Effects of body composition on the procoagulant imbalance in obese patients

Obesity is associated with increased thrombotic risk and hypercoagulability whose main driver is an excess of coagulation factor VIII relative to protein C. The aims of this study were to evaluate the association between factor VIII, protein C, factor VIII-to-protein C ratio and bioimpedance parameters of body composition in obese patients. We analysed blood from 69 obese patients and 23 non-obese healthy controls. Plasma levels of factor VIII, protein C, and factor VIII-to-protein C ratio were correlated with total fat, visceral fat, and muscle mass. Compared to controls, obese patients had significantly higher factor VIII (110.5% vs 78.05%, p < 0.001), protein C (120.99% versus 110.51%, p = 0.014), and factor VIII-to-protein C ratio (0.93 versus 0.73, p = 0.002). In obese patients, factor VIII correlated with body-mass index, body fat percentage, muscle mass percentage, and fat-to-muscle ratio, whereas protein C had significant relationships with body fat percentage, muscle mass percentage and fat-to-muscle ratio, but not with body-mass index. Factor VIII-to-protein C ratio > 1 was significantly associated with body-mass index (odds ratio 1.08, 95% CI 1.02 to 1.14) and fat-to-muscle ratio (odds ratio 2.47, 95% CI 1.10 to 5.55). Factor VIII-to-protein C ratio strongly correlated with D-dimer levels in the overall population (rho 0.44, p < 0.001) and obese patients (rho 0.41, p < 0.001). In obese patients, bioimpedance measures of body fat and muscle mass percentage were associated with factor VIII and protein C. Factor VIII-to-protein C ratio was strongly associated with fat-to-muscle ratio and only modestly related to BMI.

Sonographic demonstration of a spontaneous rectus sheath hematoma following a sneeze: a case report and review of the literature

Spontaneous rectus sheath hematoma (SRSH) is an uncommon cause of acute abdominal pain characterized by bleeding within the rectus sheath; it is a benign condition and, in most cases, it is treated conservatively. Bleeding of the abdominal wall is an unusual condition that is quite challenging to identify promptly and can be easily overlooked during a routine physical examination. In daily practice, anticoagulant therapy is one of the main risk factors for hemorrhagic events. In this respect, we report a rare case of spontaneous hematoma of the abdominal wall (diagnosed and monitored through an ultrasound examination) that arose after sneezing in a patient receiving anticoagulant treatment.

Not all abolished lung sliding are pneumothorax: the case of a particular lung atelectasis

INTRODUCTION

Lung ultrasound (LUS) is expanding from the field of emergency medicine, also to the pneumological specialist field, becoming part of the diagnostic procedure of lung consolidation.

CASE PRESENTATION

A 78-year-old male was admitted to our emergency department for exertional dyspnea. LUS was performed, thus showing at right hemitorax air interface, A lines pattern, pleural sliding abolished on the whole hemitorax, thus suggesting a pneumothorax, but no evidence of lung point. A scan of lower lung segment showed an absence of the diaphragmatic excursion, suggestive for hemiparalysis of the diaphragm muscle, then confirmed by a subcostal scan. Moreover, at the lower segment of right hemitorax there was mild pleural effusion allowing the visualization of a round-shaped parenchymal consolidation with the absence of air bronchograms.

CONCLUSIONS

LUS allowed the visualization of a particular and rare disease such as anthracosis-associated rounded atelectasis, thus leading to a more correct and faster patient management.

Focused ultrasound for the diagnosis of non-palpable endometriotic lesions of the abdominal wall: a not-uncommon surgical complication

Endometriosis is a benign disease characterized by endometrial glands and stroma outside the endometrial cavity. We reported two cases of endometriosis of the abdominal wall, with subcutaneous and intramuscular localization, that became symptomatic a few years after a cesarean intervention. These cases have a clinical pattern quite similar to cutaneous endometriosis, but they are more difficult to diagnose through physical examination because they are barely palpable. In this sense, coupled with suggestive symptoms, ultrasound examination can confirm the clinical suspicion of endometriosis without the use of computed tomography and/or magnetic resonance imaging.

Mantle cell lymphoma: from ultrasound examination to histological diagnosis

We report the case of a 42-year-old patient referred to our department for the examination of two large, symmetrical inguinal lumps. The ultrasound examination of the swollen lymph node demonstrated a cortical echogenicity greater than the medullary echogenicity, and the vascularization stop around the cortical zone suggested a pathological pattern of mantle cell lymphoma. In this type of lymphoma, lymphocytes are localized in a mantle zone, inducing a thickening of the lumps. Therefore, for the first time, ultrasound examination detected sonographic vascular features of mantle cell lymphoma, allowing the identification of the disease and suggesting the specific histological diagnosis.

Risk factors associated to bilateral rotator cuff tears

INTRODUCTION

Overuse, micro-traumas, and impingement, isolated or combined, are the more common etiological factors for rotator cuff tears. Metabolic disorders (diabetes, adiposity, hypercholesterolemia), hypertension, cigarette smoking and a genetic predisposition are considered risk factors. However, no study has compared the prevalence of these risk factors in subjects with bilateral and monolateral tears.

HYPOTHESIS

Controlateral tears can be observed in patients with symptomatic monolateral rotator cuff lesions, especially in those with comorbidities.

MATERIAL AND METHODS

In patients with symptomatic rotator cuff tear, the controlateral shoulders were evaluated by means of ultrasound imaging. Age, BMI, diabetes, hypercholesterolemia, hypertension, cigarette smoking, work habits were registered. Risk factors in subjects with bilateral tears were compared with those with monolateral lesions.

RESULTS

Of the 180 subjects recruited, 69 had a tear in the controlateral shoulder. Higher age and BMI values, heavy repetitive work and diabetes were significantly prevalent in these patients. At multivariate analysis, these factors were independently related to a higher probability to detect bilateral tears.

DISCUSSION

Metabolic risk factors are more heavily involved in presence of bilateral rotator cuff tears, in comparison to monolateral.

TYPE OF STUDY

Original study.

LEVEL OF PROOF

IV.

Ultrasound-guided Percutaneous Lavage in the Treatment of Calcific Tendinopathy of Elbow Extensor Tendons: A Case Report

We report the efficacy of the ultrasound-guided percutaneous treatment in the management of elbow extensor tendons calcific tendinopathy. The ultrasound-guided percutaneous treatment is broadly used with positive results in patients suffering from rotator cuff calcific tendinopathy. However, this interventional method has been reported only in one patient in the medical literature. A 34 years-old female who complained pain, swelling and severe functional limitation of the right elbow was referred to our unit. Elbow radiographs and ultrasound examination showed a soft-fluid calcification above the origin of the extensor tendons. Ultrasound-guided percutaneous treatment was therefore performed. After one year, the patient reported no pain and regained complete range of elbow motion. This method, in well trained hands, is an alternative treatment in the management of the uncommon elbow calcific deposit.

