Notch signaling drives intestinal graft-versus-host disease in mice and nonhuman primates

Notch signaling promotes T cell pathogenicity and graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (allo-HCT) in mice, with a dominant role for the Delta-like Notch ligand DLL4. To assess whether Notch's effects are evolutionarily conserved and to identify the mechanisms of Notch signaling inhibition, we studied antibody-mediated DLL4 blockade in a nonhuman primate (NHP) model similar to human allo-HCT. Short-term DLL4 blockade improved posttransplant survival with durable protection from gastrointestinal GVHD in particular. Unlike prior immunosuppressive strategies tested in the NHP GVHD model, anti-DLL4 interfered with a T cell transcriptional program associated with intestinal infiltration. In cross-species investigations, Notch inhibition decreased surface abundance of the gut-homing integrin α4β7 in conventional T cells while preserving α4β7 in regulatory T cells, with findings suggesting increased β1 competition for α4 binding in conventional T cells. Secondary lymphoid organ fibroblastic reticular cells emerged as the critical cellular source of Delta-like Notch ligands for Notch-mediated up-regulation of α4β7 integrin in T cells after allo-HCT. Together, DLL4-Notch blockade decreased effector T cell infiltration into the gut, with increased regulatory to conventional T cell ratios early after allo-HCT. Our results identify a conserved, biologically unique, and targetable role of DLL4-Notch signaling in intestinal GVHD.

Spatiotemporal single-cell profiling reveals that invasive and tissue-resident memory donor CD8+ T cells drive gastrointestinal acute graft-versus-host disease

Organ infiltration by donor T cells is critical to the development of acute graft-versus-host disease (aGVHD) in recipients after allogeneic hematopoietic stem cell transplant (allo-HCT). However, deconvoluting the transcriptional programs of newly recruited donor T cells from those of tissue-resident T cells in aGVHD target organs remains a challenge. Here, we combined the serial intravascular staining technique with single-cell RNA sequencing to dissect the tightly connected processes by which donor T cells initially infiltrate tissues and then establish a pathogenic tissue residency program in a rhesus macaque allo-HCT model that develops aGVHD. Our results enabled creation of a spatiotemporal map of the transcriptional programs controlling donor CD8⁺ T cell infiltration into the primary aGVHD target organ, the gastrointestinal (GI) tract. We identified the large and small intestines as the only two sites demonstrating allo-specific, rather than lymphodepletion-driven, T cell infiltration. GI-infiltrating donor CD8⁺ T cells demonstrated a highly activated, cytotoxic phenotype while simultaneously developing a canonical tissue-resident memory T cell (T_RM) transcriptional signature driven by interleukin-15 (IL-15)/IL-21 signaling. We found expression of a cluster of genes directly associated with tissue invasiveness, including those encoding adhesion molecules (ITGB2), specific chemokines (CCL3 and CCL4L1) and chemokine receptors (CD74), as well as multiple cytoskeletal proteins. This tissue invasion transcriptional signature was validated by its ability to discriminate the CD8⁺ T cell transcriptome of patients with GI aGVHD from those of GVHD-free patients. These results provide insights into the mechanisms controlling tissue occupancy of target organs by pathogenic donor CD8⁺ T_RM cells during aGVHD in primate transplant recipients.

SARS-CoV-2 Receptor ACE2 Is an Interferon-Stimulated Gene in Human Airway Epithelial Cells and Is Detected in Specific Cell Subsets across Tissues

There is pressing urgency to understand the pathogenesis of the severe acute respiratory syndrome coronavirus clade 2 (SARS-CoV-2), which causes the disease COVID-19. SARS-CoV-2 spike (S) protein binds angiotensin-converting enzyme 2 (ACE2), and in concert with host proteases, principally transmembrane serine protease 2 (TMPRSS2), promotes cellular entry. The cell subsets targeted by SARS-CoV-2 in host tissues and the factors that regulate ACE2 expression remain unknown. Here, we leverage human, non-human primate, and mouse single-cell RNA-sequencing (scRNA-seq) datasets across health and disease to uncover putative targets of SARS-CoV-2 among tissue-resident cell subsets. We identify ACE2 and TMPRSS2 co-expressing cells within lung type II pneumocytes, ileal absorptive enterocytes, and nasal goblet secretory cells. Strikingly, we discovered that ACE2 is a human interferon-stimulated gene (ISG) in vitro using airway epithelial cells and extend our findings to in vivo viral infections. Our data suggest that SARS-CoV-2 could exploit species-specific interferon-driven upregulation of ACE2, a tissue-protective mediator during lung injury, to enhance infection.

Complement Deficiencies Result in Surrogate Pathways of Complement Activation in Novel Polygenic Lupus-like Models of Kidney Injury

Lupus nephritis (LN) is a major contributor to morbidity and mortality in lupus patients, but the mechanisms of kidney damage remain unclear. In this study, we introduce, to our knowledge, novel models of LN designed to resemble the polygenic nature of human lupus by embodying three key genetic alterations: the Sle1 interval leading to anti-chromatin autoantibodies; Mfge8-/- , leading to defective clearance of apoptotic cells; and either C1q-/- or C3-/- , leading to low complement levels. We report that proliferative glomerulonephritis arose only in the presence of all three abnormalities (i.e., in Sle1.Mfge8 -/- C1q -/- and Sle1.Mfge8 -/- C3 -/- triple-mutant [TM] strains [C1q -/-TM and C3-/- TM, respectively]), with structural kidney changes resembling those in LN patients. Unexpectedly, both TM strains had significant increases in autoantibody titers, Ag spread, and IgG deposition in the kidneys. Despite the early complement component deficiencies, we observed assembly of the pathogenic terminal complement membrane attack complex in both TM strains. In C1q-/- TM mice, colocalization of MASP-2 and C3 in both the glomeruli and tubules indicated that the lectin pathway likely contributed to complement activation and tissue injury in this strain. Interestingly, enhanced thrombin activation in C3-/- TM mice and reduction of kidney injury following attenuation of thrombin generation by argatroban in a serum-transfer nephrotoxic model identified thrombin as a surrogate pathway for complement activation in C3-deficient mice. These novel mouse models of human lupus inform the requirements for nephritis and provide targets for intervention.

