basic conditions and after stimulation with factors and agents that are presumed but have never been proved to induce apoptosis in these cells. Apoptosis was analyzed after stimulation with 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], transforming growth factor beta1 (TGFbeta1), calcium, UVB, or tumor necrosis factor alpha (TNFalpha). All these factors except TNFalpha induced apoptosis in human keratinocytes. Whereas UVB and calcium were good apoptogenic stimuli at 6 and 24 h, respectively, the vitamin D derivative and TGFbeta1 induced apoptosis after 5 and 6 d in culture. Apoptosis was also established by DNA fragmentation and electron microscopy. Finally, TUNEL technique showed that the number of apoptotic cells increases slightly (5-10%) from 24 to 144 h even in untreated keratinocytes. Our studies indicate that factors normally involved in the regulation of cell growth and differentiation can also control apoptosis.

Cyclosporin A in the treatment of adult onset Still's disease

OBJECTIVE

To determine whether cyclosporin A (CyA) is a useful option in the treatment of adult onset Still's disease (ASD).

METHODS

Low dose CyA was given to 6 patients with chronic or relapsing ASD who had not been prescribed any other second line agents during the previous 6 mo.

RESULTS

The disease completely remitted in 4 patients and improved markedly in the remaining 2. The corticosteroid requirement was substantially reduced in all cases. Tolerability was rated good or very good by all patients but one, who reported good tolerance to CyA only in a new formulation.

CONCLUSION

CyA may be included among the second line agents used in the treatment of refractory ASD.

Parallel increase in carotid, brachial and left ventricular cross-sectional areas in arterial hypertension

Few data have been published about the relation between the vessels geometry and development of left ventricular (LV) hypertrophy in patients with arterial hypertension. The aim of this study is to describe arterial and LV geometry changes due to mild-to-moderate arterial hypertension in an untreated hypertensive population. In 95 untreated patients with mild-to-moderate hypertension and 23 age- and sex-matched healthy normotensives, we measured the end-diastolic diameter and wall thickness of the left ventricle and the internal diameter and intimal-medial thickness (IMT) of carotid and brachial arteries. From these data, the cross-sectional areas (CSAs) of arterial and myocardial walls were calculated. Hypertensive patients were further subdivided on the basis of the presence of LV hypertrophy defined according to Devereux et al as anatomical LV mass >125 g/m. In hypertensive patients with hypertrophy, carotid and brachial CSAs increased, without significant changes in thickness/diameter ratio (arterial 'enlargement'), while the left ventricle developed 'concentric' hypertrophy. Arterial and LV CSAs showed a significant direct correlation with systolic blood pressure (BP). However, when data were corrected for BP, the correlation between the increase in arterial and LV CSAs became much improved than for the raw data. In conclusion patients with untreated mild-to-moderate hypertension, both carotid and brachial arterial walls showed an enlargement that was proportional to the development of LV hypertrophy. These results suggest that the effects of arterial hypertension on carotid, brachial and LV wall geometry have a common modulation.

Differences in synovial fluid cytokine levels between juvenile and adult rheumatoid arthritis

OBJECTIVE

To evaluate quantitative or qualitative differences in synovial fluid (SF) cytokine levels among patients with systemic juvenile rheumatoid arthritis (JRA), antinuclear antibody positive pauciarticular JRA, or adult RA.

METHODS

SF levels of interleukin 1alpha (IL-1alpha), IL-1beta, IL-1 receptor antagonist (IL-1Ra) IL-11, tumor necrosis factor-alpha (TNF-alpha), soluble TNF receptor 1 (sTNFR1), leukemia inhibitory factor (LIF), all measured by immunoassays, and of IL-6, measured with a bioassay using B9 cells, were evaluated in 11 patients with systemic JRA, 24 with pauciarticular JRA, and 22 adult patients with RA.