Ultrasound Shear Wave Elastography for Liver Disease. A Critical Appraisal of the Many Actors on the Stage

In the last 12 - 18 months nearly all ultrasound manufacturers have arrived to implement ultrasound shear wave elastography modality in their equipment for the assessment of chronic liver disease; the few remaining players are expected to follow in 2016.When all manufacturers rush to a new technology at the same time, it is evident that the clinical demand for this information is of utmost value. Around 1990, there was similar demand for color Doppler ultrasound; high demand for contrast-enhanced ultrasonography was evident at the beginning of this century, and around 2010 demand increased for strain elastography. However, some issues regarding the new shear wave ultrasound technologies must be noted to avoid misuse of the resulting information for clinical decisions. As new articles are expected to appear in 2016 reporting the findings of the new technologies from various companies, we felt that the beginning of this year was the right time to present an appraisal of these issues. We likewise expect that in the meantime EFSUMB will release a new update of the existing guidelines 1 2.The first ultrasound elastography method became available 13 years ago in the form of transient elastography with Fibroscan(®) 3. It was the first technique providing non-invasive quantitive information about the stiffness of the liver and hence regarding the amount of fibrosis in chronic liver disease 3. The innovation was enormous, since a non-invasive modality was finally available to provide findings otherwise achievable only by liver biopsy. In fact, prior to ultrasound elastography, a combination of conventional and Doppler ultrasound parameters were utilized to inform the physician about the presence of cirrhosis and portal hypertension 4. However, skilled operators were required, reproducibility and diagnostic accuracy were suboptimal, and it was not possible to differentiate the pre-cirrhotic stages of fibrosis. All these limitations were substantially improved by transient elastography, performed with Fibroscan(®), a technology dedicated exclusively to liver elastography. Since then, more than 1300 articles dealing with transient elastography have been listed in PubMed, some describing results with more than 10,000 patients 5. The technique has been tested in nearly all liver disease etiologies, with histology as the reference standard. Meta-analysis of data, available in many etiologies 6, showed good performance and reproducibility as well as some situations limiting reliability 5. Thresholds for the different fibrosis stages (F0 to F4) have been provided by many large-scale studies utilizing histology as the reference standard 7. Transient elastography tracks the velocity of shear waves generated by the gentle hit of a piston on the skin, with the resulting compression wave traveling in the liver along its longitudinal axis. The measurement is made in a 4 cm long section of the liver, thus able to average slightly inhomogeneous fibrotic deposition.In 2008 a new modality became available, Acoustic Radiation Force Impulse (ARFI) quantification, and classified by EFSUMB 1 as point shear wave elastography (pSWE), since the speed of the shear wave (perpendicular to the longitudinal axis) is measured in a small region (a "point", few millimeters) at a freely-choosen depth within 8 cm from the skin. This technology was the first to be implemented in a conventional ultrasound scanner by Siemens(®) 8. Several articles have been published regarding this technology, most with the best reference standards 9, some including findings on more than 1000 hepatitis C patients 10 or reporting meta-analysis of data 11. Although the correlation between Siemens pSWE and transient elastography appeared high 12 13, the calculated thresholds for the different fibrosis stages and the stiffness ranges between the two techniques are not superimposable.Interestingly, pSWE appears to provide greater applicability than transient elastography for measuring both liver 13 and spleen stiffness, which is a new application of elastography 14, of interest for the prediction of the degree of portal hypertension 15 16.Nowadays other companies have started producing equipment with pSWE technology, but only very few articles have been published so far, for instance describing the use of Philips(®) equipment, which was the second to provide pSWE. These articles show preliminary good results also in comparison with TE 17 18. Not enough evidence is currently available in the literature about the elastographic performance of the products most recently introduced to the market. Furthermore, with some products the shear wave velocities generated by a single ultrasound acoustic push pulse can be measured in a bidimensional area (a box in the range of 2 - 3 cm per side) rather than in a single small point, producing a so-called bidimensional 2D-SWE 1. The stiffness is depicted in color within the area and refreshing of the measurement occurs every 1 - 2 seconds. Once the best image is acquired, the operator chooses a Region Of Interest (ROI) within the color box, where the mean stiffness is then calculated. 2D-SWE can be performed as a "one shot" technique or as a semi-"real-time" technique for a few seconds (at about 1 frame per second) in order to obtain a stable elastogram. With either technique, there should be no motion/breathing during image acquisition. A bidimensional averaged area should overcome the limitation of pSWE to inadvertently investigate small regions of greater or lesser stiffness than average. A shear wave quality indicator could be useful to provide real-time feedback and optimize placement of the sampling ROIs, a technology recently presented by Toshiba(®), but which is still awaiting validation in the literature.Supersonic Imagine by Aixplorer(®) which works with a different modality of insonation and video analysis compared to the the previously-mentioned three techniques (i. e., transient elastography, pSWE and 2D-SWE), leading to a bidimensional assessment of liver stiffness in real time up to 5 Hz and in larger regions; thus this technique is also termed real-time 2 D SWE. It has been available on the market for a few years 19 20, and many articles have been published showing stiffness values quite similar to those of Fibroscan(®) 21; likewise, defined thresholds based on histological findings have appeared in several articles 19 20 21.After this brief summary of the technological state of the art we would like to mention the following critical issues that we believe every user should note prior to providing liver stiffness reports. · The thresholds obtained from the "oldest" techniques for the various fibrosis stages based on hundreds of patients with histology as reference standard cannot be straightforwardly applied to the new ultrasound elastography techniques, even if based on the same principle (e. g. pSWE). In fact, the different manufacturers apply proprietary patented calculation modes, which might result in slightly to moderately different values. It should be kept in mind that the range for intermediate fibrosis stages (F1 to F3) is quite narrow, in the order of 2 - 3 kilopascal (over a total range spanning 2 to 75 kPa with Fibroscan), so that slightly different differences in outputs could shift the assessment of patients from one stage to another. Comparative studies using phantoms and healthy volunteers, as well as patients, are eagerly awaited. In fact, the equipment might not produce linear correlations of measurements at different degrees of severity of fibrosis. As a theoretical example, some equipment might well correlate in their values with an older technique, such as transient elastography, at low levels of liver fibrosis, but not as well in cases of more advanced fibrosis or vice versa. Consequentely, when elastography data are included in a report, the equipment utilized for the measurement should be clearly specified, and conclusions about the fibrosis stage should be withheld if an insufficient number of comparative studies with solid reference standards are available for that specific equipment.. · Future studies using histology as a reference might be biased in comparison to previous studies, since nowadays fewer patients with chronic hepatitis C or hepatitis B undergo biopsy. In fact, due to wide availability of effective drugs as well as the use of established elastography methods for patients with viral hepatitis, most cases submitted to biopsy today have uncertain etiology or inconsistent and inconclusive clinical data. Therefore, extrapolated thresholds from such inhomogeneous populations applied to more ordinary patients with viral hepatitis might become problematic in the future, although no better solution is currently anticipated. This situation might lead to the adoption of a standard validated elastographic method as reference, but this has to be agreed-upon at an international level.. · Ultrasound elastography embedded in conventional scanners usually allows the choice of where to place the ROI within the color stiffness box and whether to confirm or exclude each single measurement when determining the final value. Thus, the operator has a greater potential to influence the final findings than with Fibroscan®, where these choices are not available. This has to be kept in mind to avoid the possibility that an operator could, even inadvertently, tend to confirm an assumption about that specific patient or to confirm the patient's expectations.. · Quality criteria for the new technologies following transient elastography are absent (depending on the manufacturer) or have not been satisfactorily defined, so that the information potentially inserted in a report cannot currently be judged for its reliability by the clinician.. (ABSTRACT TRUNCATED)