CD28 blockade controls T cell activation to prevent graft-versus-host disease in primates

Controlling graft-versus-host disease (GVHD) remains a major unmet need in stem cell transplantation, and new, targeted therapies are being actively developed. CD28-CD80/86 costimulation blockade represents a promising strategy, but targeting CD80/CD86 with CTLA4-Ig may be associated with undesired blockade of coinhibitory pathways. In contrast, targeted blockade of CD28 exclusively inhibits T cell costimulation and may more potently prevent GVHD. Here, we investigated FR104, an antagonistic CD28-specific pegylated-Fab', in the nonhuman primate (NHP) GVHD model and completed a multiparameter interrogation comparing it with CTLA4-Ig, with and without sirolimus, including clinical, histopathologic, flow cytometric, and transcriptomic analyses. We document that FR104 monoprophylaxis and combined prophylaxis with FR104/sirolimus led to enhanced control of effector T cell proliferation and activation compared with the use of CTLA4-Ig or CTLA4-Ig/sirolimus. Importantly, FR104/sirolimus did not lead to a beneficial impact on Treg reconstitution or homeostasis, consistent with control of conventional T cell activation and IL-2 production needed to support Tregs. While FR104/sirolimus had a salutary effect on GVHD-free survival, overall survival was not improved, due to death in the absence of GVHD in several FR104/sirolimus recipients in the setting of sepsis and a paralyzed INF-γ response. These results therefore suggest that effectively deploying CD28 in the clinic will require close scrutiny of both the benefits and risks of extensively abrogating conventional T cell activation after transplant.

Delineating tissue-specific alloimmunity during acute GVHD

After allogeneic hematopoietic cell transplantation (allo-HCT), donor T cells undergo priming in secondary lymphoid tissues followed by migration to different target organs, where they mediate inflammation and cause acute Graft-versus-Host Disease (aGVHD). Here, we characterized T cells infiltrating GVHD-target organs using a model of aGVHD in non-human primates in order to delineate tissue-specific patterns of the alloimmune response. We found that aGVHD profoundly shifted the T cell phenotype from the naïve state toward an effector-memory state in both the blood and secondary lymphoid organs, with an attenuated shift in non-lymphoid organs. However, in all compartments, tissue-infiltrating T cells demonstrated an aGVHD-specific activated phenotype characterized by a high rate of proliferation and elevated effector functions. In addition, transcriptomic profiles of aGVHD- and tissue-residency developed in T cells residing the colon, liver and lungs as well as in the blood. To further delineate the patterns of T cell trafficking and activation during aGVHD, we directly labeled leukocytes in vivo using fluorescent anti-CD45 antibodies. Using this approach, we detected notable changes in T cell trafficking patterns which included increased T cell trafficking to lymph nodes, lungs and kidneys after allo-HCT, with rates of T cell migration to the GI tract unchanged even during aGVHD. These data provides novel insights into the spatial organization of systemic alloimmunity during aGVHD and the organ-specific impact of this disease on T cell trafficking, activation and functional maturation.

Lupus nephritis: the roles of C1q and C3 in preventing antibody mediated injury

Lupus nephritis (LN) is a common and serious complication of systemic lupus erythematosus (SLE). While defective clearance of apoptotic cells (AC) and immune complexes (IC) is implicated in LN pathogenesis, the precise way in which different complement components impact kidney protection and injury is unknown. To address this, we created C57BL/6 mice with defective clearance of AC (Mfge8 deficiency) and anti-chromatin antibodies (sle1 interval) that were also deficient in either C1q [C1q Triple mutant (C1qTM)] or C3 (C3TM). Both C1q and C3 TM mice spontaneously developed anti-DNA antibodies and glomerulonephritis associated with glomerular IgG deposits after the age of 6 months. To dissociate the effects of complement on B cells versus effects on the kidney, we examined the effects of antibody mediated kidney injury (nephrotoxic nephritis, NTN) in mice deficient in the clearance of AC with complement deficiency [double knockout (DKO) (Mfge8 C1q or Mfge8 C3) mice]. In NTN, 50% of C1q DKO and 25% of C3 DKO, but no Mfge8 KO, died after NTN induction and the surviving C1q DKO mice developed severe proteinuria. Surprisingly, both spontaneous and NTN-induced nephritis in C1q TM or C1q DKO had strong glomerular C3 and C3d staining, while strong staining for the membrane attack complex (MAC) was observed in C3 TM or C3 DKO mice. These findings indicate that: 1) C1q and C3 independently protect against kidney injury separate from their effects on B cell function 2) In the presence of excess AC and low C1q, antibody mediated kidney injury is associated with C3 activation, presumably by the lectin or alternative pathway and 3) In the presence of excess AC and low C3, antibodies can cause MAC activation by pathways that remain to be determined.

Uncoupling complement C1s activation from C1q binding in apoptotic cell phagocytosis and immunosuppressive capacity

Complement activation contributes to inflammation in many diseases, yet it also supports physiologic apoptotic cells (AC) clearance and its downstream immunosuppressive effects. The roles of individual complement components in AC phagocytosis have been difficult to dissect with artificially depleted sera. Using human in vitro systems and the novel antibody complement C1s inhibitor TNT003, we uncoupled the role of the enzymatic activation of the classical pathway from the opsonizing role of C1q in mediating a) the phagocytosis of early and late AC, and b) the immunosuppressive capacity of early AC. We found that C1s inhibition had a small impact on the physiologic clearance of early AC, leaving their immunosuppressive properties entirely unaffected, while mainly inhibiting the phagocytosis of late apoptotic/secondary necrotic cells. Our data suggest that C1s inhibition may represent a valuable therapeutic strategy to control classical pathway activation without causing significant AC accumulation in diseases without defects in AC phagocytosis.

