Treatment of Varicose Veins by Foam Sclerotherapy: Two Clinical Series

Objective:

To assess the efficacy and safety of sclerotherapy of varicose veins (VV) with sclerosing foam (SF) made using Tessari's method (three-way tap and two plastic syringes).

Design:

Two multi-centre prospective clinical series were documented (CS1 and CS2). In CS1, which ran from March to December 2000, 177 patients (39 men, 138 women), mean age 56 years, were treated in three centres for W related to incompetence of saphenous veins, recurrence, perforators or collaterals. Conventional or duplex-guided sclerotherapy was performed using SF made of purified sodium tetradecyl sulphate (PSTS) 0.2−3% (Fibro-vein, STD Pharmaceuticals, UK) and air. An average of 1.6 (SD 0.8) sessions per patient were performed and 2.9 (SD 1.0) ml of SF (i.e. 0.6 ml of PSTS) per session was employed. An elastic stocking providing 20 −30 or 30−40 mmHg compression was worn by patients following treatment. All the patients were reviewed (clinical examination and colour duplex ultrasonography) at 1 month. Sixty-six patients had a further follow-up 45−370 days after treatment. The 17 patients in CS2, a multi-centre study, were treated in March and April 2001. An independent observer assessed patients with major W (CEAP and W type distribution similar to CS1) before and after the treatment, and also observed the treatment, which was carried out using the technique employed in CS1.

Results:

In CS1 at 1 month follow-up there was: (A) obliteration of the vessel or antegrade flow in 161 (91%) patients, (B) minimal retrograde flow in the treated vein, without visible W, in 15 (8.4%) cases and (C) persistence of vessel patency with retrograde flow and visible W (failure) in 1 (0.6%) case. At 45−370 days (mean 138 days) follow-up results were: type A in 44 (67%) cases, type B in 17 (26%) cases and type C in 5 (8%) cases. The main complications were extension of sclerothrombus from superficial to deep veins (n = 2), allergy (n = 1), malaise (n = 1) and scotoma (n = 1). In CS2 at 30 days follow-up 100% of the treated venous segments had a type A outcome after an average of 1.4 sessions. No relevant complication occurred in this series.

Conclusions:

Sclerotherapy of major VV by means of SF prepared by Tessari's method is a safe and effective form of treatment. Low doses and a low concentration of drug may be successfully employed. Further studies are needed to establish the long- term results and overall safety of this form of foam sclerotherapy.

European guidelines for sclerotherapy in chronic venous disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

Foam sclerotherapy techniques: different gases and methods of preparation, catheter versus direct injection

INTRODUCTION

Foam sclerotherapy has gained a great popularity among phlebologists worldwide, although a major lack of homogeneity in the material used to produce sclerosant foam (SF) and to inject SF has been reported.

AIMS

To highlight the literature data and a few personal clinical and experimental outcomes concerning the main variables in SF production and injection.

METHODS

A review of the published literature and of our own 12 year clinical and experimental experience has been undertaken in order to focus on a few variables of the material and methods used to produce SF with Tessari method and to inject SF.

RESULTS

In SF production, differences in gas components, liquid to gas ratio, as well in disposable material can variably influence the resulting SF. Similarly SF injection through ultrasound guidance, with needle, or with short/long catheter may exhibit different foam behaviours according to the variable material and techniques which are employed. More recently the introduction of long catheters, possibly together with hook phlebectomy, seems to potentiate the short-mid term outcomes of foam sclerotherapy.

CONCLUSION

SF formation is greatly influenced by the choice of the gas component, the liquid-to-gas ratio, the type of syringes; also larger needles are to be preferred for injection of SF, while long catheters seem to represent a valid alternative especially when combined with tumescence to minimise saphenous diameter.

Preliminary experience with a new sclerosing foam in the treatment of varicose veins

BACKGROUND

Recently a new method of using a foam sclerosing agent for the treatment of leg veins has been described. We present a pilot study of a new technique for producing the sclerosing foam (Tessari's method) (SFT) and its use in sclerotherapy of major and minor varicosities.