Sarcoidosis exclusion criteria: the “simple truth” for a “complicated diagnosis”

The differentiation between sarcoidosis and sarcoid-type reactions remains a clinical and histopathologic diagnostic dilemma. A definitive distinction is yet to be determined according to the current literature data. Sarcoid-like tissue reactions with identifiable infectious or other immunogenic antigens, should be classified as non-specific clinical manifestations of a specific disease. The current assignment of this type of reaction under the generic umbrella of “sarcoidosis” is incorrect and may result in the subsequent misinterpretation of the definition of the disease in general. On the other hand, this may lead to clinical studies with incorrectly selected inclusion criteria and, therefore, contradictory statements regarding the epidemiology and pathogenesis of the disease. Thus we propose the introduction of new criteria for exclusion of sarcoidosis as an autonomous disease. Recent trials on patients with probable sarcoidosis have focused on ideal criteria, or have provided information about the genetic and immunological profile of patients with specific infections or other diseases, which manifest themself as sarcoidal granulomas. This could explain the heterogeneous clinical and/or genetic profiles of the reported patients, who in fact were not affected by the autonomous disease “sarcoidosis”. The simplification of the current available data regarding this issue will be of fundamental importance for the correct direction of future studies, whose aim is to unravel the pathogenesis of the immunological cascade in patients with sarcoidosis and sarcoid-like type of reaction. It is expected that the introduction of exclusion criteria will inevitably lead to a change in the approach to diagnosis as well as the fundamental understanding of this mysterious disease, known as sarcoidosis.

Immunopathogenesis of sarcoidosis and risk of malignancy: a lost truth?

The hypothesis of a relationship between sarcoidosis and malignancy was firstly formulated in 1972 by Brincker. He documented an association of sarcoid reactions or sarcoidosis with 19 lymphomas and associated malignancies. Based on various epidemiological studies, for more than 20 years sarcoidosis has been considered as a condition at increased risk for cancer, particularly lymphoproliferative disorders. The existence of a sarcoidosis-lymphoma syndrome was therefore proposed, highlighting, as a potential mechanism, the uncontrolled lymphocyte proliferation and mitotic activity. A reduced ability to eliminate an antigen and chronic inflammation have been suggested as triggering events. Leading to a reduced tumor immune surveillance, a diminished myeloid dendritic cells (mDC) function, despite up-regulated co-stimulatory and maturation markers, was also raised as potential mechanism. However, some subsequent studies have questioned the presence of a close association between the two entities and have explained those previously published as the result of selection bias and misclassification. Recently, a Swedish population-based cohort study documented a significant overall excess incidence of cancer among sarcoidosis patients, especially those with multiple hospitalizations or admission in older age, emphasizing again a potential neoplastic risk. Therefore, currently, whether these patients have an increased risk of developing malignant lesions is still debated. Larger and unbiased studies are needed before drawing definite conclusions.

Neoangiogenesis is reduced in chronic tendinopathies of type 2 diabetic patients

In diabetes, the prevalence of tendon degeneration is increased. As neoangiogenesis is impaired in several diabetic complications, the aim of this study is to evaluate the neovessel formation in tendinopathies. Patients aged > 55 years were selected, and divided in two groups: a) type 2 diabetic patients, and b) non-diabetic subjects. In both groups, those with ultrasound features of tendinopathy were included, and intratendinous vascularisation was estimated by means of Power Doppler. Ultrasound features of tendinopathy were observed in 104 diabetic subjects and in 221 controls. Neovascularisation, with higher Power Doppler scores, was found more frequently in controls, while lower Power Doppler scores were prevalent in diabetic subjects. In subjects with diabetes, tendinopathic features are significantly higher than healthy controls, while the prevalence of neovascularisation inside tendons is less represented.

Environment and T regulatory cells in allergy

The central role of T regulatory cells in the responses against harmless environmental antigens has been confirmed by many studies. Impaired T regulatory cell function is implicated in many pathological conditions, particularly allergic diseases. The "hygiene hypothesis" suggests that infections and infestations may play a protective role for allergy, whereas environmental pollutants favor the development of allergic diseases. Developing countries suffer from a variety of infections and are also facing an increasing diffusion of environmental pollutants. In these countries allergies increase in relation to the spreading use of xenobiotics (pesticides, herbicides, pollution, etc.) with a rate similar to those of developed countries, overcoming the protective effects of infections. We review here the main mechanisms of non-self tolerance, with particular regard to relations between T regulatory cell activity, infections and infestations such as helminthiasis, and exposure to environmental xenobiotics with relevant diffusion in developing countries.

The persistence of allergen exposure favors pulmonary function decline in workers with allergic occupational asthma

BACKGROUND

In asthmatics, a rapid decline in pulmonary function is observed, likely as a consequence of airways remodeling. Persistence of allergen exposure in patients with occupational asthma (OA) maintains chronic bronchial inflammation, resulting in a more severe lung function decline. Few studies were performed on the effects of allergen exposure cessation.

OBJECTIVE

This study aims at evaluating the influence of allergen exposure cessation on respiratory decline in allergic asthmatic workers.

METHODS

Two groups of workers with allergic OA were selected. The first group (30 workers) changed job after the diagnosis and was no more exposed to sensitizing allergens, and the second group (28 subjects) did not and, as a consequence of preventive measures in the work place, was exposed to a lower level of allergens. All were treated with conventional therapy, according to GINA protocols. FEV1 changes during a 12-year period were evaluated.

RESULTS

Despite pharmacological therapy, the pulmonary function decay slope was steeper in workers continuously exposed to the sensitizing agent (even at reduced level) than in those with a complete cessation of exposure: final FEV1 loss was 512.5 ± 180 ml versus 332.5 ± 108 ml, respectively. The difference became significant after 4 years from the cessation of the exposure.

CONCLUSIONS

The study shows that the cessation of the exposure to allergen in the work place appears the most effective measure in limiting pulmonary function decline in asthmatic workers and underlines the importance of allergic risk assessment and control in the management of occupational asthma.

Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy

Limited joint mobility is frequently observed in elderly people and in patients suffering from diabetes, who represent a growing segment of the population of western countries. Our review wishes to offer the state of art about this interesting topic, which may have important clinical implications, leading to impairment of both basic and instrumental activities of daily living. The main causes of a reduced range of motion are degenerative joint diseases and increased stiffness of collagen tissue. The main biochemical abnormality, common to aging and diabetes, is the non-enzymatic glycosilation of collagen, with advanced glycation end product (AGE) formation, which in turn leads to an increase of collagen cross-links. The most extensive accumulation of AGEs occurs in tissues that contain proteins with low turnover, such as the collagen in the extracellular matrix of articular capsule, ligaments and muscle-tendon units. The increase in collagen cross-linking alters the mechanical properties of these tissues with a decrease in elasticity and tensile strength, and an increase in mechanical stiffness. Besides this, AGEs react with specific cell surface receptors (RAGEs). The engagement of the ligand by RAGEs triggers cell-specific signalling, resulting in enhanced generation of reactive oxygen species and sustained up-regulation of pro-inflammatory mediators and adhesion molecules. An appropriate control of the glucose levels and a diet rich in antioxidant agents are recommended in patients with diabetes. Stretching and strengthening programmes are widely used, in order to prevent and to reduce joint stiffness, but the improvements with physiotherapy are little and short-lasting. Several drugs, which can interfere with AGE formation and removal, or with the cellular effects of AGEs, are under study (among them pyridoxamine, an active form of Vitamin B6, AGE-breaker compounds, glucosamine, rutin and derivatives, soluble RAGE isoforms, and statins). In experimental animal models, these drugs are effective in reducing diabetic complications due to AGE formation; however, further study is necessary before their extensive use in the clinical setting.

Environmental pollution and asthma

Clinical evidences and epidemiological studies show that allergic pathologies of the respiratory tract are increasing in the world areas with high pollution impact, demonstrating how many polluting substances favor both allergic sensitization and the bronchial inflammatory changes characteristic of asthma. It has been shown that asthma, as many other diseases, is a complex interaction between genetic predisposition and environmental stimuli that results in clinical expression of various phenotypes of asthma: allergic, intrinsic etc. Many pollutants have such a potential. Diesel exhaust particles (DEP) can favor allergic sensitization, induce acute asthma attacks and increase bronchial reactivity, acting both on allergen, on bronchial mucosa and on immune cells. In fact, DEP can favor B lymphocytes to shift to a production of IgE and T cells to produce Th2 cytokines. Asthma can be also induced by high exposure to many other substances as NO2 and first of all ozone (O3): strong oxidizing substance that is synthesized, in absence of ventilation, by photochemical reaction due to the combination of ultraviolet sun radiation on exhaust gases as NO2 and hydrocarbons. Ozone is abundant in cities with minimal concentration in the morning gradually increasing during the day until maximal levels in the afternoon and then decreasing during the night. Epidemiological studies show that the number of access to hospital for acute asthma and even the use of bronchodilator by asthmatics increase during the high level periods when Ozone constitute almost 90 percent of the total oxidants in the environment. Particulate matter of very small diameter have a crucial role in favoring asthma attacks, and smaller the substance deeper the penetration in the bronchial tree, with an inflammatory reaction in the peripheral bronchial mucosa characterized by increased vessel permeability, mucosal edema, inflammatory mediator production by damaged epithelium and inflammatory cells that determines acutely a high narrowing of the bronchial lumen and in a long period favor airways remodeling and a rapid decline of respiratory function.

T regulatory cells in allergy

The progressive understanding of the nature and mechanisms of T regulatory (Treg) cells in the last decade has changed the concept of immune tolerance, that is no longer considered as a mere lack of immune reactivity but as a finely regulated process that requires specific activity of cells, adhesion and secreted molecules. Tregs play a key role in maintenance of self-tolerance and induction of tolerance against ubiquitous innocuous non-self antigens, so preventing the onset of autoimmune diseases and allergies. This review will focus on the Treg response in allergy that is characterized by a down-regulation of allergen specific T cell proliferation and inhibition of both Th1 and Th2 cytokines production. Hence, Treg cells suppress allergen-specific Th1 and Th2 cell responses playing an important role in the physiological immune response to allergens. Further, Treg cells are able to suppress IgE production by B lymphocytes and directly or indirectly inhibit the activity of allergic inflammation effector cells, namely eosinophils, basophils and mastcells. Finally, increasing evidence suggests that Treg cells are also implicated in chronicity development of inflammatory diseases. This appears to happen through a fine interaction they entertain with resident tissue cells and has been particularly highlighted in the study of airways remodeling in asthma. The understanding of the mechanisms underlying allergen tolerance has brought new interest in the development of new allergy treatment, able to target Treg cells, both in allergy prevention and in the therapy of established allergy.

Viscosupplementation with intra-articular hyaluronic acid for treatment of osteoarthritis in the elderly

Osteoarthritis (OA) is very disabling condition in the elderly. The current therapeutic approaches (analgesics, NSAIDs, COX-2 inhibitors, steroids) do not delay the OA progression or reverse joint damage. Moreover, they may cause relevant systemic side effects. Hyaluronic acid (HA) is a physiologic component of the synovial fluid and is reduced in OA joints. Therefore, intra-articular injection of HA, due to its viscoelastic properties and protective effect on articular cartilage and soft tissue surfaces of joints, can restore the normal articular homoeostasis. These effects are evident when HA is properly administered into the articular space; therefore, the use of "image-guided" infiltration techniques is mandatory. Viscosupplementation (VS), with different HA preparations (Low and High molecular weight), can be considered when the patient has not found pain relief from other therapies or is intolerant to analgesics or NSAIDs. A 3-5 doses regimen is usually recommended with 1 week interval between each injection. Several studies have shown the efficacy of HA for the treatment of knee OA, with positive effects on pain, articular function (Western Ontario and Mc Master Universities Osteoarthritis Index [WOMAC], Lequesne Index [LI], Range of Motion [ROM]), subjective global assessment and reduction in NSAIDs consumption. In general, the benefit is evident within 3 months and persists in the following 6-12 months. Encouraging but inconclusive results have also been observed for the treatment of shoulder, carpo-metacarpal, hip and ankle OA. However there is the need of better designed studies to prove the effectiveness of these medications, in order to rule out a placebo effect. The therapy is well tolerated with absence of systemic side effects and only with limited local discomfort.

