Fabry App: the value of a portable technology in recording day-to-day patient monitored information in patients with Fabry disease

BACKGROUND

Fabry disease is a rare inherited disorder resulting from deficient α-galactosidase A enzyme activity. Common disease manifestations are sweating abnormalities, neuropathic pain, gastrointestinal symptoms and fatigue. Challenges are faced by health care professionals in evaluating symptom burden in the current clinical setting, and the demand for alternative methods for monitoring disease-specific symptoms has seen an acceleration in recent years. Smartphone technologies offer the potential for continuity of care and surveillance. As a part of a quality improvement project, a disease specific app was developed in collaboration with a software company (Health Touch Ltd) and made available for patient use in May 2018. The Fabry mobile app records five categories: pain, gastrointestinal symptoms, sweating, activity levels, medications. Fabry disease patients with gastrointestinal and pain symptoms attending the Lysosomal Storage Disorders Unit of the Royal Free London NHS Foundation Trust were reviewed to assess eligibility and invited to download the app for recording their symptoms (activity, sweating, pain and gastrointestinal) and medications. Patient-generated data were transmitted to a secure website for clinicians to review.

RESULTS

One-hundred and thirty-nine symptomatic Fabry disease patients who had a smartphone (iPhone or android) were invited to download the app. Sixty-seven patients (26 males and 41 females; median age, 49 years [range, 20-81]) downloaded and tracked the Fabry App at least once. The median frequency of use per patient was 6 (range, 1-629). Pain in the hands and abdominal pain were significantly higher (p = 0.009 and p = 0.007, respectively) in patients with classic phenotype compared with patients with non-classic phenotypes.

CONCLUSIONS

We demonstrated the feasibility and acceptability of a smartphone app to facilitate the remote assessment and monitoring of Fabry disease symptom burden on a daily/weekly basis, as an alternative to the current standard of care that requires patients to recall their symptoms during 6 to 12 monthly annual clinic visits. Patients who were more likely to use the app had greater disease burden. This innovation has the potential to assess disease progression, early therapeutic intervention, thereby decreasing the burden of morbidity and mortality among Fabry patients, and to record long-term effects of Fabry-specific therapies.

Radiographic Cortical Thickness Index Predicts Fragility Fracture in Gaucher Disease

Background Patients with Gaucher disease (GD) have a high risk of fragility fractures. Routine evaluation of bone involvement in these patients includes radiography and repeated dual-energy x-ray absorptiometry (DXA). However, osteonecrosis and bone fracture may affect the accuracy of DXA. Purpose To assess the utility of DXA and radiographic femoral cortical thickness measurements as predictors of fragility fracture in patients with GD with long-term follow-up (up to 30 years). Materials and Methods Patients with GD age 16 years and older with a detailed medical history, at least one bone image (DXA and/or radiographs), and minimum 2 years follow-up were retrospectively identified using three merged UK-based registries (Gaucherite study, enrollment 2015-2017; Clinical Bone Registry, enrollment 2003-2006; and Mortality Registry, enrollment 1993-2019). Cortical thickness index (CTI) and canal-to-calcar ratio (CCR) were measured by two independent observers, and inter- and intraobserver reliability was calculated. The fracture-predictive value of DXA, CTI, CCR, and cutoff values were calculated using receiver operating characteristic curves. Statistical differences were assessed using univariable and multivariable analysis. Results Bone imaging in 247 patients (123 men, 124 women; baseline median age, 39 years; IQR, 27-50 years) was reviewed. The median follow-up period was 11 years (IQR, 7-19 years; range, 2-30 years). Thirty-five patients had fractures before or at first bone imaging, 23 patients had fractures after first bone imaging, and 189 patients remained fracture-free. Inter- and intraobserver reproducibility for CTI/CCR measurements was substantial (range, 0.96-0.98). In the 212 patients with no baseline fracture, CTI (cutoff, ≤0.50) predicted future fractures with higher sensitivity and specificity (area under the receiver operating characteristic curve [AUC], 0.96; 95% CI: 0.84, 0.99; sensitivity, 92%; specificity, 96%) than DXA T-score at total hip (AUC, 0.78; 95% CI: 0.51, 0.91; sensitivity, 64%; specificity, 93%), femoral neck (AUC, 0.73; 95% CI: 0.50, 0.86; sensitivity, 64%; specificity, 73%), lumbar spine (AUC, 0.69; 95% CI: 0.49, 0.82; sensitivity, 57%; specificity, 63%), and forearm (AUC, 0.78; 95% CI: 0.59, 0.89; sensitivity, 70%; specificity, 70%). Conclusion Radiographic cortical thickness index of 0.50 or less was a reliable independent predictor of fracture risk in Gaucher disease. Clinical trial registration no. NCT03240653 © RSNA, 2022 Supplemental material is available for this article.