The Role of MicroRNAs and Human Epidermal Growth Factor Receptor 2 in Proliferative Lupus Nephritis

OBJECTIVE

To understand the roles of microRNAs (miRNAs) in proliferative lupus nephritis (LN).

METHODS

A high-throughput analysis of the miRNA pattern of the kidneys of LN patients and controls was performed by molecular digital detection. Urinary miRNAs were measured by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Target gene expression in human mesangial cells was evaluated by arrays and qRT-PCR. Human epidermal growth factor receptor 2 (HER-2) was analyzed by immunohistochemistry in kidney samples from LN patients and in a murine model of lupus. Urinary levels of HER-2, monocyte chemotactic protein 1 (MCP-1), and vascular cell adhesion molecule 1 (VCAM-1) were measured by enzyme-linked immunosorbent assay.

RESULTS

Levels of the miRNAs miR-26a and miR-30b were decreased in the kidneys and urine of LN patients. In vitro these miRNAs controlled mesangial cell proliferation, and their expression was regulated by HER-2. HER-2 was overexpressed in lupus-prone NZM2410 mice and in the kidneys of patients with LN, but not in other mesangioproliferative glomerulonephritides. HER-2 was found to be up-regulated by interferon-α and interferon regulatory factor 1. Urinary HER-2 was increased in LN and reflected disease activity, and its levels correlated with those of 2 other recognized LN biomarkers, MCP-1 and VCAM-1.

CONCLUSION

The kidney miRNA pattern is broadly altered in LN, which contributes to uncontrolled cell proliferation. Levels of the miRNAs miR-26a and miR-30b are decreased in the kidneys and urine of LN patients, and they directly regulate the cell cycle in mesangial cells. The levels of these miRNAs are controlled by HER-2, which is overexpressed in NZM2410 mice and in the kidneys and urine of LN patients. HER-2, miR-26a, and miR-30b are thus potential LN biomarkers, and blocking HER-2 may be a promising new strategy to decrease cell proliferation and damage in this disease.

IgM-Dependent Phagocytosis in Microglia Is Mediated by Complement Receptor 3, Not Fcα/μ Receptor

Microglia play an important role in receptor-mediated phagocytosis in the CNS. In brain abscess and other CNS infections, invading bacteria undergo opsonization with Igs or complement. Microglia recognize these opsonized pathogens by Fc or complement receptors triggering phagocytosis. In this study, we investigated the role of Fcα/μR, the less-studied receptor for IgM and IgA, in microglial phagocytosis. We showed that primary microglia, as well as N9 microglial cells, express Fcα/μR. We also showed that anti-Staphylococcus aureus IgM markedly increased the rate of microglial S. aureus phagocytosis. To unequivocally test the role of Fcα/μR in IgM-mediated phagocytosis, we performed experiments in microglia from Fcα/μR(-/-) mice. Surprisingly, we found that IgM-dependent phagocytosis of S. aureus was similar in microglia derived from wild-type or Fcα/μR(-/-) mice. We hypothesized that IgM-dependent activation of complement receptors might contribute to the IgM-mediated increase in phagocytosis. To test this, we used immunologic and genetic inactivation of complement receptor 3 components (CD11b and CD18) as well as C3. IgM-, but not IgG-mediated phagocytosis of S. aureus was reduced in wild-type microglia and macrophages following preincubation with an anti-CD11b blocking Ab. IgM-dependent phagocytosis of S. aureus was also reduced in microglia derived from CD18(-/-) and C3(-/-) mice. Taken together, our findings implicate complement receptor 3 and C3, but not Fcα/μR, in IgM-mediated phagocytosis of S. aureus by microglia.

Interplay between Aggregation and Coalescence of Polymeric Particles: Experimental and Modeling Insights

In the present work, the aggregation behavior of polymeric particles possessing different glass transition temperatures (i.e., different "softnesses") has been studied to shed light on the interplay between aggregation and coalescence. In particular, the time evolution of the clusters hydrodynamic and gyration radii as well as of their structure factor has been monitored. With the help of an ad hoc developed deterministic model, based on population balance equations, it was possible to establish a link between the experimentally obtained light scattering data and the predicted particle size distribution. The simplicity of the model, involving one single adjustable parameter based on the coalescence characteristic time, allowed us to obtain a good accordance between simulations and experimental results with little computational effort.

Donor Requirements for Regulatory T Cell Suppression of Murine Graft-versus-Host Disease

Adoptive transfer of freshly isolated natural occurring CD4(+)CD25(+)Foxp3(+) regulatory T cells (Treg) prevents graft-versus-host disease (GVHD) in several animal models and following hematopoietic cell transplantation (HCT) in clinical trials. Donor-derived Treg have been mainly used, as they share the same MHC with CD4(+) and CD8(+) conventional T cells (Tcon) that are primarily responsible for GVHD. Third party-derived Treg are a promising alternative for cellular therapy, as they can be prepared in advance, screened for pathogens and activity, and banked. We explored MHC disparities between Treg and Tcon in HCT to evaluate the impact of different Treg populations in GVHD prevention and survival. Third-party Treg and donor Treg are equally suppressive in ex vivo assays, whereas both donor and third-party but not host Treg protect from GVHD in allogeneic HCT, with donor Treg being the most effective. In an MHC minor mismatched transplantation model (C57BL/6 → BALB/b), donor and third-party Treg were equally effective in controlling GVHD. Furthermore, using an in vivo Treg depletion mouse model, we found that Treg exert their main suppressive activity in the first 2 d after transplantation. Third-party Treg survive for a shorter period of time after adoptive transfer, but despite the shorter survival, they control Tcon proliferation in the early phases of HCT. These studies provide relevant insights on the mechanisms of Treg-mediated protection from GVHD and support for the use of third-party Treg in clinical trials.