OBJECTIVE

A preliminary multicenter experience of sclerotherapy performed by means of this new kind of sclerosing foam made of purified sodium tetradecylsulfate is described. The authors evaluated the safety and efficacy of different doses and concentrations of the drug as well as different methods of preparing the foam in addition, the results of this technique were evaluated.

METHODS

Over a 6-week period the three authors performed sclerotherapy or duplex-guided sclerotherapy using SFT, treating 77 patients. The SFT was formed using a three-way stopcock and two syringes, mixing air with liquid sodium tetradecylsulfate to create a foam. Each author used different concentrations (0.1-3%) and doses (2-8 ml) of SFT according to the size and number of the veins. Alternate methods of preparing the foam were examined as well. Seventy percent of the sclerotherapy sessions were performed on either the long or short saphenous veins, recurrent varices, or collaterals. Thirty percent of the treatments were for reticular varices and telangiectases.

RESULTS

At 1-month follow-up, the vast majority of treated larger veins were either obliterated or showed a normal state of cephalad blood flow. Results for minor varicosities were good, but with related complications of hyperpigmentation and small areas of cutaneous necrosis. Two patients experienced transient scotomas and one patient developed segmental phlebitis of a collateral vein. The best foam was obtained by mixing one part liquid sodium tetradecylsulfate and four to five parts air, but the duration of the foam product was also related to several other factors.

CONCLUSION

This preliminary pilot study demonstrates that the technique of producing sclerosing foam according to Tessari's method (three-way stopcock device) is very promising, especially for larger veins. No serious complications were reported, and further standardization of the method may improve the results and feasibility of this technique. Further studies are needed to validate this new technique.

Surgical treatment of far lateral lumbar disc herniation. Identification of compressed root and discectomy by lateral approach

STUDY DESIGN

A new method is described of compressed root identification and discectomy for extraforaminal disc herniation, by a lateral intertransversalis approach.

OBJECTIVES

To describe a safe surgical approach that does not require resection of adjacent bone structures during extraforaminal discectomy.

SUMMARY OF BACKGROUND DATA

Most earlier series have reported approaches that damaged bordering bone structures with wide laminoarthrectomy. This is an attempt at a safer, simpler surgical approach.

METHODS

Thirteen patients with lateral hernia have undergone this surgical procedure since 1995. Herniectomy was performed after identification of the compressed root within the iliopsoas muscle.

RESULTS

All the patients resumed the upright position with the aid of semirigid brace 24 hours after surgery. Upon awakening from the anesthesia, no patient reported peripheral pain. Motor deficits resolved after physical rehabilitation in all but one patient. At a mean follow-up of 14 months, there was no report of back pain.

CONCLUSION

The procedure described in this article offers a simple alternative to the valid procedures presently at hand. It offers the advantage of no bone resection and of minimizing nerve structures manipulation.

Early ultrasound diagnosis of developmental dysplasia of the hip

The results of ultrasound diagnosis of developmental dysplasia of the hip (DDH) in several studies of 1,000 and 1,332 consecutive patients, performed according to Graf's method from 1984 to the present, are presented. Prior to 1984 the authors used radiography exclusively in suspected cases of DDH, however, the change from radiography to ultrasonography resulted in significant improvement in the ability to diagnose and treat DDH. Different standard methods of treatment have been developed for the management of each morphological type of the newborn's and infant's hip. Ultrasound is more sensitive than clinical assessment for diagnosing DDH since it detects the dysplastic morphology of the hip when Ortolani's test is negative. Instability can be demonstrated directly. The success of treatment of DDH depends on the time of diagnosis the early diagnosis obtained by ultrasound screening can significantly improve the results of treatment.