Platelets from patients with visceral obesity promote colon cancer growth

Several studies highlighted the importance of platelets in the tumor microenvironment due to their ability to interact with other cell types such as leukocytes, endothelial, stromal and cancer cells. Platelets can influence tumor development and metastasis formation through several processes consisting of the secretion of growth factors and cytokines and/or via direct interaction with cancer cells and endothelium. Patients with visceral obesity (VO) are susceptible to pro-thrombotic and pro-inflammatory states and to development of cancer, especially colon cancer. These findings provide us with the impetus to analyze the role of platelets isolated from VO patients in tumor growth and progression with the aim to explore a possible link between platelet activation, obesity and colon cancer. Here, using xenograft colon cancer models, we prove that platelets from patients with visceral obesity are able to strongly promote colon cancer growth. Then, sequencing platelet miRNome, we identify miR-19a as the highest expressed miRNA in obese subjects and prove that miR-19a is induced in colon cancer. Last, administration of miR-19a per se in the xenograft colon cancer model is able to promote colon cancer growth. We thus elect platelets with their specific miRNA abundance as important factors in the tumor promoting microenvironment of patients with visceral obesity.

Transcriptional, epigenetic and metabolic signatures in cardiometabolic syndrome defined by extreme phenotypes

BACKGROUND

This work is aimed at improving the understanding of cardiometabolic syndrome pathophysiology and its relationship with thrombosis by generating a multi-omic disease signature.

METHODS/RESULTS

We combined classic plasma biochemistry and plasma biomarkers with the transcriptional and epigenetic characterisation of cell types involved in thrombosis, obtained from two extreme phenotype groups (morbidly obese and lipodystrophy) and lean individuals to identify the molecular mechanisms at play, highlighting patterns of abnormal activation in innate immune phagocytic cells. Our analyses showed that extreme phenotype groups could be distinguished from lean individuals, and from each other, across all data layers. The characterisation of the same obese group, 6 months after bariatric surgery, revealed the loss of the abnormal activation of innate immune cells previously observed. However, rather than reverting to the gene expression landscape of lean individuals, this occurred via the establishment of novel gene expression landscapes. NETosis and its control mechanisms emerge amongst the pathways that show an improvement after surgical intervention.

CONCLUSIONS

We showed that the morbidly obese and lipodystrophy groups, despite some differences, shared a common cardiometabolic syndrome signature. We also showed that this could be used to discriminate, amongst the normal population, those individuals with a higher likelihood of presenting with the disease, even when not displaying the classic features.

Case Report: Mutation in AIMP2/P38, the Scaffold for the Multi-Trna Synthetase Complex, and Association With Progressive Neurodevelopmental Disorders

Background: Leukodystrophies constitute a heterogeneous group of inherited disorders primarily affecting the white matter of the central nervous system. Aminoacyl-tRNA synthetases (ARSs) catalyze the attachment of an amino acids to their cognate transfer RNAs (tRNAs). Pathogenic variants in both cytosolic and mitochondrial ARSs have been linked to a broad range of neurological disorders, including hypomyelinating leukodystrophies and pontocerebellar hypoplasias (PCH). Aminoacyl tRNA synthetase-interacting multifunctional protein 2 (AIMP2), one of the three non-catalytic components of multi ARS complex, harbors anti-proliferative activity and functions as a proapoptotic factor thus promoting cell death. We report a case of a 7-month-old infant with a complex clinical presentation, including weight loss, severe anemia, skeletal abnormalities, microcephaly and MR imaging features of leukodystrophy with a novel mutation in AIMP2.

Methods: Whole-exome sequencing (WES) was performed on the proband. Parental samples were analyzed by PCR amplification and Sanger sequencing.

Results: Whole-exome sequencing revealed a novel variant c.A463T in the homozygous state in exon 3 (NM_001,326,607) of AIMP2 [p.(K155X)] in the proband. Parental carrier status was confirmed by target sequencing.

Conclusion: Here, we present an Iranian case with leukodystrophy with a novel AIMP2 mutation. This finding broadens the mutational and phenotypic spectra of AIMP2-related leukodystrophy and offers guidance for proper genetic counselling for pre- and post-natal screenings as well as for disease management.

Jaw involvement in Gaucher disease: a not-so-uncommon feature of a rare disease

Gaucher disease is an inborn error of metabolism resulting from the deficiency of the enzyme glucocerebrosidase and consequent accumulation of glucocerebroside within the lysosomes of macrophages. The clinical presentation is very diverse, depending on the age of onset and the severity of the disease, and results from the progressive infiltration of lipid-laden cells in various organs. Common manifestations of Gaucher disease include enlarged liver and/or spleen (hepatosplenomegaly), bone marrow disease (pancytopenia) and bone abnormalities, which are extremely variable and can affect multiple skeletal sites. While bone involvement of long bones and vertebrae is a well-recognised feature of Gaucher disease, jawbone involvement is less commonly noted. Here, we describe a case of a 63-year-old patient with type 1 Gaucher disease with a history of long-term use of bisphosphonates and who had presented with dental pain, with subsequent investigations confirming the radiological features of jaw involvement in Gaucher disease, including periodontal disease.