IL-17 gene ablation does not impact Treg-mediated suppression of graft-versus-host disease after bone marrow transplantation

Regulatory T cell (Treg) immunotherapy is a promising strategy for the treatment of graft rejection responses and autoimmune disorders. Our and other laboratories have shown that the transfer of highly purified CD4(+)CD25(+)Foxp3(+) natural Treg can prevent lethal graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation across both major and minor histocompatibility barriers. However, recent evidence suggests that the Treg suppressive phenotype can become unstable, a phenomenon that can culminate in Treg conversion into IL-17-producing cells. We hypothesized that the intense proinflammatory signals released during an ongoing alloreaction might redirect a fraction of the transferred Treg to the Th17 cell fate, thereby losing immunosuppressive potential. We therefore sought to evaluate the impact of Il17 gene ablation on Treg stability and immunosuppressive capacity in a major MHC mismatch model. We show that although Il17 gene ablation results in a mildly enhanced Treg immunosuppressive ability in vitro, such improvement is not observed when IL-17-deficient Treg are used for GVHD suppression in vivo. Similarly, when we selectively blocked IL-1 signaling in Treg, that was shown to be necessary for Th17 conversion, we did not detect any improvement on Treg-mediated GVHD suppressive ability in vivo. Furthermore, upon ex vivo reisolation of transferred wild-type Treg, we detected little or no Treg-mediated IL-17 production upon GVHD induction. Our results indicate that blocking Th17 conversion does not affect the GVHD suppressive ability of highly purified natural Treg in vivo, suggesting that IL-17 targeting is not a valuable strategy to improve Treg immunotherapy after hematopoietic cell transplantation.

Skin improvement with two different oestroprogestins in patients affected by acne and polycystic ovary syndrome: clinical and instrumental evaluation

BACKGROUND

Despite it is accepted that acne is mostly caused by an hyper-responsiveness of the pilo-sebaceous unit to normal circulating androgen hormones, in a few patients, especially women, acneic lesions can be associated with increased serum androgen levels (hyperandrogenism), of which polycystic ovary syndrome (PCOS) is the most common cause. In women with acne and proven PCOS therapy with estroprogestins (EPs) can be an excellent option.

OBJECTIVE

The aim of the study was to assess the effects of two estroprogestins (EPs), ethinyl-estradiol (EE) 30 mcg/drospirenone (DRSP) 3 mg, and ethinyl-estradiol (EE) 30 mcg/chlormadinone acetate (CMA) 2 mg, both on increased serum androgen levels and on several skin parameters in women affected by mild to severe acne and polycystic ovary syndrome (PCOS).

METHODS

Fifty-nine women were randomized to receive EE/DRSP (n = 32) or EE/CMA (n = 27) for six months. Evaluation of serum androgen levels, grading of acne and hirsutism (respectively with Pillsbury and Ferriman-Gallwey score) and non-invasive assessment of skin hydration, transepidermal water loss (TEWL) and skin homogeneity were performed at baseline, at 3 and 6 months (end of treatment).

RESULTS

Both treatments were well tolerated and showed a significant improvement of skin and hormonal parameters, although EE/DRSP showed a more potent effect on acne and seborrhea.

CONCLUSIONS

Estroprogestins represent an effective and safe treatment in women with acne and polycystic ovary syndrome (PCOS). Nevertheless, the combination EE 30 mcg/DRSP 3 mg appears to be a more potent therapeutic option.

[Short-term effect of an estroprogestin containing ethinylestradiol 20 mcg + drospirenone 3 mg in 24+4 regimen at hormonal and cutaneous level in ovarian hyperandrogenism]

AIM

evaluate the efficacy of an estroprogestin EP containing 20 mcg ethinilestradiol (EE) and 3 mg drospirenone (DRSP) in the treatment of hyperandrogenism.

METHODS

In this study, twenty hyperandrogenic patients were treated with an EP containing EE 20 mcg and DRSP 3 mg in 24+4 regimen for three months. Skin evaluation was performed both quantitatively and qualitatively.

RESULTS AND CONCLUSION

This EP combination showed, after a short-term treatment (three months) to decrease significantly seborrhea, acne, and circulating androgens (testosterone, deidroepiandrosterone sulphate, and androstenedione), while increased sex hormone binding globulin levels. Moreover, this EE 20 mcg/DRSP 3mg EP combination changed some parameters of skin quality, increasing corneometry (a parameter related to skin hydration), and reduced trans epidermal water loss (TEWL, a parameter related to skin evaporation), and erythema (a parameter related to skin inflammation). These results could be taken into account in individualizing the treatment of hyperandrogenic patients.

[Progestins]

Progestins are a group of different compounds sharing the ability to induce secretory changes on a endometrium pretreated with estrogen, while they are different in some abilities, for example the interaction with receptors other than progestin receptor, as androgenic or mineralocorticoid receptor. Some progestins have antiandrogenic properties and are used in treating hyperandrogenic manifestations (seborrhea, acne, hirsutism). The different clinical pharmacology of the various progestins is the basis for an individualized treatment in different clinical conditions. Key words.

Therapeutic targeting of Syk in autoimmune diabetes

In APCs, the protein tyrosine kinase Syk is required for signaling of several immunoreceptors, including the BCR and FcR. We show that conditional ablation of the syk gene in dendritic cells (DCs) abrogates FcgammaR-mediated cross priming of diabetogenic T cells in RIP-mOVA mice, a situation phenocopied in wild-type RIP-mOVA mice treated with the selective Syk inhibitor R788. In addition to blocking FcgammaR-mediated events, R788 also blocked BCR-mediated Ag presentation, thus broadly interrupting the humoral contributions to T cell-driven autoimmunity. Indeed, oral administration of R788 significantly delayed spontaneous diabetes onset in NOD mice and successfully delayed progression of early-established diabetes even when treatment was initiated after the development of glucose intolerance. At the DC level, R788 treatment was associated with reduced insulin-specific CD8 priming and decreased DC numbers. At the B cell level, R788 reduced total B cell numbers and total Ig concentrations. Interestingly, R788 increased the number of IL-10-producing B cells, thus inducing a tolerogenic B cell population with immunomodulatory activity. Taken together, we show by genetic and pharmacologic approaches that Syk in APCs is an attractive target in T cell-mediated autoimmune diseases such as type 1 diabetes.

