Extracts from St John's Wort and their antimicrobial activity

In an effort to carry out a more in-depth investigation on the antimicrobial properties of H. perforatum, we have assayed different extracts (MeOH; petroleum ether; CHCl(3) and EtOAc) from the aerial parts of the plant against selected microorganisms. Growth inhibition was observed only for Gram-positive bacteria, B. subtilis and B. cereus being the most susceptible to the tested drugs. The Hypericum extract obtained with EtOAc was the most active. The main constituents of this extract, as determined by HPLC analysis, were flavonoids, hypericins and hyperforins. Incubation of the selected microorganisms with the pure chemicals resulted in a significant inhibition of their growth by hypericin, hyperforin and its stable dicyclohexilammonium salt. Flavonoids appeared inactive at all.

Classification criteria for Sjögren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group

Classification criteria for Sjögren's syndrome (SS) were developed and validated between 1989 and 1996 by the European Study Group on Classification Criteria for SS, and broadly accepted. These have been re-examined by consensus group members, who have introduced some modifications, more clearly defined the rules for classifying patients with primary or secondary SS, and provided more precise exclusion criteria.

Clinical, immunological, and immunogenetic aspects of autoantibody production against Ro/SSA, La/SSB and their linear epitopes in primary Sjögren's syndrome (pSS): a European multicentre study

OBJECTIVES

To investigate the clinical and immunogenetic aspects of antibody formation against Ro/SSA and La/SSB as well as their linear B cell epitopes in patients with primary Sjögren's syndrome (pSS) from different European countries.

PATIENTS AND METHODS

Ninety patients with pSS from six European centres were studied. Serum samples from all patients were tested in a control laboratory for anti-Ro/SSA and anti-La/SSB autoantibodies by RNA precipitation assay and autoantibodies to the previously reported B cell linear epitopes of Ro 60 kDa (p169-190aa and p211-232aa) and La/SSB (p147-154aa, p291-302aa, p301-318aa, and p349-364aa). DNA from 88 patients was used for the determination of HLA-DRB1, -DQA1, and -DQB1 genotypes. Analysis of the results was performed in the 88 patients who were genotyped and tested also for antipeptide antibodies.

RESULTS

Antibodies to B cell epitopes of Ro 60 kDa were detected at a low frequency (range 10-37%). In contrast, B cell epitopes of La/SSB were detected frequently (range 58-86%) among the anti-La/SSB positive sera. Autoantibodies to the La/SSB epitope, p349-364aa, were significantly positively associated with longer disease duration (p<0.05), recurrent or permanent parotid gland enlargement (p<0.005), and a higher proportion of non-exocrine manifestations (p<0.005), compared with patients without autoantibodies. The presence of anti-Ro/SSA and anti-La/SSB autoantibodies was significantly associated with the presence of HLA-DRB1*03 and DQB1*02 (p=0.038 and p=0.034, respectively). This association was even more prominent and extended to HLA-DQA1*0501 when patients were stratified according the presence of autoantibodies to discrete La/SSB B cell epitopes in comparison with autoantibody negative patients (p<0.01). They were found also to be highly associated with the alleles HLA-DQB1*02 and HLA-DQA1*0501 as well as the presence of a shared amino acid motif in the region 59-69aa of DQB1 first domain (p<0.01, respectively).

CONCLUSIONS

Autoantibodies against La/SSB, binding to four synthetic peptides, derived from the sequence of the La protein were identified with increased frequency in sera of patients with pSS. The formation of autoantibodies against B cell epitope analogues of La/SSB in European patients with pSS may be dependent on the presence of a permissive HLA-DQ heterodimer, most prominently represented by the HLA-DQA1*0501/DQB1*0201 heterodimer, suggesting that a model of HLA restricted presentation of La/SSB peptide determinants is crucial for the autoimmune response against La/SSB.