Impact of SARS-CoV-2 (COVID-19) pandemic on patients with lysosomal storage disorders and restoration of services: experience from a specialist centre

This study aims to evaluate the impact of the COVID-19 pandemic on the lysosomal disorders unit (LSDU) at Royal Free London NHS Foundation Trust (RFL), a highly specialised national service for diagnosis and management of adults with lysosomal storage disorders (LSD). Review of home care enzyme replacement therapy (ERT) and emergency care, and COVID-19 shielding categories as per UK government guidance. New clinical pathways were developed to manage patients safely during the pandemic; staff well-being initiatives are described. LSDU staff were redeployed and/or had additional roles to support increased needs of hospitalised COVID-19 patients. During the first lockdown in March 2020, 286 of 602 LSD patients were shielding; 72 of 221 had home care ERT infusions interrupted up to 12 weeks. During the pandemic, there was a 3% reduction in home care nursing support required, with patients learning to self-cannulate or require support for cannulation only. There were no increased adverse clinical events during this period. Twenty-one contracted COVID-19 infection, with one hospitalised and no COVID-19 related deaths. In 2020, virtual clinics were increased by 88% (video and/or telephone) compared to 2019. RFL well-being initiatives supported all staff. We provide an overview of the impact of the COVID-19 pandemic on staff and patients attending a highly specialised rare disease service. As far as we are aware, this is the first detailed narrative on the challenges and subsequent rapid adaptations made, both as part of a large organisation and as a specialist centre. Lessons learnt could be translated to other rare disease services and ensure readiness for any future pandemic.

Short-term benefits of an unrestricted-calorie traditional Mediterranean diet, modified with a reduced consumption of carbohydrates at evening, in overweight-obese patients

The Mediterranean diet (MeD) is believed to promote health; nevertheless, changes in the nutritional patterns in the Mediterranean area (increased intake of refined carbohydrates/saturated fats; reduced fibers intake; main calorie load shifted to dinner) led to reduced MeD benefits in recent decades. We retrospectively investigated the effects of a MeD with a low intake of refined carbohydrates in the evening ("MeDLowC") on body weight (BW) and metabolic profile of overweight/obese subjects. According to their adherence to MeDLowC, subjects were classified into 44 (41%) individuals with "excellent" adherence and 63 (59%) with "poor" adherence. Nutritional counseling induced an improvement in BW, glucose metabolism and liver transaminases in both groups, with an increased magnitude of these effects in the "Excellent" adherence group. "Excellent" adherence to MeDLowC improved insulin sensitivity and lipid metabolism. In conclusion, MeD with a restriction of carbohydrates in the evening significantly ameliorates obesity and associated metabolic complications.

Genes and miRNA expression signatures in peripheral blood mononuclear cells in healthy subjects and patients with metabolic syndrome after acute intake of extra virgin olive oil

Extra virgin olive oil (EVOO) consumption has been associated with reduced cardiovascular risk but molecular mechanisms underlying its beneficial effects are not fully understood. Here we aimed to identify genes and miRNAs expression changes mediated by acute high- and low-polyphenols EVOO intake. Pre- and post-challenge gene and miRNAs expression analysis was performed on the peripheral blood mononuclear cells (PBMCs) of 12 healthy subjects and 12 patients with metabolic syndrome (MS) by using microarray and RT-qPCR. In healthy subjects, acute intake of EVOO rich in polyphenols was able to ameliorate glycaemia and insulin sensitivity, and to modulate the transcription of genes and miRNAs involved in metabolism, inflammation and cancer, switching PBMCs to a less deleterious inflammatory phenotype; weaker effects were observed in patients with MS as well as in healthy subjects following low-polyphenol EVOO challenge. Concluding, our study shows that acute high-polyphenols EVOO intake is able to modify the transcriptome of PBMCs through the modulation of different pathways associated with the pathophysiology of cardio-metabolic disease and cancer. These beneficial effects are maximized in healthy subjects, and by the use of EVOO cultivars rich in polyphenols. Nutrigenomic changes induced by EVOO thus legitimate the well-known beneficial effects of EVOO in promoting human health and, potentially, preventing the onset of cardiovascular disease and cancer.

Integrative miRNA and whole-genome analyses of epicardial adipose tissue in patients with coronary atherosclerosis

BACKGROUND

Epicardial adipose tissue (EAT) is an atypical fat depot surrounding the heart with a putative role in the development of atherosclerosis.