Risk factors for type 2 diabetes in women attending menopause clinics in Italy: a cross-sectional study

OBJECTIVE

To analyze risk factors for type 2 diabetes among women attending menopause clinics in Italy for counselling about the menopause.

SUBJECTS

Women attending a network of first-level outpatient menopause clinics in Italy for general counselling about menopause or treatment of menopausal symptoms.

METHODS

Cross-sectional study with no exclusion criteria. Type 2 diabetes was defined according to National Diabetes Data Groups Indications and the fasting blood glucose at an oral glucose tolerance test within the previous year.

RESULTS

Out of the 44 694 considered in this analysis, 808 had a diagnosis of diabetes type 2 (1.8%). In comparison with women aged < 50 years, the multivariate odds ratios (OR) of type 2 diabetes were 1.31 (95% confidence interval (CI), 0.99-1.74) for women aged 50-52 years, 1.66 (95% CI, 1.27-2.17) at 53-56 years and 2.84 (95% CI, 2.20-3.67) in women aged > or = 57 years. Type 2 diabetes was less frequently reported in more educated women (OR high school/university vs. primary school = 0.44 (95% CI, 0.36-0.55)). Being overweight was associated with an increased risk of type 2 diabetes. In comparison with women reporting a low level of physical activity, the multivariate OR of type 2 diabetes was 0.67 (95% CI, 0.54-0.84) for women reporting regular physical activity. In comparison with premenopausal women, the multivariate OR of type 2 diabetes was 1.38 (95% CI, 1.03-1.84) in women with natural menopause. This finding was present also after allowing for the potential confounding effect of age. The multivariate OR of diabetes for users of hormonal replacement therapy was 0.58 (95% CI, 0.46-0.73).

CONCLUSIONS

This large cross-sectional study suggests that postmenopausal women are at higher risk of type 2 diabetes after allowance for the effect of age. Other main determinants of risk of type 2 diabetes in women around menopause were low socioeconomic status and being overweight. Diabetes was found less frequently in those taking hormone replacement therapy.

A specialized vascular niche for adult neural stem cells

Stem cells reside in specialized niches that regulate their self-renewal and differentiation. The vasculature is emerging as an important component of stem cell niches. Here, we show that the adult subventricular zone (SVZ) neural stem cell niche contains an extensive planar vascular plexus that has specialized properties. Dividing stem cells and their transit-amplifying progeny are tightly apposed to SVZ blood vessels both during homeostasis and regeneration. They frequently contact the vasculature at sites that lack astrocyte endfeet and pericyte coverage, a modification of the blood-brain barrier unique to the SVZ. Moreover, regeneration often occurs at these sites. Finally, we find that circulating small molecules in the blood enter the SVZ. Thus, the vasculature is a key component of the adult SVZ neural stem cell niche, with SVZ stem cells and transit-amplifying cells uniquely poised to receive spatial cues and regulatory signals from diverse elements of the vascular system.

[Effect on skin and hormonal hyperandrogenic manifestations of an oral estroprogestin association containing ethynilestradiol 30 mg and drospirenone 3 mg]

AIM

This study evaluated hormonal and skin effects in hyperandrogenic women of an oral estroprogestin (EP) association containing ethynilestradiol 30 mcg plus drospirenone 3 mg.

METHODS

Thirty two women with signs and symptoms of hyperandrogenism (seborrhea, acne, increased hair); hormonal assessment (follicle-stimulating hormone, [FSH]; luteinizing hormone, LH; 17-hydroxi-progesterone, 17OHP; androstenedione, A, testosterone, T; dehydroepiandrosterone sulfate, DHEAS; sex hormone binding globulin, [SHBG]; Free Androgen Index [FAI, Tx100/SHBG] was performed before the start of treatment, and after 3 and 6 months of administration of EP. The impact on seborrhea, acne, and hair pattern (Ferriman-Gallwey score) was assessed, and, by non-invasive technique, hydration, water transpiration, and homogeneity of the skin were evaluated.

RESULTS

Treatment with this EP for 6 months decreased significantly circulating androgen levels (A, T, DHEAS) and FAI, and increased SHBG levels, also reducing seborrhea, acne and hirsutism. Moreover, EE/DRSP increased hydration and improved overall appearance of skin surface (homogeneity).

CONCLUSION

Treatment with EE 30 mcg+DRSP 3 mg improves hormonal pattern and skin appearance in hyperandrogenic patients, potentially with subsequent, beneficial effects on quality of life of these women.

Regulatory T cells inhibit dendritic cells by lymphocyte activation gene-3 engagement of MHC class II

Lymphocyte activation gene-3 (LAG-3) is a CD4-related transmembrane protein expressed by regulatory T cells that binds MHC II on APCs. It is shown in this study that during Treg:DC interactions, LAG-3 engagement with MHC class II inhibits DC activation. MHC II cross-linking by agonistic Abs induces an ITAM-mediated inhibitory signaling pathway, involving FcgammaRgamma and ERK-mediated recruitment of SHP-1 that suppresses dendritic cell maturation and immunostimulatory capacity. These data reveal a novel ITAM-mediated inhibitory signaling pathway in DCs triggered by MHC II engagement of LAG-3, providing a molecular mechanism in which regulatory T cells may suppress via modulating DC function.