Oral hyposensitization to nickel induces clinical improvement and a decrease in TH1 and TH2 cytokines in patients with systemic nickel allergy syndrome

Some patients with nickel (Ni) allergic contact dermatitis suffer from systemic (intestinal or cutaneous) symptoms after ingestion of Ni-rich foods and experience symptoms reduction with low-Ni diet, a condition termed Systemic Ni Allergy Syndrome (SNAS). We aimed at evaluating whether oral administration of low nickel doses improved clinical conditions and modulated immunological aspects of SNAS, without significant side effects. Thirty-six SNAS patients were enrolled. Treatment started after 1-month of low-Ni diet and consisted in an incremental oral NiOH dose phase (0.3ng to 1.5 microg/week) followed by a 12-months maintenance phase (1.5 microg/week). Randomly, twenty-four patients added Ni therapy to low-Ni diet and 12 remained with diet alone. All patients were allowed rescue medications (antihistamines and topical steroids). After 4 months, Ni-rich foods were gradually reintroduced. In vitro allergen-driven IL13, IL5 and IFN-gamma release by peripheral blood mononuclear cells was evaluated before and after treatment. Twenty-three patients receiving NiOH and the 12 control patients completed the study. Evaluation of SNAS clinical severity (by VAS and drug consumption) showed a significant difference in favor of NiOH-treated patients compared to controls. Twenty of 23 patients in the NiOH group and none in the control group tolerated Ni-rich food reintroduction. Release of all studied cytokines in culture supernatants was significantly lower after NiOH treatment. In conclusion NiOH is effective in reducing symptoms and drug consumption in SNAS and is able to modulate inflammatory parameters.

Survival Time of Nasal Mucous Membrane Ciliated Cells: A Preliminary Study of Cytological Examination by Phase-Contrast Microscopy

The observation of the ciliated cell dynamics by phase-contrast microscope has allowed a profound study of some parameters of the cellular components. The aim of this preliminary study is to assess the surviving time of ciliary cells using the phase-contrast microscope. Nasal cytology was carried out on 50 healthy volunteers. The ciliary beat time was assessed by a video-camera connected with a PC. The time of ciliary beat persistence was extraordinarily long (mean 210 minutes, with range 74–1260). The ciliary activity remained valid as rhythm, synchronism and metachronality. In conclusion, this preliminary study demonstrated that cilia has an energetic autonomy of great importance, able to allow a valid functional activity also in the case of partial sufferance of the cellular unit.

Maintenance venom immunotherapy administered at a 3-month interval preserves safety and efficacy and improves adherence

BACKGROUND

Hymenoptera venom immunotherapy (VIT) is a safe and effective approach to insect sting allergy. However, after discontinuation, relapses can occur in some patients, especially those with a high occupational risk, and they may need to prolong VIT indefinitely. In order to improve adherence, we propose extending the interval between injections of maintenance VIT (MVIT).

OBJECTIVE

To evaluate the safety, efficacy, and patient acceptance of a 3-month interval between MVIT injections in a group of Hymenoptera-allergic patients who are occupationally exposed to insect stings.

PATIENTS AND METHODS

We included 72 patients with severe systemic reactions to Hymenoptera stings. MVIT was administered for 4 years at intervals increasing up to 3 months and then continued for a further 2 years. Patients were informed of the risk of relapse after discontinuation and of the need for indefinite treatment at 3-month intervals.

RESULTS

During the 3-month interval maintenance phase, only 235 local reactions (17.8%) were observed in 17 patients. Sixty patients experienced 125 field re-stings and only 1 experienced a systemic reaction with generalized urticaria.

CONCLUSIONS

The study confirms that the conventional MVIT interval of 4 to 6 weeks can be extended to 3 months in most patients with no adverse events, while maintaining safety and efficacy, improving adherence, and guaranteeing safe continuation of professional activity.

Imaging spectrum of EBV-infection in a young patient

A wide variety of atypical presentations with complications affecting multiple organ systems during acute infectious mononucleosis (IM) is described in the literature, with an increase in the number of teenagers who are susceptible to a severe case of the disease. We report a case of a 14-year-old girl with severe IM and acute abdominal pain. Ultrasonographic (US) evaluation showed a marked thickening of the gallbladder wall (GBW) with enlargement of some mesenteric lymph nodes. CT scan showed multiple enlarged lung nodules of various sizes and a small pleural and pericardial effusion; a hypodense solid mass of unknown etiology was detected in the anterior mediastinum, mimicking a malignant tumor. Hematological analysis of peripheral blood smear was performed to exclude neoplastic pathology. IM was identified as the only underlying disease. The patient was carefully monitored: clinical evaluation, laboratory analysis and US examination were repeated at weekly intervals, until recovery.

Occupational asthma due to low molecular weight agents

Occupational asthma is defined as variable airflow obstruction and airways hyperresponsiveness caused by exposure to agents present in the workplace. Low molecular weight agents such as isocyanates, aldehydes, anhydrides, colophony, dyes, persulphate, amines, acrylates and metals are steadily increasing as causative agents of occupational asthma. Isocyanates, aldehydes and anhydrides my cause sensitisation through an IgE mediated response in some workers. These agents act as haptens which combine with a carrier protein to form a complete antigen. Assays for the detection of specific IgE are standardized for very few agents and have a good specificity, but poor sensitivity. The diagnosis of occupational asthma relies not only on a suggestive hystory showing that asthma is caused or exacerbated specifically by work exposure, but in most cases needs to be confirmed by objective means. Combined monitoring of lung function parameters, such as peak expiratory flow rate at the work site and non specific bronchial hyperresponsiveness during and away from exposure, is necessary. The "gold standard" for confirming a diagnosis in an individual worker still remains the specific bronchoprovocation test, which has now reached a high degree of sensitivity, specificity and reproducibility for agents such a s isocyanates. In occupation asthma due to low molecular weight agents there are no individual risk factors which could predict the susceptibility to develop the disease. The primary prevention is based on appropriate interventions tn the workplace. The strict medical surveillance of workers may allow the early diagnosis and removal from further exposure in order to prevent morbidity and disability.

Cobalt nano-particles modulate cytokine in vitro release by human mononuclear cells mimicking autoimmune disease

The use of particles from micro to nanoscale provides benefits to diverse scientific fields, but because a large percentage of their atoms lie on the surface, nanomaterials could be highly reactive and pose potential risks to humans. Due to their wide range of application, Cobalt nano-particles are of great interest both in industry and in life-science. To date, there are few studies on Co nano-particle toxicology. In this respect, this study aims at evaluating in vitro the potential interference of Co nano-particles on the production of several cytokines (IL-2, IL-4, IL-6, IL-10, IFNgamma and TNFalpha) by PBMCs, comparing their effects to those of Co micro-particles and Co solution (CoCl2). Cells were cultured in Opticell flasks with escalating concentrations (10-5, 10-6 and 10-7 M), of Co nano and micro-particles and CoCl2 or without metal. Cytokines were quantified in the supernatants using a human Th1/Th2 cytokine cytometric bead array. Co micro-particles showed a greater inhibitory effect compared to other Co forms. Its inhibitory activity was detected at all concentrations and towards all cytokines, whereas Co solutions selectively inhibited IL-2, IL-10 and TNF-alpha at maximal concentration. Co nano-particles induced an increase of TNF-alpha and IFN-gamma release and an inhibition of IL-10 and IL-2: a cytokine pattern similar to that detected in the experimental and clinical autoimmunity. On the basis of the obtained data, immune endpoints should be sought in the next series of studies both in vitro and in vivo in subjects exposed to cobalt nano-particles.