Apoptosis in the OC-k3 immortalized cell line treated with different agents

The aim of this study is to outline the mechanisms leading cochlear cells to die. We utilized an immortalized cell line (OC-k3 cells) derived from the organ of Corti of transgenic mice in order to perform in-depth biochemical studies with no limitations on sample size and number. We probed these cells with cisplatin and gentamicin, two drugs which display in vivo undesired ototoxic side-effects. We investigated cell viability, reactive oxygen species (ROS) production and glutathione (GSH) levels and tested the effects of different concentrations of cisplatin and gentamicin from 0 to 48 h. Results show that cells undergo a dose- and treatment-time-dependent apoptosis characterized by nuclear fragmentation, integrity of the cell membrane and mitochondria, and absence of DNA endonuclease activity. During the early part of treatment, ROS production increases and intracellular GSH decreases, probably due to the activation of protein kinase C alpha. Use of antioxidants such as N-acetylcysteine, GSH and vitamin C rescues cells from apoptosis almost completely. Overall, these data indicate that ROS generation might play a central role in inducing inner ear cell apoptosis and may have an additive role in the ageing process.

The validity of the ECLAM index for the retrospective evaluation of disease activity in systemic lupus erythematosus

AIM

To determine whether the European Consensus Lupus Activity Measurement Index (ECLAM) can be used to evaluate disease activity in patients retrospectively from the data provided in their clinical charts.

METHODS

The ECLAM score was calculated twice in a series of 64 consecutive SLE patients: first for each patient during the course of a standard clinical evaluation (direct-ECLAM), and then one to two weeks later solely on the basis of the data provided in the patient's clinical chart (chartECLAM). The scorings for each patient were performed by two different assessors.

RESULTS

The direct-ECLAM and chart-ECLAM scores were highly correlated (Spearman's rank correlation coefficient = 0.86). The regression line was not significantly different from the identity line (t-test). The Pearson's coefficient was 0.88. The interobserver variability of the chart-ECLAM showed a low inter-rater variability.

CONCLUSION

ECLAM could represent a valid and reliable instrument for the retrospective analysis of disease activity in SLE patients.

Allylsulfide constituents of garlic volatile oil as antimicrobial agents

Six different mixtures of garlic distilled oils containing diallyl disulfide (DDS) and diallyl trisulfide (DTS), ranging from 1 to 51% and 88 to 38% respectively, have been assayed against a number of yeasts (C. albicans, C. tropicalis and B. capitatus), gram-positive bacteria (S. aureus and B. subtilis) and gram-negative bacteria (P. aeruginosa and E. coli). Results obtained support a specific antifungal more than an antibacterial activity and implicate DDS as the active constituent. Incubation of garlic extracts made up of 1% DDS and 88% DTS resulted, in fact, in the absence of growth inhibition against all the tested microorganisms, whereas garlic oils with higher quantities of DDS showed significant inhibitory activity, increasing with the increase of DDS amount.

Presence of antibodies against Helicobacter pylori and its heat-shock protein 60 in the serum of patients with Sjögren's syndrome

OBJECTIVE

Helicobacter pylori infection elicits a local and systemic immune response against bacterial antigens, including a heat-shock protein of 60 kDa (HSP60). The homology between microbial and human HSP suggests that the immune response to bacterial HSP may play a role in the pathogenesis of autoimmune disorders. Since gastric involvement and H. pylori have been reported in Sjögren's syndrome (SS), we investigated the prevalence of antibodies against H. pylori and its specific HSP60 in sera from patients with SS.

METHODS

Four groups of patients were studied. Group 1, 34 patients with primary SS (pSS); Group 2.19 patients with secondary SS; Group 3, 22 patients with various autoimmune diseases and Group 4, 43 healthy controls. Serum IgG levels against HSP60 were determined by an ELISA using recombinant full length HSP60 expressed in Escherichia coli, as the antigen. To confirm the H. pylori infection, a commercial ELISA was used.