Fc gamma receptor IIB on dendritic cells enforces peripheral tolerance by inhibiting effector T cell responses

The uptake of immune complexes by FcRs on APCs augments humoral and cellular responses to exogenous Ag. In this study, CD11c+ dendritic cells are shown to be responsible in vivo for immune complex-triggered priming of T cells. We examine the consequence of Ab-mediated uptake of self Ag by dendritic cells in the rat insulin promoter-membrane OVA model and identify a role for the inhibitory FcgammaRIIB in the maintenance of peripheral CD8 T cell tolerance. Effector differentiation of diabetogenic OT-I CD8+ T cells is enhanced in rat insulin promoter-membrane OVA mice lacking FcgammaRIIB, resulting in a high incidence of diabetes. FcgammaRIIB-mediated inhibition of CD8 T cell priming results from suppression of both DC activation and cross-presentation through activating FcgammaRs. Further FcgammaRIIB on DCs inhibited the induction of OVA-specific Th1 effectors, limiting Th1-type differentiation and memory T cell accumulation. In these MHC II-restricted responses, the presence of FcgammaRIIB only modestly affected initial CD4 T cell proliferative responses, suggesting that FcgammaRIIB limited effector cell differentiation primarily by inhibiting DC activation. Thus, FcgammaRIIB can contribute to peripheral tolerance maintenance by inhibiting DC activation alone or by also limiting processing of exogenously acquired Ag.

Abnormal costimulatory phenotype and function of dendritic cells before and after the onset of severe murine lupus

We analyzed the activation and function of dendritic cells (DCs) in the spleens of diseased, lupus-prone NZM2410 and NZB-W/F1 mice and age-matched BALB/c and C57BL/6 control mice. Lupus DCs showed an altered ex vivo costimulatory profile, with a significant increase in the expression of CD40, decreased expression of CD80 and CD54, and normal expression of CD86. DCs from young lupus-prone NZM2410 mice, before the development of the disease, expressed normal levels of CD80 and CD86 but already overexpressed CD40. The increase in CD40-positive cells was specific for DCs and involved the subset of myeloid and CD8α⁺ DCs before disease onset, with a small involvement of plasmacytoid DCs in diseased mice. In vitro data from bone marrow-derived DCs and splenic myeloid DCs suggest that the overexpression of CD40 is not due to a primary alteration of CD40 regulation in DCs but rather to an extrinsic stimulus. Our analyses suggest that the defect of CD80 in NZM2410 and NZB-W/F1 mice, which closely resembles the costimulatory defect found in DCs from humans with systemic lupus erythematosus, is linked to the autoimmune disease. The increase in CD40 may instead participate in disease pathogenesis, being present months before any sign of autoimmunity, and its downregulation should be explored as an alternative to treatment with anti-CD40 ligand in lupus.

Nuclear autoantigen translocation and autoantibody opsonization lead to increased dendritic cell phagocytosis and presentation of nuclear antigens: a novel pathogenic pathway for autoimmunity?

Autoreactivity in lupus requires the delivery of autoantigens to APCs in a proinflammatory context. It has been proposed that apoptotic cells are a source of lupus autoantigens and targets for autoantibodies. Using a histone H2B-GFP fusion protein as traceable Ag, we show here that lupus autoantibodies, directed against nuclear autoantigens, can opsonize apoptotic cells, enhance their uptake through induction of proinflammatory Fc gammaR-mediated phagocytosis, and augment Ag-specific T cell proliferation by increasing Ag loading. Apoptotic blebs and bodies seemed to be a preferred target of DC phagocytosis, via both "eat-me signals" and Fc gammaR-mediated mechanisms; furthermore, inhibition of nuclear Ag redistribution, by blockade of chromatin fragmentation, could stop binding and opsonization of apoptotic cells by autoantibodies, and inhibited Fc gamma-R-mediated enhancement of phagocytosis. Our results suggest that DC uptake of opsonized histones and other nuclear Ags from apoptotic cells is a novel pathway for the presentation of nuclear Ags in a highly inflammatory context. Blockade of chromatin fragmentation in lupus is a potential therapeutic approach, which could theoretically limit DC access to autoantigens delivered in proinflammatory context, while leaving available for tolerization those delivered in a noninflammatory context.

Factors associated with climacteric symptoms in women around menopause attending menopause clinics in Italy

OBJECTIVE

To obtain data on correlates of climacteric symptoms in women around menopause attending menopause clinics in Italy.

METHODS

Since 1997 a large cross sectional study has been conducted on the characteristics of women around menopause attending a network of first level menopause outpatient's clinics in Italy. A total of 66,501 (mean age 54.4 years) women are considered in the present paper.

RESULTS

The odds ratios of moderate and severe hot flashes/night sweats were lower in more educated women and (for severe symptoms only) in women reporting regular physical activity. Depression, difficulty to sleep, forgetfulness and irritability tended to be less frequent in more educated women and (depression only) in women reporting regular physical activity. Parous women reported more frequently these symptoms.

CONCLUSIONS

This large study confirms in Southern European population that low education, body mass index and low physical activity are associated with climacteric symptoms. Parous women are at greater risk of psychological symptoms.