Simple renal cysts in hypertensive patients: relation between cyst growing and anti-hypertensive therapy

The study investigates relationship between simple renal cyst enlargement studied by ultrasonography and anti-hypertensive treatment. To this purpose we enrolled 42 patients with newly diagnosed hypertension affected by simple renal cysts. Fourteen were randomly assigned to treatment with ACE-Inhibitors (group 1), twelve to diuretics (group 2) and sixteen to Ca-Antagonists (group 3). Patient performed a basal ultrasonography to evaluate basal cyst dimension before starting anti-hypertensive treatment. Following 12 months of the anti-hypertensive regimen, a new echograph was performed to evaluate changes in cyst size. A control group consisting of 15 patients with normal blood pressure and simple renal cysts was enrolled (group 0). An enlargement of cysts was detected in all patients. However, the enlargement observed in patients treated by Ca-Antagonists was significantly greater than that observed in the other groups (p<0.05). Our study supports the hypothesis that Ca-Antagonists may favor cyst enlargement by enhancing cyclic AMP production. In fact, cAMP and cAMP agonists stimulate fluid secretion by lining cells of the cyst wall, inducing cyst enlargement.

Interleukin-4 and interferon-gamma production during HIV-1 infection and changes induced by antiretroviral therapy

Several lines of evidence indicate that a switch of the cytokine pattern from a predominant type 1 (antiviral and cell mediated response) to type 2 (polyclonal humoral immune response) occurs during the course of Human Immunodeficiency Virus-1 (HIV-1) infection, and represents a key event in the progression of immunodeficiency and dysregulated immune activation. We proposed to further investigate this immunological aspect of HIV-1 disease, in naive and in patients treated with Highly Active Antiretroviral Therapy (HAART). The prototypic cytokines chosen were Interleukin (IL)-4 and Interferon-gamma (IFN-gamma), whose in vitro production was determined in mononuclear cell cultures stimulated with different T lymphocyte mitogenic agents (anti-CD3, Phytohaemoagglutin-P -PHA-, E. coli B04/035 Lipopolysaccharide -LPS-). We classified all the patients on the basis of the number of CD4+ lymphocytes and we found a progressive, even if not significant decrease in the baseline production of IFN-gamma with the progression of the immunodeficiency. The mean value of baseline IFN-gamma in the group of patients with CD4+>500 cells/microL was 7.79 +/- 3.1 pg/mL while in the group with CD4+<200 cells/microL it was 4.66 +/- 2.22. We didn't find significant differences in the baseline production of IL-4 in these groups and in IFN-gamma and IL-4 production in LPS-stimulated cultures. We also re-assessed 12 patients after one year's follow-up. They presented a significant increase in IFN-gamma production compared to the first assessment in the LPS-stimulated cultures (baseline IFN-gamma 2.87 +/- 1.17 pg/mL, after 12 months 19.15 +/- 5.19 pg/mL; p= 0.03). In the 12 patients in follow-up IL-4 production showed a decreased in PHA-stimulated cultures with mean values of 16.65 +/- 14.32 pg/mL at baseline and 6.54 +/- 6.54 pg/mL after follow-up. These results highlight the immunorestoring effects of HAART. IL-4 production was lower in the treated subjects compared to the naive ones in PHA-stimulated cultures (mean values: IL-4=13.42 +/- 11.08 pg/mL in the naive patients and 9.75 +/- 65 pg/mL in the treated patients). The IFN-gamma values in anti-CD3 stimulated cultures were also higher in the treated patients, but this increase was not significant.

Atherosclerotic plaque formation and risk factors

Atherosclerosis (AT) is a progressive disease characterized by the accumulation of lipids, fibrous materials, and mineral in the arteries. Although many generalized or systemic risk factors predispose to its development, AT affect various regions of the circulation preferentially and yields distinct clinical manifestations depending on the particular circulatory bed affected. The progression of AT is currently believed to involve the interaction of endothelium, monocytes, and leukocytes, as well as the influences of cytokines, oxidized lipoproteins, hypertension, tobacco use, dyslipidemia, homocystinemia, and genetic determinants.

The role of antileukotrienes in the treatment of asthma

Cysteinyl leukotrienes (Cys-LTs) are mediators released in asthma and are both direct bronchoconstrictors and proinflammatory substances that mediated several steps in the pathophysiology of chronic asthma, including inflammatory cells recruitment, vascular leakage, and possibly airway remodelling. Available evidence from clinical trials and real world experience derived from managing patients with asthma justifies a broader role for antiLTRAs in asthma management than that recommended in the National Asthma Education and Prevention Programm (NAEPP) and National Health Lung and Blood Institute (NHLBI) treatment guidelines. Leukotriene-receptor antagonist drugs (LTRAs) seem to be effective alternatives to inhaled corticosteroids (ICS) either as monotherapy or as adjunctive therapy that reduces the need for higher doses of ICS in patients with mild-to-moderate persistent asthma. LTRAs may be used as adjunctive therapy for al levels of disease severity because they are effective in combination with ICS during long-term maintenance therapy. The agents seem especially effective in preventing aspirin-induced asthma, exercise-induced asthma (EIA) and they may provide an additional advantage of reducing nasal congestion in patients with both asthma and rhinitis.

A spectrum of antibody (IgG. IgG1, IgM) response in mice infected with trichinella spiralis treated with L-mimosine

The purpose of this study was to demonstrate the anti-inflammatory effects of L-mimosine on chronic inflammation, by investigating its effect on the immunological response of BALB/c mice infected with the nematode parasite Trichinella spiralis. Specific anti-parasite immunoglobulins (IgG, IgG1 and IgM) were detected by the ELISA method in the serum of both the treated and the untreated animals at different periods of time for 60 days post infection. Two groups consisting of 18 mice each were used. The mice were 6 weeks of age. Both groups were infected with 220 larvae (L1-T. spiralis) per os: one group was administered an intraperitoneal injection of L-mimosine (200 &mgr;g/100 ml/dose) for 27 days (the first injection started 7 days before infection) and the second group was administered an intraperitoneal injection of saline solution (100 &mgr;l/dose). Parasite specific IgG, IgG1 and IgM levels were determined in the sera of infected, untreated mice. The levels of IgG and IgG1 were increased following infection and remained elevated throughout the experimental period, while IgM was significantly decreased on the 50th day post-infection. These levels were found to be lower in the L-mimosine treated infected mice, compared to the untreated mice. The inhibition started from day 10 and continued until day 60. In healthy animals, the production of immunoglobulins was not measurable. Non-infected animals treated with L-mimosine also showed no detectable anti-parasite specific immunoglobulins.