RESULTS

Out of 34 patients in Group 1, 27 (79.4%) and 30 (88.2%) had antibodies against H. pylori and its HSP60, respectively. The prevalence was significantly higher than that found in Group 3 (18.2%, p < 0.0001 and 27.3%, p < 0.0001) and in Group 4 (48.8%, p < 0.005 and 37.2%, p < 0.0001) but not than that of Group 2 (48.8% and 37.2%). If the prevalence of patients either positive or negative for both antibodies was considered, a statistically significant difference was found between Group I and respectively Groups 3 and 4.

CONCLUSION

The hypothetical role of HSP60 in the development of the immune response both in pSS and secondary SS seems strictly linked to the prevalence rate of H. pylori infection.

Synthesis and antibacterial activity of 2-aryl-2,5-dihydro-3(3H)-oxo-pyridazino[4,3-b]indole-4-carboxylic acids

The in vitro antibacterial and antifungal activities of a series of pyridazinoindolonic acids II against some selected representative of Gram-positive, Gram-negative bacteria and fungi have been investigated. Some interesting observations among the structural features necessary for high antibacterial activity are presented and discussed.

Development of a clinical chart to compute different disease activity indices for systemic lupus erythematosus

Between 1990 and 1995 a European Consensus Group carried out a multicenter study to reach agreement of the definition of disease activity in systemic lupus erythematosus (SLE). A new index, the European Consensus Lupus Activity Measurement (ECLAM) index, was developed. In a second phase of the study, a prospective survey aimed at validating ECLAM and 4 other scales as steady-state and transition indices for disease activity in SLE was completed. We present the results of this survey. A standardized clinical chart was developed, together with a computer program that could automatically calculate the ECLAM score, as well as the scores for some of the disease activity scales most widely used at present, i.e., the British Isles Lupus Assessment Group, Systemic Lupus Activity Measure, SLE Disease Activity Index, and the SLE Index Score (SIS). With the participation of 28 centers in 15 different European countries, data from 121 prospectively selected new lupus patients were collected. The validity of the 5 activity scales was assessed by comparing the computed scores for each patient to a gold standard, i.e., the physician's subjective judgment on disease activity measured using a semiquantitative scale. All the indices were found to be valid instruments for measuring disease activity in SLE in both the steady-state and transition phases. The results for the various indices closely correlated with one another. Thus, the computerized chart developed by the European Consensus Group offers a simple and reliable instrument to assess disease activity and could be used to monitor lupus patients both in clinical practice and in clinical trials.

The diagnosis of Sjögren's syndrome: definition and validation of classification criteria for this disorder

Classification criteria currently exist for most of the rheumatic diseases. Different criteria sets have also been proposed in the past for Sjögren's syndrome (SS), but none of these has been validated and no single one is in general use by the entire scientific community. Between 1988 and 1996 the European Study Group for the Classification Criteria for SS performed a multicenter study in which a new classification criteria set for this disease was defined and then validated. This European set of classification criteria for SS is rapidly becoming the most widely accepted procedure to classify patients with the primary and secondary variants of the syndrome.

Antimicrobial activity of polyacetylenes from Bellis perennis and their synthetic derivatives

The chemical investigation of the essential oils from the aerial organs of Bellis perennis L., the common daisy, showed that polyacetylenes were one of the dominant class of compounds. The major constituents, methyl deca-4,6-diynoate and deca-4,6-diynoic acid, and their structural analogues, deca-4,6-diyne, dimethyl octa-3,5-diyne-1,8-dioate and deca-4,6-diyne-1,10-dioic acid, were synthesised and their antimicrobial activity evaluated. Only deca-4,6-diynoic acid and deca-4,6-diyne-1,10-dioic acid showed antimicrobial activity, being the two compounds mainly effective against Gram-positive and Gram-negative bacteria, respectively. Structure-activity relationships of the tested polyacetylenes are discussed.