RESULTS

SF IL-6 levels were significantly higher in patients with systemic JRA than patients with pauciarticular JRA (p = 0.003) or RA (p = 0.002). IL-1alpha was detectable in 12/24 SF samples from pauciarticular JRA, in 2/22 SF from RA, and in no sample from systemic JRA (p = 0.004 vs RA; p = 0.005 vs systemic JRA). SF IL-11 levels were significantly higher in patients with RA than patients with systemic JRA (p = 0.012) or pauciarticular JRA (p = 0.005). We found no significant differences in SF levels of IL-1beta, IL-1Ra, TNF-alpha, sTNFR1, or LIF.

CONCLUSION

In systemic JRA, SF levels of IL-6 are significantly higher than in pauciarticular JRA or in RA; IL-1alpha is present in a significant proportion of patients with pauciarticular JRA, but not in those with RA or systemic JRA.

Akinetic versus dyskinetic postinfarction scar: relation to surgical outcome in patients undergoing endoventricular circular patch plasty repair

OBJECTIVES

This retrospective study attempted to relate surgical outcome with the extent and type of preoperative wall motion asynergy in patients with postinfarction myocardial scar who underwent endoventricular circular patch plasty repair and associated coronary grafting.

BACKGROUND

Left ventricular (LV) pump function improvement is difficult to predict after aneurysmectomy, for either akinetic or dyskinetic scar, and previous studies have reported that the absence of paradoxic systolic motion correlates with higher operative mortality and no improvement in pump function.

METHODS

Two hundred forty-five patients who underwent endoventricular circular patch plasty repair and associated coronary grafting were retrospectively selected if they had technically adequate right and left anterior LV angiograms before the operation. All had right and left cardiac catheterization. The centerline method was applied to preoperative right anterior oblique LV angiography to assess the absolute motion of the chords and the percent length of the perimeter showing a fractional shortening <2 SD from the normal mean value (extent of asynergy ([A%]).

RESULTS

The overall perioperative mortality rate was 6%; 120 patients had akinetic and 125 had dyskinetic scar, and no differences were found among the groups in terms of all the clinical and hemodynamic variables collected in the study. Patients with a large scar (A% >60), either akinetic or dyskinetic, had a higher perioperative mortality rate (12%) than patients with a small scar (2.2%). After the operation, the ejection fraction (EF) increased from 36 +/- 13% to 50 +/- 13% (mean +/- SD), and pulmonary pressures significantly decreased. End-diastolic volume decreased from 199 +/- 75 to 89 +/- 36 ml/m2. Patients with a large akinetic scar had the most severely impaired preoperative function (largest ventricular volumes and highest pulmonary mean pressure); nevertheless, they had an impressive improvement in function (EF from 25 +/- 9% to 41 +/- 12%), not different from that observed with large dyskinetic scarring (EF from 26 +/- 7% to 46 +/- 11%).

CONCLUSIONS

Surgical outcome of endoventricular circular patch plasty repair for postinfarction myocardial scar relates to the extent of LV asynergy rather than to the presence or absence of dyskinesia. Patients with a large akinetic scar and severely depressed pump function benefit from a relatively simple surgical procedure previously reserved only for dyskinetic aneurysm. The reduction of wall tension and oxygen demand, owing to the marked decrease of volumes, and the increase in oxygen supply, owing to revascularization, may play a major role in improving pump function.