METHODS AND RESULTS

We profiled genes and miRNAs in perivascular EAT and subcutaneous adipose tissue (SAT) of metabolically healthy patients without coronary artery disease (CAD) vs. metabolic patients with CAD. Compared with SAT, a specific tuning of miRNAs and genes points to EAT as a tissue characterized by a metabolically active and pro-inflammatory profile. Then, we depicted both miRNA and gene signatures of EAT in CAD, featuring a down-regulation of genes involved in lipid metabolism, mitochondrial function, nuclear receptor transcriptional activity, and an up-regulation of those involved in antigen presentation, chemokine signalling, and inflammation. Finally, we identified miR-103-3p as candidate modulator of CCL13 in EAT, and a potential biomarker role for the chemokine CCL13 in CAD.

CONCLUSION

EAT in CAD is characterized by changes in the regulation of metabolism and inflammation with miR-103-3p/CCL13 pair as novel putative actors in EAT function and CAD.

Adenomatous polyposis coli (APC)-induced apoptosis of HT29 colorectal cancer cells depends on mitochondrial oxidative metabolism

Adenomatous polyposis coli (APC) is a tumor suppressor involved in the Wnt signaling, the primary driving force of the intestinal epithelium homeostasis. Alterations of components of the Wnt pathway, and in most cases mutations of APC, have been reported to promote colorectal cancer (CRC). During differentiation the enterocytes migrate from the crypt to the tip of the villus where they undergo apoptosis thus ensuring the continual renewal of the intestinal mucosa. The differentiation process is characterized by an activation gradient of the Wnt signaling pathway accompanied by a metabolic switch from glycolysis to mitochondrial oxidative phosphorylation along the crypt-villus axis. In the present work, we study the relationship between the expression of wild type APC protein and mitochondrial oxidative metabolism in HT29 colorectal cancer cells, originally carrying endogenous inactive APC alleles. By generating mtDNA-depleted (rho0) APC-inducible HT29 cells, we demonstrate for the first time that the APC-dependent apoptosis requires the production of reactive oxygen species (ROS) by the mitochondrial respiratory chain. The possible role of mitochondria as putative target in the prevention and/or therapy of colorectal cancer is herein discussed.

Clustering nuclear receptors in liver regeneration identifies candidate modulators of hepatocyte proliferation and hepatocarcinoma

Background & Aims

Liver regeneration (LR) is a valuable model for studying mechanisms modulating hepatocyte proliferation. Nuclear receptors (NRs) are key players in the control of cellular functions, being ideal modulators of hepatic proliferation and carcinogenesis.

Methods & Results

We used a previously validated RT-qPCR platform to profile modifications in the expression of all 49 members of the NR superfamily in mouse liver during LR. Twenty-nine NR transcripts were significantly modified in their expression during LR, including fatty acid (peroxisome proliferator-activated receptors, PPARs) and oxysterol (liver X receptors, Lxrs) sensors, circadian masters RevErbα and RevErbβ, glucocorticoid receptor (Gr) and constitutive androxane receptor (Car). In order to detect the NRs that better characterize proliferative status vs. proliferating liver, we used the novel Random Forest (RF) analysis to selected a trio of down-regulated NRs (thyroid receptor alpha, Trα; farsenoid X receptor beta, Fxrβ; Pparδ) as best discriminators of the proliferating status. To validate our approach, we further studied PPARδ role in modulating hepatic proliferation. We first confirmed the suppression of PPARδ both in LR and human hepatocellular carcinoma at protein level, and then demonstrated that PPARδ agonist GW501516 reduces the proliferative potential of hepatoma cells.

Conclusions

Our data suggest that NR transcriptome is modulated in proliferating liver and is a source of biomarkers and bona fide pharmacological targets for the management of liver disease affecting hepatocyte proliferation.

Nuclear receptors expression chart in peripheral blood mononuclear cells identifies patients with Metabolic Syndrome

BACKGROUND

Nuclear receptors are a class of 48 ligand-activated transcription factors identified as key players of metabolic and developmental processes. Most of these receptors are potential targets for pharmacological strategies in the Metabolic Syndrome. In the present study, we analyzed changes in the mRNA expression of nuclear receptors in the peripheral blood mononuclear cells of patients with Metabolic Syndrome, in order to identify novel biomarkers of disease and candidate targets for putative therapeutical approaches.

METHODS AND RESULTS

We enrolled thirty healthy controls (14 M:16 F) and thirty naïve patients (16 M: 14 F; >3 criteria for Metabolic Syndrome upon Adult Treatment Panel III) without organ damage. Using quantitative real-time PCR, we assessed the expression patterns of nuclear receptors in peripheral blood mononuclear cells. 33/48 nuclear receptors were expressed in peripheral blood mononuclear cells. In patients with Metabolic Syndrome, we found a significant down-regulation of the entire PPAR, NR4A and RAR families, together with a repression of RXRα, VDR, and Rev-Erbα. Furthermore, we performed a novel statistical analysis with classification trees, which allowed us to depict a predictive core of nuclear receptor expression patterns characterizing subjects with Metabolic Syndrome. Random Forest Analysis identified NOR1 and PPARδ, which were both reduced in peripheral blood mononuclear cells and specifically in CD14(+) cells (mostly monocytes), as classifiers of Metabolic Syndrome, with high specificity and sensitivity.