Steroid and antihistamines modulate RANTES release in cultured peripheral blood mononuclear cells of atopic patients

RANTES plays a crucial role in cell recruitment in allergic inflammation. We investigated the pharmacological modulation of RANTES release in cultured peripheral blood mononuclear cells obtained from allergic patients with active asthma. Chemokine production was assessed before and after 15 day treatment with histamine-1 receptor antagonists (antihistamines) (Loratadine or Cetirizine) and a steroid (Deflazacort), both in unstimulated and PHA-stimulated cell cultures. Results were compared with those obtained from placebo-treated patients. During the treatment period, patients recorded morning and evening peak expiratory flow (PEF) by the mini-Wright procedure. PEF absolute values and diurnal variability significantly improved respect to the pre-treatment in steroid-treated patients, in comparison to the placebo and antihistamine-treated groups (p&#x003C;0.001 and 0.01, respectively). PEF diurnal variability in the antihistamine-treated group were lower than placebo-treated group without statistical significance (p=0.06). No differences could be found in RANTES levels in supernatants of all cultures between the two antihistamines. RANTES release significantly decreased in supernatants of all cell cultures from steroid (p&#x003C;0.01) and antihistamine (p=0.03 and 0.04) groups after treatments, compared to the basal values; whereas it increased slightly in controls. Co-variance analysis on RANTES levels, adjusting for pre-treatment values, showed a significant reduction of RANTES release by PHA-stimulated PBMCs from steroid (p=0.003) and anti-histamine (p=0.03) groups, with respect to the placebo group. The same statistical tool applied between the steroid and the antihistamine groups showed, after therapy, the lowest levels of RANTES to be associated with steroid treatment (p=0.005). The study shows that the steroid is the most effective drug in modulating RANTES release from PBMCs. However, antihistamines, which are able to reduce cell recruitment due to chemokine release, avoiding important side effects, may be useful in long term therapy in controlling and preventing allergic inflammation.

Zafirlukast versus budesonide on bronchial reactivity in subjects with mild-persistent asthma

Asthma is one of the most common chronic diseases in children and adults. Recent studies have shown that in asthmatic patients treated with inhaled corticosteroids there is a better disease’s control when adding a second drug, than increasing the corticosteroid’s dose. The aim of this study has been to evaluate the effectiveness and tolerance of zafirlukast, a leukotriene receptor antagonist, versus budesonide in clinically steady patients with mild persistent bronchial asthma. We have enrolled 36 subjects non smokers, with mild persistent bronchial asthma and 12 healthy subjects as control group. At the beginning of this study and at the end of the treatment (8 weeks), all patients underwent complete clinical work-up, pulmonary function testing (FEV1, PEF and FVC) and methacholine challenge test. The patients were divided into 3 groups: group A) 20 mg of zafirlukast twice a day; group B) 400 mg of budesonide twice a day; group C) 20 mg of zafirlukast twice a day and 400 mg of budesonide twice a day. Basal FEV1 and PEF presented no significant statistical differences between control subjects and patients of group A, B and C. After eight weeks there were no significant changes for FEV1 and PEF among the three groups. After therapy a strong significant increase of PD20 was documented in group A (p&#x003C;0.005), group B (p&#x003C;0.001) and group C (p&#x003C;0.005), respect to baseline values. The antileukotriene drugs could be taken as an alternative drug, or in association with low-dose inhaled corticosteroids, in patients with mild persistent asthma, both for their clinical effectiveness and their easy ingestion, which is confirmed in compliance studies on inhaled steroids.

Histochemical and biochemical analysis of phospholipase C isoforms in normal human gastric mucosa cells

The expression and activity of PIP2-specific phospholipase C (PLC) in healthy human gastric mucosa cells were investigated by means of Western blotting, immunohistochemistry and in vitro activity assays. The results provide direct evidence for an almost exclusive expression of the PLC beta family and at the same time supply a cellular cartography of each represented isoform of this family. In this context, the putative roles of each isoform in the signaling events regulating the gastric mucosa metabolic machinery are discussed. These data provide a unique map of the specific expression and cellular distribution of the most represented PLC isoforms in healthy human gastric mucosa cells, which may constitute a reference point in future studies aimed at highlighting possible cytochemical and biochemical hallmarks of metaplastic or malignant transformation.

Pharmacological and dietary prophylaxis and treatment of acute actinic esophagitis during mediastinal radiotherapy

Our purpose was to evaluate a pharmacological and dietary protocol of prophylaxis and treatment of acute actinic esophagitis during mediastinal radiotherapy. This phase II study was conducted on 29 patients affected by cancer not directly involving the esophagus. The irradiated volume included at least 10 cm of esophagus with a median dose of 46 Gy and the incidence of clinical acute esophagitis was scored with RTOG-EORTC tables. During the entire course of radiation therapy all patients were subjected to prophylaxis pharmacological therapy in addition to dietetic rules commonly used. All patients were evaluable, 9 (31%) had no acute esophageal toxicity, 20 (69%) had toxicity of degree 1, and no patient showed a toxicity of degree 2, 3, or 4, there were no toxicity-related related interruptions of the radiotherapy course. In conclusion, this low cost protocol seems to reduce the incidence and degree of acute radiation esophagitis (without added morbidity), compared with literature reports.

Seasonal variability of non-specific bronchial responsiveness in asthmatic patients with allergy to house dust mites

The aim of the study was to assess the seasonal variability of non-specific bronchial responsiveness to methacholine in allergic asthma. One hundred sixty-five patients (83 male and 82 female) entered the study: 86 subjects (group A) with allergy exclusively to mites and 79 (group B) with concomitant allergy to pollens, e.g., "Graminae" and "Parietaria." Inclusion criteria were the absence of sensitization to other allergens, no smoking habit, withdrawal from steroids, bronchodilators, sodium cromoglycate, and antihistamines for at least four weeks before enrollment, FEV1 > 70% of the predicted value, and absence of other respiratory diseases and of upper and lower respiratory tract infections for at least one month before the methacholine challenge. None of the patients had been previously treated with specific immunotherapy. Subjects of each group (A and B) underwent methacholine challenge at first visit and were divided into four subgroups according to the period when the challenge was performed. Subgroups A1 and B1 performed the challenge in December, January, and February; subgroups A2 and B2 in March, April, and May; subgroups A3 and B3 in June, July, and August; subgroups A4 and B4 in September, October, and November. PD20 values were expressed as the natural logs of the cumulative dose of methacholine causing at least a 20% fall in FEV1. Statistical analysis was carried out using multiple group analysis and Student's t-test. Results showed that the highest non-specific bronchial responsiveness was observed in autumn (ln PC20 = 4.54 +/- 1.51) in patients allergic to mites only (group A), and in summer (ln PC20 = 4.72 +/- 2.11) in those of group B. Multiple group analysis showed statistical significant differences between subgroups within each group (group A, p = 0.039; group B, p < 0.001). In patients allergic exclusively to house dust mites (group A), multiple comparisons and Student's t-test showed statistically significant differences between non-specific bronchial responsiveness (NSBR) assessed in autumn and those of other seasons (winter, p = 0.002; spring, p < 0.001; summer, p = 0.082). These results confirm that the level of allergen exposure may influence NSBR. Mite-allergic patients showed an increase of NSBR in autumn, possibly as a consequence of higher indoor mite concentration. However, mite- and grass-allergic patients had wider variations of NSBR, possibly reflecting changes in seasonal pollen concentration.