Quantitative assessment of salivary gland inflammatory infiltration in primary Sjögren's syndrome: its relationship to different demographic, clinical and serological features of the disorder

The aim of this study was to investigate the possible relationship between the degree of inflammatory infiltration of salivary glands in Sjögren's syndrome (SS) and the different demographic, clinical and serological features of the disease. A quantitative assessment of the extension of the infiltrates was performed on histology samples from the labial salivary glands (LSG) of 82 patients with primary SS, by calculating the ratio of the infiltrated area to the total area of glandular tissue in the samples. The correlations between the amount of inflammatory infiltrate and the main features of the disorder were then analysed. A significant negative correlation between the degree of LSG infiltration and the patient's age at disease onset was observed (P < 0.05). In contrast, the percentage of infiltrate did not correlate with the disease duration. A significant correlation was found between the degree of infiltration of the salivary tissue and (i) the total number of extraglandular features (P < 0.01) and (ii) the presence of specific extraglandular features such as Raynaud's phenomenon (P < 0.05), vasculitis (P < 0.0001), lymph node or spleen enlargement (P < 0.05) and leucopenia (P < 0.02). Finally, patients with antinuclear antibodies, anti-SSA/Ro antibodies, or anti-SSA/Ro plus anti-SSB/La antibodies showed a more widespread inflammatory infiltration in the LSG tissue than patients without these autoantibodies (P < 0.01). The degree of infiltration in the salivary tissue was significantly greater in those patients with anti-SSA/Ro plus anti-SSB/La antibodies in their sera than in patients with anti-SSA/Ro antibodies alone (P < 0.05). In conclusion, patients with SS and active inflammatory infiltration of the salivary glands usually experience an earlier disease onset and a larger number of systemic extraglandular manifestations. In addition, the antibodies directed against certain nuclear/cytoplasmic specificities, and particularly those which react with the SSB/La antigen, seem to play a key role in enhancing the autoimmune process in the salivary glands.

International survey on the management of patients with SLE. III. The results of a questionnaire regarding renal involvement

OBJECTIVE

To assess the practice patterns in the management of lupus nephritis (LN) of physicians dealing with systemic lupus erythematosus.

METHODS

A multiple choice questionnaire was sent to 135 lupus centers, mainly in Europe. It was divided into 4 sections, one of which regarded LN. Sixty-one centers (40%) sent the questionnaire back before the meeting; however two of them did not fill out the LN section. Therefore, 59 valid LN questionnaires were collected and analyzed. Statistical evaluation was performed using frequency analysis and the chi-square test.

RESULTS

In 50 centers (85%), renal biopsy is performed in all patients with clinically evident renal involvement, and in most of them it is repeated in cases of relapse and/or ineffectiveness of treatment. Oral steroid alone is the therapy preferred by 67% of responding physicians in patients with WHO class II LN. Multi-drug therapy is favoured by 57% in patients with class III LN, by 79% for mild-to-moderate forms of class IV LN (IVm), by 84% for moderate-to-severe forms of class IV LN (IVs), by 47% for mild-to-moderate forms of class V LN (Vm), and by 65% for moderate-to-severe forms of class V LN (Vs). Steroids plus cyclophosphamide (CYPH) is the association most commonly used for class III, IVm and IVs LN, having been indicated by 70%, 80% and 88% of the centers, respectively. Furthermore, pulse CYPH is largely preferred to oral CYPH by the majority of centers. It is worth noting that 41 centers (70%, p < 0.01) utilise the same drugs in the treatment of both WHO class IVm and IVs LN. No clear trends in the use of multi-drug associations were identifiable in the treatment of class V LN. Moreover, most of the centers (64%) said that they rely on histologic parameters in order to define renal prognosis and that they consider the chronicity index to be the best predictor of poor renal outcome (74% of the centers).

CONCLUSIONS

It was possible to identify some clear trends in the behaviour of physicians who are "expert" in lupus patients: (i) they perform a renal biopsy in order to charaterize the LN and repeat it when they are faced with relapse or ineffective therapy; (ii) they treat WHO class II LN with oral steroids alone and class III and IV LN with steroids associated with CYPH (CYPH, generally in a pulse regimen); and (iii) they define renal prognosis by means of histologic predictors, especially the chronicity index. However, no trend seemed to exist for the treatment of class V LN, particularly Vm.