Diagnostic value of compression ultrasonography and fibrinogen-related parameters for the detection of postoperative deep vein thrombosis following elective hip replacement: a pilot study

To determine their ability to diagnose postoperative deep vein thrombosis (DVT) D-dimer - by three methods -, fibrinogen degradation products (FgDP) and fibrinogen levels were measured in 68 consecutive patients before elective surgery for hip replacement and on postoperative day 1, 3, 6, and 10. All patients received prophylaxis and underwent compression real-time B-mode ultrasonography (C-US) on postoperative day 5 and 9, and bilateral ascending venography on day 10. Twenty-two out of 68 patients developed asymptomatic postoperative DVT, which was limited to the calf veins in 14 and involved the proximal veins in 8 patients. C-US was negative in all patients on day 5. On day 9, C-US sensitivity and specificity for proximal DVT were 63% (95% confidence interval: 26%-90% and 98% (89%-100%) respectively. Postoperative changes in the laboratory parameters evaluated were not different in patients with or without DVT until day 10. On day 10, mean D-dimer, FgDP and fibrinogen levels were significantly higher in patients with DVT than in those without DVT (p values between 0.006 and 0.032), but only D-dimer was higher with DVT involving two or more venous segments than with thrombosis involving one venous segment only (p < 0.05). Stepwise logistic regression analysis identified D-dimer and fibrinogen on day 10 as predictors of postoperative DVT. In a receiver operator curve and after weighing for the coefficients generated by logistic regression analysis, the combination of a latex photometric immuno-assay and of PT-derived fibrinogen yielded-at a cut-off value of 7.0 a sensitivity of 100% (73%-100%) and a specificity of 58% (39%-75%) for DVT, with a negative predictive value of 100% (78%-100%), a positive predictive value of 52% (32%-71%) and an overall accuracy of 71% (55%-83%). These results suggest that two simple, fast and reproducible tests may permit the identification of patients at low risk of having postoperative DVT and that a combination of sensitive laboratory assays and of the highly specific C-US may select patients requiring anticoagulant treatment. Efficacy and cost-effectiveness of this approach should be evaluated in large clinical management studies.

[Influence of nutrition, age and vitamin D status on fasting urinary excretion of calcium in postmenopausal women]

The purpose of the present study was to evaluate the influence of nutrition, age, and Vitamin D status on fasting urinary calcium (Ca) as a function of creatinine excretion (Ca/Cr) and of glomerular filtration rate (Ca/GFR) in postmenopausal women. Fasting urinary calcium, urinary Cr and GFR were measured in 18 women aged 54 to 91 years before and after six days of a calcium (400 mg/die) and sodium (100 mEq/die) restricted diet with a controlled content of proteins, lipids and glucides. Aged (over 64 y.) women having an adequate vitamin D status showed fasting urinary Ca/Cr and Ca/GFR after the controlled diet significantly lower than those showed before. It is concluded that fasting Ca/Cr and Ca/GFR may be nutrition-dependent. A revision of the significance of the fasting urinary Ca excretion is consequently suggested.

[Nutrients, anthropometric characteristics and osteoporosis in women in the recent and late postmenopausal period]

Bone mineral content (BMC) at two different radial sites (mid-diaphysis and ultra-distal epiphysis), anthropometric measurements (Body Mass Index, Lipidic Area, and Muscular Area) and nutrients intake were measured in two populations of women selected on the basis of early (< 9 years) or remote (> 15 years) menopause. The results show the presence of positive relationships between BMC, and protein and lipid intakes in the population of women in early menopause; in the other population no relationships were found. Glucid, fibre and calcium intakes were not related to the BMC of both populations. The positive relationships between BMC, and protein and lipid intakes in the population of women in early menopause is likely mediated by anthropometric characteristics as Body Mass Index and Muscular Area.

[A case of cutaneous disorders of the lower limbs due to lymphostasis in a patient with multiple sclerosis. Use of a dynamic phlebologic footboard]

Tessari hemo-phlebo-dynamic steps are a passive physiotherapy device which cause the "ankle pump" to work, thereby contributing to venous return in the lower limbs. These steps can be used in phlebology in disorders due to stasis affecting the lower limbs, in orthopedics in functional rehabilitation as preventive treatment in the case of sedentary activities.