Arterial disease in dipper and nondipper hypertensive patients

Carotid artery and small vessel structural changes were evaluated in 45 dipper and 45 nondipper hypertensive subjects matched for sex, age, body mass index, smoking habit, and serum lipids. Patients underwent carotid ultrasonography to evaluate lumen diameter, intima-media thickness, cross-sectional area, and atherosclerotic plaques, and plethysmographic examination to record minimum forearm vascular resistance. In the whole study population, carotid cross-sectional area and prevalence of atherosclerotic plaques tended to be higher in nondippers than in dippers (19.9 +/- 6.0 v 17.5 +/- 6.1 mm2, P = .07, and 40% v 26%, P = .18), whereas intima-media thickness and minimum forearm vascular resistance were significantly higher in nondippers than in dippers (0.89 +/- 0.12 v 0.8 +/- 0.15 mm, P < .02, and 2.53 +/- 0.3 v 2.34 +/- 0.3 arbitrary resistance units (RU), P < .02). When gender was taken into account, different results were obtained in men and women. In men, vascular characteristics were not significantly different between dippers and nondippers. In women, carotid cross-sectional area and prevalence of atherosclerotic plaques tended to be higher in nondippers than in dippers (18.3 +/- 4.9 v 15.5 +/- 4.5 mm2, P = .06, and 40% v 15%, P = .15), and intima-media thickness and minimum forearm vascular resistance were significantly higher in nondippers than in dippers both before (0.84 +/- 0.1 v 0.73 +/- 0.1 mm, P < .01, and 2.38 +/- 0.3 v 2.16 +/- 0.2 RU, P < .01) and after adjustment for 24-h blood pressure. In conclusion, our data suggest that the progression of vascular disease may be differently affected in the two sexes by a different circadian blood pressure profile.

Target organ status and serum lipids in patients with white coat hypertension

Target organ status and serum lipids were investigated in white coat hypertension in comparison with sustained hypertension and normotension. We selected three groups balanced for sex, age, body mass index, and smoking habit: 50 sustained hypertensives (clinical hypertension and 24-hour ambulatory blood pressure > 135/85 mm Hg, a cutoff limit obtained from a normotensive population), 25 white coat hypertensives (clinical hypertension and 24-hour ambulatory blood pressure < 135/85 mm Hg), and normotensives. Subjects underwent echocardiographic examinations to assess left ventricular mass index, carotid ultrasonography to evaluate intima-media thickness and atherosclerotic plaques, venous occlusion plethysmography to record minimum forearm vascular resistance, and determinations of serum lipid profile and 24-hour urinary albumin excretion. Compared with sustained hypertensives, the white coat hypertensives had significantly lower values of left ventricular mass index (125.9 +/- 20 versus 97.6 +/- 11.5 g/m2, P < .05, intima-media thickness (0.85 +/- 0.18 versus 0.71 +/- 0.15 mm, P < .05), minimum forearm vascular resistance (2.33 +/- 0.11 versus 2.04 +/- 0.08 resistance units, P < .05), urinary albumin excretion values (15.1 +/- 13.8 versus 4.45 +/- 1.48 mg per 24 hours, P < .0001), prevalence of left ventricular hypertrophy (versus 4%, P < .002), intima-media thickening 28% versus 4%, P < .015), and microalbuminuria (22% versus 0%, P < .015). No significant difference, however, was observed between the white coat hypertensives and the normotensives. Serum lipid profile was similar in the white coat hypertensives and in the normotensives.(ABSTRACT TRUNCATED AT 250 WORDS)

Captopril therapy in severe hypertension: effects of intravenous administration

In 10 severe hypertensives the effects of intravenous administration of scalar doses of captopril were evaluated. The behaviour of blood pressure, heart rate, electrocardiographic pattern and left ventricular (LV) diastolic function, in basal condition (T0) and after 60 min of captopril infusion (T60), were analysed. Diastolic performance was assessed by pulsed wave Doppler echocardiography, evaluating transmitral peak flow velocities in early diastole (PEDV), late diastole (PLDV) and the PEDV/PLDV ratio. All patients showed an increase in LV mass (assessed by M-mode echocardiography) and altered diastolic performance, documented by high PLDV and low PLDV/PEDV ratio values. Clinical, haematological, urinary and biochemical data were also assessed for possible side effects. Captopril significantly reduced BP in 7 out of the 10 patients. Supine BP decreased from 212 +/- 15.3/126 +/- 5.6 to 171 +/- 17.7/98 +/- 11.8 mmHg (T0 vs. T60 P less than 0.0001). No electrocardiographic abnormality was observed during the study. The goal of antihypertensive effect was reached at 40-50 min after the onset of captopril therapy. Heart rate showed a small but constant decrease (from 76 +/- 7.7 to 72.8 +/- 5.7 beats/min, T0 vs. T60, P less than 0.05). Side effects of intravenous captopril were always mild and transient; no severe hypotension as 'first dose effect' was observed in our study. The echocardiographic data showed a significant decrease in LV end-systolic dimension after captopril infusion, while left atrial, LV diastolic dimension and fractional shortening remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

[A heparin-glucuronylglucosaminoglycan combination for topical use. An evaluation of the therapeutic effects in induced experimental muscle damage and in minor sports injuries]

The aim of the study was to evaluate the clinical efficacy of the association of heparin and sulodexide on experimental pain and on "small sport traumatology". In the experimental part of the study, cutaneous pain threshold and subcutaneous tissue ticking were measured after the induction of an algogenic focus in deep somatic side. In the clinical part of the study, pain intensity (by A.V. scale), athletic performance and therapy duration, in athletes from muscular or articular posttraumatic injuries, were also assessed. After the therapy with the examined drug, a less significant lowering of cutaneous pain threshold and a less subcutaneous tissue thickening were found in the experimental study; in the clinical study a significant reduction of pain intensity and a quick restore of athletic performance were revealed. These results allow to conclude that the drug in effective to reduce painful symptomatology in both experimental and clinical conditions, by the limitation of some aspects of inflammation.

[Use of citiolone in chronic hepatitides. Results of a research with clinical and laboratory controls]

The therapeutic possibilities offered by the use of a new substance, 3-acetamido-2-oxo-tetrahydro-thiophene or citiolone, in two groups of patients, the first suffering from persistent chronic hepatitis, the second from aggressive chronic hepatitis and-or compensated cirrhosis diagnosed on the basis of clinical, laboratory, and bioptic findings have been studied. The experiment was of "between patients" pattern and findings were obtained with the double-blind method. Tests were compared with a placebo and all patients were treated with a basic therapy consisting of a polyvitaminic complex. In both groups, the results confirmed the therapeutic effectiveness of the new substance and this was demonstrable, including statistically, in an improvement in the clinical picture and, above all, in certain liver function exploration tests. At termination of the treatment cycle, liver biopsies were carried out in certain patients and these showed an improvement in the liver cell picture.