International survey on the management of patients with SLE. II. The results of a questionnaire regarding neuropsychiatric manifestations

OBJECTIVE

To determine the diagnostic and therapeutic approach used in clinical practice for the management of systemic lupus erythematosus (SLE) patients with primary SLE-mediated neuropsychiatric (NP) manifestations.

METHODS

A questionnaire was drawn up to assess how clinicians manage various clinical manifestations of SLE. A portion of this questionnaire was designed to assess how clinicians diagnose and treat primary NP-SLE. Most of the questions in the NP-SLE section consisted of lists of different clinical manifestations and laboratory or radiological studies that participants were asked to rate on a scale of importance [from 1 (extremely important) to 5 (not important)] to the diagnosis of primary NP-SLE. The questionnaire also assessed how different NP manifestations are treated in clinical practice. The relative importance of each clinical manifestation was determined through its mean score, and the agreement among participants on each issue was determined using the coefficient of variation (CV). Fifty-nine lupus centers participated in the NP-SLE portion of the survey.

RESULTS

The clinical manifestations which were considered to be of extreme or major importance for the diagnosis of primary NP-SLE were seizures, psychosis, transverse myelitis, stroke, transient ischemic attack (TIA) and aseptic meningitis. Among the radiological and laboratory studies, only brain magnetic resonance imaging (MRI) and antiphospholipid antibodies (aPL) achieved "extremely important" mean scores (between 1 and 2). aPL testing was used routinely in the majority of patients (mean 96.8%; CV = 0.1), while brain MRI was used less frequently (mean 56.5%; CV = 0.61). Only brain MRI and cerebral angiography were considered to be helpful in differentiating cerebral vasculopathy from multi-infarct (mean score = 1.6 and 1.9, respectively), whereas a prompt response to treatment with increased doses of steroids was considered helpful in differentiating SLE-related psychosis from steroid-induced psychosis (mean score = 1.58). The results of aPL testing, coagulation tests for the lupus anticoagulant, an brain MRI were considered to be of extreme or major importance in decisions involving treatment with anticoagulant or anti-platelet therapy. Symptomatic therapies, such as heparin, or anti-convulsant, anti-platelet, oral anticoagulant, and antipsychotic therapy were the most widely used. Corticosteroids were the most frequently used immunosuppressive therapy. The administration of other immunosuppressive agents as specific treatment for NP-SLE was uncommon.

CONCLUSIONS

Our survey found that in clinical practice, the NP manifestations currently considered to be diagnostic of primary SLE-mediated CNS involvement are not limited to those included in the American Rheumatism Association (ARA) criteria, e.g. seizures and psychosis. Antiphospholipid antibodies appeared to be the laboratory parameter most frequently relied upon in the diagnosis of NP-SLE, and in decisions regarding treatment. Apart from that, only brain MRI and, in selected cases, cerebral angiography seemed to be of real help in diagnosis. The lack of consensus regarding the treatment of primary NP-SLE manifestations most probably reflects both the complex nature of neurological illness in SLE patients and the lack of clear diagnostic criteria.

International survey on the management of patients with SLE. I. General data on the participating centers and the results of a questionnaire regarding mucocutaneous involvement

OBJECTIVE

The diagnosis and treatment of the mucocutaneous (MC), neuropsychiatric (NP), and renal (RN) manifestations of systemic lupus erythematosus (SLE) remain unsolved issues. To shed light on these issues, a questionnaire was prepared and sent to 153 lupus centres around the world, in order to determine the level of agreement between experts in their approach to these complex aspects of the disease.

METHODS

The first section of the questionnaire was designed to collect information on the characteristics of the responding lupus centres. The second section was dedicated to MC manifestations, with questions focusing on: (i) the frequency of MC manifestations as a whole and of the single clinical MC entities; (ii) clinical features, outcome and therapy of subacute cutaneous lupus erythematosus (SCLE); (iii) the utility of the lupus band test (LBT); and (iv) the use of various therapeutic protocols to treat MC manifestations.