CONCLUSIONS

Our results point to the use of PPAR and NR4A mRNA levels in the overall peripheral blood mononuclear cells as biomarkers of Metabolic Syndrome and bona fide putative targets of pharmacological therapy.

A systems biology approach to the hepatic role of the oxysterol receptor LXR in the regulation of lipogenesis highlights a cross-talk with PPARα

The Liver X Receptors (LXRs) α and β and the Peroxisome Proliferator-Activated Receptor α (PPARα) are transcription factors that belong to class II nuclear receptors. They drive the expression of genes involved in hepatic lipid homeostasis and therefore are important targets for the prevention and treatment of nonalcoholic fatty liver disease (NAFLD). LXRs and PPARα are regulated by endogenous ligands, oxysterols and fatty acid derived molecules, respectively. In the liver, pharmacological activation of LXRs leads to the over-expression of genes involved in de novo lipogenesis, while PPARα is critical for fatty acid catabolism in nutrient deprivation. Even if these two nuclear receptors seemed to play opposite parts, recent studies have highlighted that PPARα also influence the expression of genes involved in fatty acids synthesis. In this study, we used pharmacological approaches and genetically engineered mice to investigate the cross-talk between LXRs and PPARα in the regulation of genes responsible for lipogenesis. We first investigated the effect of T0901317 and fenofibrate, two synthetic agonists of LXRs and PPARα, respectively. As expected, T0901317 and fenofibrate induce expression of genes involved LXR-dependent and PPARα-dependent lipogenic responses. Considering such overlapping effect, we then tested whether LXR agonist may influence PPARα driven response and vice versa. We show that the lack of PPARα does not influence the effects of T0901317 on lipogenic genes expression. However, PPARα deficiency prevents the up-regulation of genes involved in ω-hydroxylation that are induced by the LXR agonist. In addition, over-expression of lipogenic genes in response to fenofibrate is decreased in LXR knockout mice as well as the expression of PPARα target genes involved in fatty acid oxidation. Altogether, our work provides in vivo evidence for a central interconnection between nuclear receptors that drive hepatic lipid metabolism in response to oxysterol and fatty acids.

[New and old strategies against osteoporosis]

Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture that affects both cortical bone and trabecular bone. Osteoporosis may be either primary or secondary. Primary osteoporosis can be distinguished into two types: diffuse or local. The treatment can be managed through drugs, exercise and lifestyle. The aim of this paper is to highlight new and old therapeutic strategies.

Fibulin-6 expression and anoikis in human salivary gland epithelial cells: implications in Sjogren's syndrome

Important changes in acinar and ductal morphology and function, together with pronounced extracellular matrix (ECM) remodelling, are detectable in the labial salivary glands of Sjögren's syndrome (SS) patients. The objective of this work was to determine the effect of treatment with the anti-Ro/SSA auto-antibodies, characterizing SS, on the expression of fibulin-6, a member of the fibulins family of the ECM, in primary human salivary gland epithelial cell (SGEC) cultures established from biopsies of labial minor salivary glands obtained from healthy donors. The induction of cell detachment and anoikis in SGECs treated with anti-Ro/SSA auto-antibodies were also investigated. Changes in fibulin-6 mRNA expression were measured by semi-quantitative reverse transcriptase-PCR and real-time PCR. Fibulin-6 expression in cells treated with anti-Ro/SSA auto-antibodies was evaluated by flow cytometric analysis and confocal laser scanning microscopy. SGECs undergoing death by anoikis were identified and quantified using Calcein blue/YOPRO-1 dyes. Herein, we present the first evidence of fibulin-6 expression in SGEC that results distributed in the cytoplasm surrounding the inner side of the plasma membrane. Fibulin-6 was down-regulated in SGECs treated with anti-Ro/SSA auto-antibodies in which a marked cell detachment and a reduction of cell viability were observed. Notably, a reduction of fibulin-6 expression in SGECs treated with anti-Ro/SSA auto-antibodies corresponds to an increase of anoikis cell death. Our observations demonstrate a dysregulation of fibulin-6 in the pathological processes observed in SS and provide new evidence that disorganization of the ECM environment could damage the architecture and function of the salivary glands.

[Hospital anxiety and depression]

OBJECTIVE

The study investigate the presence of depressive disorders in patient who are taken in general hospital, to prevent and reduce the risk of developing a psychological pathology (anxious-depressive symptoms).

METHODS

We used two tests: 1. General Health Questionnaire (GHQ-12) by Goldberg, a self-report questionnaire, consisting of 12 items, used to estimate the probability of detecting non-psychotic mental disorders and problems in every day's activity. 2. Personal Health Questionnaire (PHQ), a self-report questionnaire, consisting of 10 items. It is a new tool for detecting individuals with ICD-10 depressive disorders, used to estimate the probability to individuate the presence of major depression symptoms, and minor depression symptoms. Tests have been administered to 140 subjects (males' experimental group, 32 subjects; males' control group, 20 subjects; females' experimental group 58 subjects; females' control group, 30 subjects) from eight departments of university hospital, medical faculty, and social services.