Alpha4beta1 and alpha4beta7 CD4 T cell numbers increase and CLA CD4 T cell numbers decrease in systemic sclerosis

We studied the expression of adhesion molecules affecting recirculation and homing on peripheral blood CD4(+) T cells of patients with systemic sclerosis (SSc), in order to evaluate whether the distribution of tissue targeted subsets could reflect the participation of internal organs or the extent of cutaneous involvement [i.e. limited cutaneous (lc) and diffuse cutaneous (dc)]. Peripheral blood mononuclear cells (PBMC) from 51 patients with SSc and 19 sex- and age-matched controls were investigated by cytofluorimetric analysis for lymphocyte subpopulations carrying the following surface molecules: CD3, CD4, CLA, alpha4beta7 and alpha4beta1. Standard routine biochemistry and clinical examinations were also performed in all patients. We found that both alpha4beta1(+) and alpha4beta7(+) cells within the CD4(+) T cell population were significantly increased, while CLA(+) CD4(+) T cells were significantly reduced in SSc, compared to healthy donors. Significantly lower absolute numbers of alpha4beta7(+) cells were found in lc- compared to dc-SSc. Patients with oesophageal involvement had high numbers of alpha4beta7(+) cells, while those with nephritis also showed low levels of CLA(+) cells. Lung involvement was related directly to alpha4beta1(+) cell numbers and inversely to alpha4beta7(+) CD4 cell numbers. Taken together, our findings demonstrate that distinct CD4(+) T cell populations with selective homing properties show changes from normal distribution in SSc, and such changes are related to clinical expression and organ involvement in the course of the disease.

Heart infarct in NOD-SCID mice: therapeutic vasculogenesis by transplantation of human CD34+ cells and low dose CD34+KDR+ cells

Hematopoietic (Hem) and endothelial (End) lineages derive from a common progenitor cell, the hemangioblast: specifically, the human cord blood (CB) CD34+KDR+ cell fraction comprises primitive Hem and End cells, as well as hemangioblasts. In humans, the potential therapeutic role of Hem and End progenitors in ischemic heart disease is subject to intense investigation. Particularly, the contribution of these cells to angiogenesis and cardiomyogenesis in myocardial ischemia is not well established. In our studies, we induced myocardial infarct (MI) in the immunocompromised NOD-SCID mouse model, and monitored the effects of myocardial transplantation of human CB CD34+ cells on cardiac function. Specifically, we compared the therapeutic effect of unseparated CD34+ cells vs. PBS and mononuclear cells (MNCs); moreover, we compared the action of the CD34+KDR+ cell subfraction vs. the CD34+KDR- subset. CD34+ cells significantly improve cardiac function after MI, as compared with PBS/MNCs. Similar beneficial actions were obtained using a 2-log lower number of CD34+KDR+ cells, while the same number of CD34+KDR- cells did not have any effects. The beneficial effect of CD34+KDR+ cells may mostly be ascribed to their notable resistance to apoptosis and to their angiogenic action, since cardiomyogenesis was limited. Altogether, our results indicate that, within the CD34+ cell population, the CD34+KDR+ fraction is responsible for the improvement in cardiac hemodynamics and hence represents the candidate active CD34+ cell subset.

Anti-p110 autoantibodies identify a subtype of "seronegative" myasthenia gravis with prominent oculobulbar involvement

Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness and pathogenetic autoantibodies directed against the nicotinic acetylcholine receptor (seropositive myasthenia gravis; SPMG). Nearly 15% to 20% of MG patients do not have these antibodies (seronegative myasthenia gravis; SNMG), but several evidence indicate that these patients have circulating pathogenic autoantibodies directed against other muscle antigens. Using the TE671 rhabdomyosarcoma cell line as an antigen source, we analyzed sera from 63 SNMG and 26 SPMG patients and 26 healthy blood donors by FACS analysis. We found that 40 of 63 SNMG patients and only 1 of 26 SPMG patients had IgG binding to the TE671 cell line. None of the sera bound to the unrelated MRC5 cell line. To identify the antigen, we analyzed sera immunoreactivity in more detail by immunoprecipitation of biotinylated membrane proteins from TE671 cells. When the immunoprecipitated proteins were separated by SDS-PAGE electrophoresis and then transferred to nitrocellulose membranes, we found that SNMG IgG identify a band corresponding to a protein with a molecular weight of 110 kDa (P110), which is not recognized by seropositive MG sera. This anti-P110 immunoreactivity is significantly associated with a distinct clinical picture characterized by a prominent involvement of ocular and bulbar muscles, with frequent respiratory problems (p < 0.005), and is recognized by a specific antimuscle specific kinase (MuSK) antiserum. In a recent article, the presence of anti-MuSK antibodies was described in SNMG. Our results confirm the presence of these antibodies in SNMG and suggest that anti-P110/MuSK autoantibodies identify a subtype of SNMG in which the different pathogenesis induces the distinct clinical picture.

Quantitative nailfold capillary microscopy findings in patients with acrocyanosis compared with patients having systemic sclerosis and control subjects

BACKGROUND

The morphologic capillary microscopy (capillaroscopy) pattern of acrocyanosis is characterized by hemorrhages, pericapillary edema, and widened capillaries. These findings can result in a difficult differential diagnosis with systemic sclerosis (SSc).

OBJECTIVE

We sought to quantify the characteristics of the capillaroscopy pattern that distinguishes patients with acrocyanosis from patients with SSc and control subjects.

METHODS

A videomicroscope with fiberoptic illumination and personal computer-based image processing was used to measure capillary density, giant capillaries, loop width, and arterial and venous limbs in 10 patients with acrocyanosis, 10 patients with SSc, and 10 healthy control subjects.

RESULTS

Acrocyanotic patients differed in every quantitative parameter both from control subjects and patients with SSc. In particular, capillary density, which was reduced compared with that of control subjects, was much higher than that of patients with SSc: one giant capillary per finger was observed in 2 patients with acrocyanosis, whereas more than 2 giant capillaries per finger were observed in each patient with SSc.

CONCLUSION

These differences may aid in making the distinction between the capillaroscopy patterns in acrocyanosis and SSc.