RESULTS

Sixty-one questionnaires from 19 countries were analysed. Out of these, 37 were completed by Departments of Rheumatology, 21 by Departments of Internal Medicine or Clinical Immunology, and 3 by Departments of Nephrology. About 66% of these centres stated that they were currently following more than 100 lupus cases, 95% had an in-patient ward and 82% had their own laboratory. The American College of Rheumatology classification criteria and various scales for disease activity assessment were regularly used by 87% and 57% of centres respectively. The overall prevalence of MC manifestations was judged to be over 30% by 82% of the respondents (Rs), and over 60% by 36% of the Rs. Among the different MC manifestations, malar rash was reported to be the most frequent (40%), followed by alopecia (24.1%) and oral ulcers (18.6%). In reporting the prevalence of each MC manifestation, the Rs showed a low level of agreement, the coefficient of variation (CV) being > 0.75 for all of the manifestations listed with the exception of malar rash (CV = 0.54). Poor agreement among centers was also found for the reported association of various MC manifestations with SCLE (15 different answers), and on the prognostic factors for SCLE (17 different answers). There was agreement on the best procedure (up to 70% of the Rs preferred a non-UV exposed skin area) and on the utility of the LBT (83% using it only for diagnostic purpose). Hydroxychloroquine was the most popular therapeutic protocol, being used by 85% of the Rs for a wide variety of MC manifestations. Among other therapies, azathioprine was used by 59%, dapsone by 41%, and thalidomide by 35% of the Rs, all to treat a wide spectrum of MC manifestations. Pulse steroid, cyclosporin A and pulse cyclophosphamide were less commonly employed (by 27%, 22% and 13% of the Rs, respectively), and were reserved for the most severe MC manifestations, particularly vasculitis.

CONCLUSION

The present survey indicates that, although most of the participating centres had extensive experience in the management of SLE, their approach to the MC manifestations was not homogeneous, and collaborative studies are clearly needed, particularly to optimise the therapeutic protocols.

Ophthalmological and neuro-ophthalmological involvement in Churg-Strauss syndrome: a case report

BACKGROUND

It is well known that different types of eye involvement may develop during the course of systemic vasculitides.

METHODS

We report here a case of Churg-Strauss syndrome (allergic granulomatous angiitis) characterized by the presence of multiple ophthalmological and neuro-ophthalmological lesions, i.e., mononeuritis of the fourth cranial nerve, multifocal choroidal ischaemia, and bilateral ischaemic optic neuropathy.

RESULTS

Ischaemic lesions in the posterior ciliary plexus and chorio-retinal circulation, which appeared simultaneously after a phase of disease activity, were documented.

CONCLUSION

The simultaneous occurrence of multiple ocular features in a patient with Churg-Strauss syndrome suggests that regional vasculitis may be the pathological mechanism underlying the multiple ophthalmological lesions in this disorder.

[The imaging diagnosis of Sjögren's syndrome: echography, sialography and scintigraphy compared in the study of the salivary glands]

The aim of the present study was to evaluate the sensitivity and specificity of the ultrasonography, in comparison with other methods of investigation (scintigraphy, sialography, and biopsy), in scanning morphostructural changes in the parotid gland in patient with Sjögren's syndrome. During the period June-October 1994, 34 patients (5 males and 29 females, age ranged between 20 and 88 years) with "sicca syndrome" underwent to echography, scintigraphy, sialography and biopsy. The diagnosis was confirmed or excluded using the European Community Epidemiologic Committee criteria for Sjögren's syndrome. Twenty-two patients out of 34 were affected by Sjögren's syndrome, while the others resulted as control subjects. The ultrasonographic investigation has shown 76.19% of sensitivity and 30.43% of specificity. Even if echography is a non-invasive method, which could be used as preliminary approach for studying the diffused involvement of the parotid gland, at the status of the art, it is not completely reliable for the global evaluation of the morphostructural changes in patients with Sjögren's syndrome, in comparison with the other techniques. Because of the double nature of the gland injury, it appears to be essential the diagnostic integration between echography and sialography.