RESULTS

It can be noted that with GHQ-12, the presence of non-psychotic mental disorders does not come out: just the females' group, experimental and control, shows some problems with insomnia and stress. On the other hand, with PHQ, the presence of no great entity depressive symptoms comes out for all groups. In the experimental groups the quantity of depressive symptoms is greater than in the control groups.

CONCLUSIONS

We have find the presence of a number of depressive symptoms into a hospitalized population. It is known that detecting such symptoms is important for protection and care of depressive disorders in hospitalized and non-hospitalized populations.

[Hereditary thrombophilia and systemic sclerosis. An unusual case report]

Authors describe a case of systemic sclerosis with deep venous thrombosis. Great attention must be taken for this case because it represents the condition of hereditary thrombophilia. No similar case was reported in literature; therefore, further studies must go ahead understand the possible relation between the two pathologies.

[Dermatomyositis and hypokalemia: a difficult diagnosis]

The idiopathic inflammatory myopathies are systemic autoimmune diseases characterizes by chronic muscle inflammation. The frequent extramuscolar manifestations contribute to the morbidity and mortality of the disease. The goal of medical therapy is based on immune suppression with first-line agent glucocorticoids and additional immunosuppressants can be used when severe side effects occur or glucocorticoids are considered to be ineffective. We report the case of a female patient with dermatomyositis and reduced potassium levels. This case illustrates the difficulty of establishing the differential diagnosis of hypokalemia.

Receptor activator of NF(Kappa)B ligand/osteoprotegerin (RANKL/OPG) system and osteopontin (OPN) serum levels in a population of apulian postmenopausal women

AIM

Osteoporosis is a bone disease, characterized by a reduction of bone resistance; in postmenopausal period bone metabolism is imbalanced. Several parameters have been proposed as markers of bone metabolism; the attention have been recently placed on the receptor of activator of NF(Kappa)B ligand receptor (RANKL) and osteoprotegerin (OPG), namely RANKL/OPG system. The aim of this paper is to evaluate changes in postmenopausal women in serum concentration of OPG, RANKL, and their ratio (i.e. RANKL/OPG ratio), osteopontin (OPN), bone-type alcaline phosphatase (BAP), serum-N-Telopeptide of type I collagen (serum-NTX); and their correlations with bone mineral density (BMD).

METHODS

An Apulian population group of 163 native postmenopausal women were followed at the Osteoporosis Centre of Policlinico of Bari (Southenrn Italy). Patients were classified into 3 separate groups, according to T-score: osteoporotic, osteopenic and control group. Serum concentrations of OPG, RANKL, RANKL/OPG ratio, BAP and NTX have been calculated.

RESULTS

No differences were found in OPG and BAP values. Significant correlations were found in the osteopenic group between OPG and RANKL (negative), and between RANKL and OPN or serum-NTX, OPN and serum-NTX or RANKL/OPG ratio, BAP and serum-NTX, serum-NTX and RANKL/OPG ratio (positive). In the other groups a significant correlation was observed between BAP and NTX.

CONCLUSIONS

In postmenopausal women, important modifications of bone metabolism markers (i.e. RANKL, OPG and OPN) could be due to serious engagement of bone turnover, especially in the pre-osteoporotic phase. Low bone density in postmenopausal women should be identified as soon as possible, and urgent measures are needed to reverse the process. Parameters namely RANKL e OPG may become an important index for the evaluation of the activity of drugs against osteoporosis, old and new like AMG 162 (anti-RANKL action).

[Wegener's granulomatosis: that is the risk of diagnostic hypervaluation]

Iter for diagnosis of Wegener's granulomatosis is delineated, underling the role of ANCA, histological test and the risk of diagnostic hypervalutation.

[Complication after vertebroplasty in patient with senile osteoporosis: strategical therapy to revise?]

Compression fractures are common in patients with osteoporosis and they are crippling. By 1892, Julius Wolff et al. realized that mechanical loads can affect bone architecture in living beings, but the mechanisms responsible for this effect were unknown, and it had no known clinical applications. In 2003 we know how this effect occurs and some of its applications. Vertebroplasty and kyphoplasty are relatively new techniques used to treat painful vertebral compression fractures. Percutaneous vertebroplasty is a therapeutic, interventional radiologic procedure. The technique consists of the percutaneous puncture of the affected vertebral body, followed by injection of bone cement into a vertebral body for the relief of pain, and the strengthening of the bone. This procedure also carries a risk of complications, and the fracture risk of vertebrae adjacent to cement vertebrae may be increased. The authors describe a case of vertebrae's fractures adjacent to cement vertebrae that are occurred in a patient with senile osteoporosis.