[Reduction in parathormone secretion after oral calcium loading in osteoporotic adults]

The purpose of this study was to verify if a decreased inhibition of PTH secretion (abnormal suppressibility) in response to physiological increment of plasma calcium is present in patients with osteoporosis. The plasma concentration curve of intact PTH 1-84 following an oral calcium load (Pak) has been calculated in a selected population of 38 osteopenic patients (16 males and 22 females) and in a control group of 9 young healthy adults. All the patients included in this study a) had no past or present diseases and medications of potential influence on calcium homeostasis, b) showed a maximal calcemic response to the oral calcium load equal to that of the control group. PTH suppressibility was significantly smaller in the osteoporotic patients (-42% in males and -32% in females) than in the control group (-76%). This abnormal suppressibility of PTH is independent on sex and, in the females, also on postmenopausal estrogen deficiency. These results support the hypothesis that osteoporosis is associated to an altered secretory response of parathyroid glands maybe due to reduced sensitivity of the parathyroid cells to extracellular calcium.

[The blood calcium error induced by oral calcium loading: study of the homeostatic compensation mechanism]

The oral calcium load test, originally proposed for evaluating the intestinal calcium absorption and the renal calcium leak triggers some endocrine and metabolic responses addressed to correct the "calcemic error" induced by the load. Besides the increased plasma calcium there are: plasma PTH drop, increment in the urinary calcium excretion and in the threshold of tubular phosphate reabsorption. These responses have been measured and reciprocally correlated in 9 young adults at different times after the oral calcium load. The responses can be assessed with high precision in clinical practice and are in agreement with the known physiological models. The oral calcium load test is proposed as a tool for studying in the osteopenic population in the individual's capacity of correcting the calcemic error induced by the load.

[A method for the in vivo measurement of the mineral content in an experimental animal]

Bone mineral content measurement is not as widely used in experimental conditions as in clinical practice because of the lack of adequate experimental methods. An in vivo measurement method of bone mineral content in the rat is here presented. Measurements were made at the proximal tibio-peroneal segment, which has a mainly trabecular structure, by means of single photon absorptiometry. The presence of the fibula, having cortical structure, has been shown not to affect the read values, which can be therefore attributed to the tibial metaphysis, having a mainly trabecular structure. Expressing mineral content values as a function of the measured bone diameter has proven useless. Limb repositioning on the instrument holding device is critical for the reproducibility of the measurement, but the latter is not affected by the repositioning method. Method reproducibility (depending on either the intrinsic instrumental error or the repositioning error) is 5-6%. This relatively low reproducibility of the suggested method does not prevent its use in the study of physiological and pathological variations of bone mineral content in rats, and of the means to influence it.

Morphological or functional criteria in evaluation of the newborn hip?

Classifying the infant hip as normal or dysplastic before the stage of radiological significance, in other words during the first three months of life, has always been trusted to functional maneuvers causing clinical signs. From the results it is possible to deduce if the hip morphology is normal or somehow altered. In other words, because insufficient radiographic significance makes it impossible to directly assess the "morphological" criterion, diagnosis of the state of the hip is carried out using an indirect "functional" criterion. In contrast to radiographic imaging, ultrasound screening is already significant in the first weeks of life; it is therefore now possible to obtain real images of the infant hip earlier than it was possible using radiography. This eliminates the need for symptomatic evidence of dislocation. As a result, the "functional" indirect criterion used up till now for early diagnosis of infant hip can today be replaced by a direct "morphological" criterion. This innovation is not without epidemiological consequences, and this must be taken into account in order to rationalise between the opposing risks of over or under estimating the incidence of congenital hip dysplasia.

[Effect of insulin on the activity of bone alkaline phosphatase in culture]

Diabetes and osteoporosis are linked. The question remains, however, as to whether insulin has any direct effect on bone formation. To test this hypothesis we have measured, as a marker of osteoblast activity, alkaline phosphatase (ALP) released by rat limb intact bones incubated in the presence and in the absence of physiological concentration of insulin. The results indicate that insulin significantly (p less than 0.012) increases ALP by a mean value of 48% (from 5.4% to 215%) over matched controls. We conclude that insulin has a direct stimulatory effect on osteoblast activity, and that in the absence of this effect, as in diabetes, bone loss might occur.