Cancer mortality among chemical workers in an Italian plant

Objective of this study was to assess the mortality experience of a cohort of chemical workers at a plant located in central Italy. Subjects employed for any time between 1954 and 1970 at the chemical plant were included in the cohort and followed up to June 1991. The workers were classified as having ever/never worked in one of the following work processes: organic chemicals, acid mixtures, cleansing agents and insecticides. Mortality experience of the cohort was compared with that of the regional population by computing SMRs (standardized mortality ratios) and 90% CI (confidence intervals). Vital status was ascertained for 96% of the 505 cohort members. All causes of mortality for the entire cohort were lower than expected (Obs: 176; SMR: 0.90; 90% CI: 0.79-1.03). Analysis by work process revealed an increased mortality for lymphatic and hematopoietic tissue neoplasm in the cleansing agents department (Obs: 3; SMR: 5.00; 90% CI: 1.36-12.9); peritoneum and retropertioneum neoplasm in the organic compounds production (Obs: 2; SMR: 13.33; 90% CI: 2.37-42.0), and bladder cancer in the insecticides process (Obs: 3; SMR: 3.53; 90% CI: 0.96-9.12). Although the study had a low statistical power, the increased cancer risks detected are consistent with previous observations and may be of etiologic interest.

T-wave alterations at the onset of wall motion abnormalities during dobutamine echocardiographic stress test

At the onset of wall motion alterations during dobutamine echocardiographic stress testing, a steeper increase in the overall T-wave amplitude in the precordial leads was observed in 17 patients with baseline normal wall motion, electrocardiogram, and critical coronary stenoses compared with 11 control subjects. Eleven patients with increasing T-wave amplitude had localized apical dyssynergy, whereas 6 patients with downward displacement of the ST segment had widespread wall motion alterations also located at the basal and midsegments.

Neuropeptides, nerve growth factor and the skin

Cutaneous nerve fibers can modulate inflammatory reactions through local release of neuro-peptides (NP). In fact, NP are able to regulate both acute and chronic aspects of cutaneous inflammatory processes, such as vascular motility, cellular traffic-king, activation and trophism. Several experimental evidences suggest a participation of NP to the pathogenesis of inflammatory dermatoses: in particular, modulation of inflammatory reactions in the skin can be obtained through pharmacologic manipulation of the neuropeptidergic system. Furthermore, evidence of local alterations of NP levels in inflamed skin has been obtained. It has been hypothesized that the inflammatory process induces reactive changes in the neuronal NP content. The primary candidate as mediator of this neuronal recruitment in the course of inflammatory reactions is the neurotrophin nerve growth factor, that is produced in the skin in increased amounts during inflammatory processes and may regulate peptidergic synthesis at a neuronal level.

Is the control of disease progression within our grasp? Review of the GRISAR study. (Gruppo Reumatologi Italiani Studio Artrite Reumatoide)

A prospective, open, multicentre, randomized study with a blinded radiological end-point was started in 1991. The aim of the study was to assess whether cyclosporin A (CyA) controls ongoing anatomical damage in active early rheumatoid arthritis (RA) better than conventional disease-modifying anti-rheumatic drugs (DMARDs) as used in everyday clinical practice. A total of 340 consenting patients with early RA (mean duration 1.4 yr) were recruited; 167 were randomized to CyA 3mg/kg per day and 173 to DMARDs. Hand, wrist and foot X-rays were blindly scored by a central committee of three radiologists using the Larsen-Dale method. Any side-effects were carefully recorded. The control of clinical symptoms was similar in both groups. Radiological evaluation of 284 patients (141 on CyA; 143 on DMARDs) after 12 months showed a significant decrease in the mean progression in the eroded joint count (1.3 +/- 3.1 vs 2.4 +/- 3.0, P < 0.001). There was also better maintenance on treatment with CyA than in the group treated with DMARDs (89.2 vs 77.5%, respectively; P = 0.002). CyA seems to offer greater control of ongoing anatomical joint damage in early RA than conventional DMARDs after 12 months.

Slow progression of joint damage in early rheumatoid arthritis treated with cyclosporin A

OBJECTIVE

To evaluate the ability of low-dose cyclosporin A (CsA) to control radiologic disease progression, and to assess the clinical efficacy and tolerability of CsA, compared with conventional disease-modifying antirheumatic drugs (DMARDs), in patients with early active rheumatoid arthritis (RA).