[The strange case of a patient affected by acromegaly with osteoporomalacia without hypogonadism]

Acromegaly is a rare disease that, in the majority of cases, is due to the presence of a benign growth hormone (GH)-producing tumor of the pituitary. Growth hormone has profound effects on linear bone growth, bone metabolism, and bone mass. In acromegaly, the skeletal effects of chronic GH excess have been mainly addressed by evaluating bone mineral density (BMD). Most data were obtained in patients with active acromegaly, and apparently high or normal BMD was observed in the absence of hypogonadism. The Autors describe a case of patient affected by acromegaly without hypogonadism with serious osteoporosis and biological signs of osteomalacia.

[Adverse events in rheumatoid arthritis patient with etanercept therapy: the appearance of osteomalacia]

Rheumatoid arthritis (RA) is a systemic autoimmune disease of unknown origin that predominantly involves synovial tissue. RA affects 0.5-1% of the global population, with females affected more frequently than males. Patients receiving standard care for RA have significantly better status in 2000 than in 1985, associated with aggressive treatment strategies, prior to the introduction of biologic agents. Disease-modifying antirheumatic drugs (DMARDs) decrease clinical signs and symptoms in RA. Methotrexate, leflunomide and biological agents are analyzed. Glucocorticoids have long been recognized to have beneficial effects in RA. Rickets and osteomalacia are metabolic bone diseases due to a mineralization defect as principal pathophysiology. The Authors present a case report on a female patient with RA in treatment con etanercept and with osteomalacia (secondary?).

[RANKL/RANK, OPG and OPT in a group of patients affected by chronic arthritis. Preliminary report]

Recently, receptor activator of nuclear factor-kappaB ligand (RANKL), its receptor RANK, and the decoy receptor osteoprotegerin (OPG), have been identified as paracrine mediator of bone functions. The balance of RANKL/RANK and OPG is critical for osteoclastogenesis modulation and physiological bone remodeling. Osteopontin (OPN) is an extracellular glycosylate bone phosphoprotein and acts both as chemokine and cytokine. It is produced by osteoclast, macrophages, T cells, hematopoietic cells and vascular smooth muscle cells. It is present particularly at high concentration in the lamina limitans and cement line, suggesting its role in the initiation and termination of the bone turnover. Chronic arthritis are a group of rheumatic pathologies characterized by periodical continuous or desultory use of corticosteroids. The main aims of this study are to evaluate OPG, RANKL and OPN serum concentrations in patients affected by chronic arthritis and to compare the above results with those ones obtained by young healthy population. OPG, RANKL and OPN serum concentration has been measured by ELISA method both in 40 patients affected by chronic arthritis then in young healthy population of 81 subjects. The differences between the two considered groups have been analyzed using unpaired T-Student. The difference between the two groups is significant for considered variables: OPG: t = -6.54, p < 0.001; RANKL: t = -2.71, p = 0.008; OPN: t = 2.55, p = 0.01. These results suggest that RANKL/RANK system,OPG and OPN have important role in patients with chronic arthritis.

Osteoporosis in adult with Marfan syndrome: casuality or causality?

Marfan syndrome (MFS) is an inherited connective tissue disorder transmitted as an autosomal dominant trait. Recent studies indicate that decreased bone mineral density (BMD) occurs in the spine, femoral necks and greater trochanters of some adults and children with MFS. Since there is uncertainty regarding the BMD status of patients with MFS, the authors present a case report on a female patient with MFS and alteration of phosphocalcic metabolism.

[Etanercept in the treatment of rheumatoid arthritis. A case report]

Authors present a case of a patient affected by rheumatoid arthritis, non responder to the different DMARDs treatment; besides some of these treatments have even provoked relevant side effects. It has been attempted the use of biological therapy, using etanercept. After some months of this treatment with a high performance of the therapy and great subsidence of the disease, the appearance of a severe infection has compelled the interruption of the therapy, causing very slow recovery. Authors underline the relevant importance of a careful and constant observation of the patients under biological therapy, since it could be always possible the appearance of serious infections.

[Asymptomatic hyper-creatine-phosphokinasemia: a veritable disease? Observation in some cases]

Myopathy is a pathology of the muscle function, without clinical and instrumental signs that are involved the central nervous system and the peripheral one. In all pathologies causing a damage of the muscle fibres, a release of enzymes as GOT, GPT, LDH, aldolase, CPK occurs. The most significant enzyme for the muscle damage is CPK. Studies state that an increase of the CPKemia is not always an expression of muscle damages, but there are physiological changes in relation to the age, physical activities and racial variations. By the way, it is necessary to focus our attention on this matter. Authors, starting from the observation of lots of cases under their studies, have described two of them, that up to their careful observation could reveal significant.