Intranasal and intramuscular human calcitonin in female osteoporosis and in Paget's disease of bones: a pilot study

It has been shown that human calcitonin (hCT) is absorbed through the nasal mucosa when administered together with promoters like sodium glycocholate (SGC) or dihydrofusinate. The aim of this study was to compare the clinical and metabolic effect of intranasal (in) and intramuscular (im) hCT in patients with osteoporosis or with Paget's disease of bones. Fifteen women with postmenopausal or with senile osteoporosis entered a randomized six months trial with in hCT (plus SGC) or with im hCT 100 U on alternate days. Six women in each group were treated for 2 months, and only four women in each group continued treatment for an additional 4 months period. In hCT, but not im hCT, reduced subjective pain, while urinary cAMP increased to a similar extent in the 2 groups. Other metabolic indexes and bone mineral content (BMC) were unchanged, no new fractures took place, and side effects were fewer with in than with im hCT. To confirm the analgesic effect of in hCT, twelve patients with Paget's disease of bone were randomly treated for 20 days with in or im hCT 100 U/day: during the short period of treatment, pain was reduced by in, not by im hCT, and urinary cAMP excretion similarly increased in the two groups of patients.

[Canyon-varices. Consequence and cause of sclerous cellulitis and their treatment]

Cutaneous and subcutaneous sclerosis of venous origin ("hypodermite chronique" to the French and "indurated cellulitis" to the Anglo-saxons) is always created by a "varicose vein-canyon", which communicates with one or several inadequate perforating? Varicose vein-canyons, or rather the circulatory and hypertensive disturbances that they engender, are without doubt mainly responsible for chronic panniculitis. It is extremely important to inactivate them to bring about regression of the sclerosis. The various ways of tackling the problem are based on three different principles: --contrasting the reflux from varicose vein-canyons by external compression; --cutting only vertical long reflux, by ablation or sclerosis of the inadequate saphenous veins and the other proximal varicose veins; --adding to the suppression of the long reflux by interruption of short reflux in the legs. The author insists yet again on the value of the "Glauco Bassi hook method", for which panniculitis is a choice indication, either because is enables the largest of the varicose vein-canyons (the "Leonardo vein") to be reached easily (and sometimes even to remove a few centimeters by rolling around forceps introduced into two incisions ten millimetres long at the most), or because there are few alternatives for interrupting the leakage points, if "sunk" varicose-veins are involved.

[Repercussions of venous diseases on the osteoarticular system of the lower extremities]

Two centuries ago, a leading light of phlebology (J.-L. Petit) wrote, "When ulcers, located beside bones, have been present for more than one year, the bones rot". Today, on the basis of many anatomical and radiological studies, this statement can be modified as follows: bone lesions may occur even before the onset of an ulcer; their nature is very variable and they are certainly more extensive in long-standing phlebopathies. In legs presenting open ulcers for more than 5 years, bone lesions are nearly always present but may not coincide with the location of the ulcer; the changes occur in the same way and follow the same pattern in post-phlebitic ulcer and in essential varices. Within the legs, notable reciprocal potentially pathogenic relationships are set up between the joints and the veins. These are more marked in the distal section of the limb than in the proximal section. It is therefore essential that at the first phlebological consultation, particularly in the presence of serious cutaneous lesions, an in-depth investigation should be carried out of the functional state of the osteoarticular system in order to be able to combine treatment of the venous pathology with a correct restoration of the hemokinetic pump.

[Patients' rights, being the fourth third of phlebology therapy. Tribute to Glauco Bassi]

Current social, cultural and ethnic patterns all have an influence on phlebology therapy. At the present time, the desire to improve the appearance of their legs is much stronger than before in subjects who have uncomplicated varicose veins. This must be taken into consideration. However, it should also be noted that "capillary phobias" are met with, and these are nothing more than neuroses due to lack of adaptation to present-day life and are certainly not curable by phlebology therapy. On the contrary, care should be taken not to practice "Utopian medicine" in chronic venous insufficiency by prescribing treatment that the patient cannot or does not want to carry out. For this reason, it is not sufficient to prescribe the most logical treatment; a careful examination should be undertaken of the patient's character, requirements, family circle and work, as well as the influence exerted upon him by current social behaviour. Above all, three observations should be made. Some patients undertake cures that are completely different from those prescribed by their phlebologist, since they still have faith in certain outmoded rules. Others put into practice fragments of medical knowledge that have been passed on by popular wisdom. Very often the case is met of post-phlebitis patients who are unable to put on and take off their support stockings and who are the victims of current social conditions which no longer oblige families to help their close relations.(ABSTRACT TRUNCATED AT 250 WORDS)