METHODS

In this long-term, multicenter, prospective, open, blinded end point, randomized trial, 361 consenting patients with early (<4 years since diagnosis) active RA were enrolled. Of the eligible patients, 167 were treated with CsA at 3 mg/kg/day, and 173 with DMARDs. The decision to use conventional antirheumatic drugs as controls was based on the fact that joint erosion could be expected to occur after 1 year regardless of the type of DMARD being used. The possibility of switching therapies in both groups was intended to keep the largest possible number of patients in the study.

RESULTS

Blinded evaluation of hand and foot radiographs after 12 months of treatment showed that CsA led to a significant (P < 0.001) delay in the mean +/- SD progression in the eroded joint count (1.3 +/- 3.1 versus 2.4 +/- 3.0 for the control group) and in the joint damage score (3.6 +/- 8.9 versus 6.9 +/- 9.1 for the control group), both measured by the Larsen-Dale method. When only the patients without erosion at baseline were considered (37 in the CsA-treated group and 54 in the control group), erosion appeared in only 10.8% of the CsA-treated patients, but in 51.8% of the controls (P = 0.00005). Low-dose CsA was as effective as traditional DMARDs in controlling clinical symptoms. Maintenance on the initially prescribed treatment regimen ("survival on treatment") was also better at 12 months with CsA than with DMARDs (89.2% versus 77.5%; P = 0.002). The tolerability of CsA was acceptable.

CONCLUSION

These 12-month results suggest that low-dose CsA decreases the rate of further joint damage in previously involved joints as well as the rate of new joint involvement in previously uninvolved joints, in patients with early RA.

Left-ventricular diastolic dysfunction during pneumonectomy--a transesophageal echocardiographic study

Left-ventricular dysfunction, with acute increase in capillary pulmonary pressure, can unexpectedly develop in patients submitted to pneumonectomy. In order to study the morphofunctional modifications induced by pneumonectomy on the left cardiac chambers, we performed intraoperative transesophageal echocardiography (TEE) in 8 patients (7 males, mean age 66 years) undergoing pneumonectomy for lung cancer. No patient had any cardiac involvement before surgery. The opening of the pericardium was associated with a slight paradoxical movement of the basal interventricular septum. After ligature of the pulmonary artery, the interventricular septum changed its geometry, losing the normal curvature and becoming rectilinear. These changes were related to an increase in right-ventricular (RV) dimensions. In all patients the pulmonary vein flow-profile (pulsed Doppler) showed an increased turbulence, associated with a reduced amplitude (5 patients) or an inversion (3 patients) of the second systolic component and with the development of mild mitral regurgitation (color Doppler). These changes disappeared at the end of intervention, before chest closure. No alteration in left-ventricular systolic function was found. These results suggest that the altered geometry of the interventricular septum, mainly due to acute RV overload, induces a transient left-ventricular diastolic dysfunction, associated with mild mitral regurgitation.

Neurochemical markers in human cutaneous Merkel cells. An immunohistochemical investigation

Merkel cells (MCs) are specialized sensory cells widely distributed in the epithelia of vertebrates. A variable immunohistochemical pattern of neuronal and neurotransmitter markers has been demonstrated in MCs of several species including man. In the present study, we investigated the expression of neurochemical markers in a selected population of human cutaneous MCs by immunofluorescence. The structural neural proteins protein gene product 9.5 and neuron-specific enolase were found to be the most reliable markers for MC identification. Moreover, neurofilament immunoreactivity was shown in a small subset of epidermal MCs. Among the neurotransmitter markers, evidence for expression of calcitonin gene-related peptide, vasoactive intestinal polypeptide, peptide histidine isoleucine amide, neuropeptide Y, neurokinin A, galanin, substance P, somatostatin and phenylethanolamine N-methyltransferase was found. These immunoreactivities were highly variable as far as number of positive cells and staining intensity were concerned. The results indicate that a complex and heterogeneous immunophenotype can be expressed even within a homogeneous population of human MCs.