[Postmenopausal osteoporosis: risk factors and possible therapies]

Risk factors for osteoporosis and the therapies (including those still being validated) utilisable in the primary and secondary management of patients with declared osteoporosis or those at risk of the disease are reviewed. The role of oestrogens in the pathogenesis of postmenopausal osteoporosis is well documented and replacement hormonal therapy prevents the rapid bone loss that accompanies the menopause, albeit with the well-known limitations. A valid alternative would seem to be provided by a diet rich in phyto-oestrogens which as they are natural SERMs, are able to produce effects similar to the oestrogens. The drugs of the new generation are also taking on an increasingly important role in the treatment of postmenopausal osteoporosis, although it is reasonable to think that in order to define them as effective and innocuous it will be necessary to await the conclusion of ongoing trials and an adequate number of years.

[Tumor markers in some chronic inflammatory diseases in rheumatology: a statistical evaluation]

BACKGROUND

Since tumor markers can be high in the course of many inflammatory diseases, the aim of this study is to verify if it also occurs in the course of rheumathologic chronic inflammatory diseases, and if there is any statistical correlation between tumor markers and inflammatory indices.

METHODS

Seventy-nine patients (51 females and 28 males) with rheumatologic chronic inflammatory diseases, aged 17-92 years, were studied, all of them took 4 mg of prednisone. alphaFP, CEA, TPA, CA19.9, CA15.3, CA72.4, CA125, ferritina, beta2 microglobuling, betaHCG, and free and total PSA in males, were evaluated as tumor markers; and VES, PCR and Fibrinogen, as inflammatory indices.

RESULTS

The results obtained showed that there is a significative correlation between ferritin, beta2 microglobulin, TPA and PCR, and between free and total PSA and Fibrinogen.

CONCLUSIONS

PCR is a very good index of an active disease and it can be helpful, along with tumor markers, in the monitoring of chronic inflammatory diseases.

[Sex hormones and male osteoporosis. A physiologic prospective for prevention and therapy]

BACKGROUND

Male osteoporosis is often an underestimate and non-acknowledged pathology because it is less frequent then post-menopausal women osteoporosis. The causes of osteoporosis in males were reviewed, considering the importance of the assessment of sexual hormones, even without symptoms of hypogonadism.

METHODS

Sixty-two patients ranging in age from 45 to 75 years, males, were studied. None of them had assumed steroids nor other drugs causing osteoporosis. These patients have been subjected to bone mineral analysis (BMA) together with the following sexual hormones: LH, FSH, total testosterone, free testosterone, SHBG, estrone, estradiol. Two methods of BMA have been employed (Norland 2780 and UBA 575 Walker and Sonix).

RESULTS

When osteoporosis or osteopenia were present, always there were modifications of sex hormones values. Statistic evaluation (linear regression, Pearson coefficient, Multiple regression, Backward Stepwise Multiple Regression), showed that there was a significant association between total testosterone and osteoporosis.

CONCLUSIONS

Total testosterone resulted the most predictive sex hormone for the loss of bone mass; therefore, it is important to evaluate sex hormones in males with osteoporosis, for a correct and "physiological" therapy.

[Biochemical markers of bone turnover and YKL 40 in ankylosing spondylitis. Relation to disease activity]

BACKGROUND

YKL-40 is a glycoprotein produced by chondrocytes and synovial cells. The plasmatic levels of this metabolite increase in some pathologies such as rheumatoid arthritis and osteoarthrosis, so much so that it can be considered an effective marker of disease activity and in the therapeutic monitoring of these diseases. It has been interesting to dose a group of both male and female subjects affected by seronegative spondylarthritis, comparing this parameter with the disease activity indexes and with the bone turnover markers.

METHODS

The study has been carried out on 48 subjects (26 males and 22 females) between 17 and 68 years affected by spondylarthritis, diagnosed in conformity with ARA standards. None of the patients carried out basic treatment or by glycocorticoids, and 22 patients took FANS when required. In these subjects the disease activity markers (VES, PCR, fibrinogen, mucoprotein) and some of the classic bone remodelling markers (blood calcium and phosphates, calciuria, phosphaturia, Ca++, Ntx, osteocalcine, bone isoenzyme of alkaline phosphatase, hydroxyproline, procollagen and YKL-40) were dosed.

RESULTS

The comparison between different parameters pointed out that the highest values are obtained in subjects of most advanced age with the highest phlogosis indexes, without any correlation with sex. The quite interesting comparison shows a correlation between the bone remodelling indexes and YKL-40, being particularly remarkable when the disease is more aggressive or during relapse.

CONCLUSIONS

It is then possible to confirm that, though preliminary, these data may suggest evaluations on wider case histories to research YKL-40 as a surgical monitoring marker in seronegative poliarthritis.

[Splenic pseudocystic. Report of a case]

Splenic pseudocysts represent 70 to 80% of the non parasitic cysts of this organ. Malaria, infectious mononucleosis, tuberculosis and t. pallidum infection are predisposing factors. Cystic characteristics are determined by CT-SCAN and ultrasound. Final diagnosis is achieved by hystological examination. This is a case report.