Motion of the center of gravity of the body in clinical evaluation of gait

The motion of the center of gravity during walking was analyzed in five hemiplegic subjects and eleven subjects affected by unilateral hip arthritis. In the hemiplegic subjects and 6 subjects with hip arthritis the transfer between kinetic and potential energy (with a passive pendular motion) was found to be 9-95% greater during the step performed on the affected limb ("pathological" step); as a consequence, the muscular work done during this step was 7-81% of the work done during the step performed on the second limb ("normal" step). Qualitatively similar gait anomalies were recorded in all hemiplegic subjects with hypertonus of the paretic limb: these subjects had to lift the spastic limb as a whole during the normal step, with the consequence that the center of gravity was lifted 0.6-3 cm more than during the pathological step. In contrast, various motor patterns were found in patients with hip arthritis. During the pathological step the center of gravity reached a height 0.5-3 cm greater in 7 subjects, 1 cm smaller in one subject, and about the same height reached during the normal step in 3 subjects. This was consistent with the various motor deficits caused by hip arthritis.

A reference curve for axial bioelectric potentials in rabbit tibia

A high coefficient of variation is characteristic of the bioelectric potentials recorded from living long bones. As a consequence, the data collected from animal and human experiments are difficult to use in practical ways. A distribution curve for bone bioelectric potentials has been calculated using polynomial regression analysis to process the voltage values recorded on the whole length of rabbit tibiae, with reference electrodes positioned in three different points of the bone. The distribution curve so obtained is presented to fulfill the need for a reference curve for the bioelectric potentials recorded from rabbit tibial surfaces.

A correlation analysis between bone formation rate and bioelectric potentials in rabbit tibia

The origin of the bioelectric potentials in unstressed living bones is still an open question. Blood-flow in vessels, stationary potentials on peripheral nerves, muscle injury potentials, and viability of bone cells are claimed to be possible sites of origin of the electric potentials recorded on bone surface. The present data show that the topographic quantitative distribution of tetracycline labeling at sequential levels of rabbit tibia and the distribution pattern of the bioelectric potentials in this bone are significantly superimposable. This coincidence of bone formation rates and bioelectric potentials seems to support the view that the latter are in some way linked with the laying down of new bone.

[Endogenous thermotherapy in patients with prosthesis and metal implants]

The conditions where metallic implants may be exposed to metric and centimetric electromagnetic irradiation have been experimentally produced "in vitro". Irradiation doses equal to those currently chosen for human physiotherapy, induce temperature increases which seem to be well tolerated by muscular and connective tissues. Conditions of maximal temperature increase around the metallic implant are those where the relative position of the electrodes to the body segments never occurs in practice.

[A case of duodenal schwannoma (clinical study)]

Taking a case of duodenal schwannoma, that they had observed, as a starting point, on the base of their experience and the data of literature, the authors discuss the epidemiological, of classification and anatomo-pathological aspects of this rare neoplastic form. They particularly outline the clinical aspect, the diagnostic pre-operating iter and the correct and radical surgical behaviour that must be practiced during laparatomy.

[Pharmacological and clinical aspects of S-adenosylmethionine (SAMe) in primary degenerative arthropathy (osteoarthrosis)]

After some preliminary remarks of a biochemical and pharmacological nature, the authors have started a clinical study to test the antiinflammatory activity of the S-adenosyl-methionine (SAMe). An open trial, carried out on 90 patients with severe degenerative arthropathies has shown that 30 mg SAMe intravenously twice a day for 14 days have a marked anti-inflammatory effect a rather term and no side-effects. In a "double-crossover" investigation, SAMe was next compared to indomethacin by i.m. administrations to 15 arthropathic patients. The therapeutic responses of the two drugs proved exactly alike, whereas the side-effects following indomethacin administration were not present after SAMe. In 9 patients affected with rheumatoid arthritis administrations of SAMe have proved less effective, although some clinical parameters showed improvements.