Long-term safety and efficacy of amisulpride in subchronic or chronic schizophrenia. Amisulpride Study Group

Amisulpride is an atypical antipsychotic with selective affinity for dopamine D2/3 receptors. In this long-term, open, randomised, multicentre trial, patients with chronic or subchronic schizophrenia received amisulpride (n =370) or haloperidol (n = 118) for 12 months. Dosage regimens were flexible (amisulpride 200-800 mg/day, haloperidol 5-20 mg/day). Improvement in mean Brief Psychiatric Rating Scale total score was significantly greater for amisulpride than haloperidol (17.0 versus 12.8, P = 0.01). Positive symptoms (Positive and Negative Syndrome Scale [PANSS] positive) improved in a similar way in each group but amisulpride caused a significantly better improvement in negative symptoms (PANSS negative) (7.1 versus 3.7, P < 0.0001). Improvements in Global Assessment of Functioning (GAF) and Quality of Life Scale (QLS) scores were also significantly greater in the amisulpride group (GAF -20.1 versus -13.6, P = 0.001; QLS -0.64 versus -0.30, P = 0.02). Adverse events were mainly psychiatric in nature, and occurred with similar frequency in each group (amisulpride 254/370, 69%; haloperidol 82/118, 70%). Extrapyramidal symptoms were more frequent for haloperidol (48/118, 41% versus 96/370, 26% for amisulpride), leading to a greater requirement for antiparkinsonian medication (haloperidol 66/118, 56% versus amisulpride 118/370, 32%). Haloperidol significantly aggravated parkinsonism, akathisia and involuntary movement compared to amisulpride. The overall incidence of endocrine events was comparable between groups (4% for amisulpride, 3% for haloperidol). Maintenance of efficacy was comparable in both treatment groups; 59% of amisulpride patients and 55% of haloperidol patients improved after 1 month of therapy remained improved throughout the study period. Amisulpride is effective following flexible long-term administration and significantly improves social functioning and quality of life.

[Biological treatment of depression]

Pharmacotherapy remains the main medical means of treating depression, and constant progress during recent years has led to the present availability of many effective and well tolerated drugs. Some essential conditions should be present for optimum therapeutic efficacy. The appropriate indications should be precisely defined. The most active and best tolerated product should be chosen for each patient. The medical treatment should be associated with psychotherapy. Finally, the patient should be followed-up with regard to restoration of his relations with his family, social and professional groups. Much progress remains to be made. The most important are better knowledge of the mechanisms of action of antidepressants and of the pathophysiopsychological mechanisms of depression. Some rare cases of very severe depression, either unresponsive to medical treatment or when such treatment is contraindicated, still require the use of electroconvulsive therapy. Light therapy is used in seasonal affective disorder.

Pigmented purpura-like eruption as cutaneous sign of mycosis fungoides with autoimmune purpura

We describe the clinical and laboratory findings of a young man with mycosis fungoides. The disease was associated, since the early stages, with autoimmune purpura. Interferon alfa (IFN-alpha) administration improved this patient's condition, both the purpuric eruption and patchy cutaneous lesions, thus suggesting T-cell abnormalities may be responsible for the development of the disease.

[Acidosis, hypoxia and hypotension in abdominal chemotherapy with blockade of arterial and venous circulation (stop flow)]

BACKGROUND AND AIM

A study was performed of the perioperative systemic effects of a recent zoned chemotherapy technique administered in conditions of extreme acidosis, hypoxia and modern hypotension.

METHODS

EXPERIMENTAL DESIGN

a prospective analysis of the changes compared to basal values using Student's t test for paired data.

SETTING

Operating theatres and Recovery room.

PATIENTS OR PARTICIPANTS

A population of 16 consenting patients suffering from abdominal or pelvic neoplasms, ASA 1-3, recruited according to the parameters suggested by the international literature.

SURGERY

central venous catheter, radial arterial catheter, open catheter of the e.v. femoral artery, general anesthesia using isoflurane. Tests performed: Blood gas analysis of systemic arteries, abdominal veins and the superior vena cava at times preceding clamping (T0) and 7 and 14 mins after the start, at declamping, on reawakening from anesthesia and 30 and 60 mins afterwards (T1, T2, T3, T4, T5, T6). Serial evaluation of activated coagulation time.

RESULTS

Mean 25% reduction of neoplastic mass, systemic arterial and venous pH diminished at T1 and T2, but more marked and transient at T3; district venous pH significantly diminished during entire Stop-Flow. Systemic PaO2 increased throughout method (SaO2 > 98%). PaO2 in the superior vena cava recorded significantly higher intraoperative values compared to basal and postoperative levels, no major differences found at time T3. SaO2 showed statistically significant differences between the superior vena cava and the abdominal distrist at both T 1 (p 0.0002) and T2 (p 0.004). No toxic effects due to NPS were observed.

CONCLUSIONS

This is a safe technique but not without risks, which requires considerable anesthesiological commitment.

Efficacy of amineptine in the prevention of relapse in unipolar depression

The clinical properties of amineptine, a mainly dopaminergic antidepressant, were assessed in a double-blind controlled study involving patients fulfilling Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria for unipolar depression. The aim was to determine how relapses could be prevented in this frequently recessing disorder. The study was a two-phase, 12-month, multicentre trial of patients suffering from major depression or dysthymia, diagnosed using DSM-III criteria and evaluated on the Montgomery-Asberg Depression Rating Scale and the Mood, Anxiety, Retardation, Danger scale. Phase I was an open-label 3-month period, with the patients being given 200 mg amineptine per day. The second, 9-month period was a placebo-controlled prophylactic phase. A total of 458 patients were initially included in the study. Of the 376 who completed phase I, 303 (66%) were responders; 284 entered the prophylactic study, randomly assigned to two groups. Of the 134 patients in the placebo group who completed phase II, 25 (18.7%) suffered a relapse, compared with nine out of the 136 (6.6%) in the amineptine group. After resolution of an acute episode of major depression or dysthymia, long-term antidepressant therapy with amineptine significantly reduced the relapse rate.

Managing recurrent vulvovaginal candidiasis. Intermittent prevention with itraconazole

OBJECTIVE

To evaluate the efficacy of one-day, intermittent, monthly prophylaxis with 400 mg itraconazole in the management of recurrent vulvovaginal candidiasis.

STUDY DESIGN

In a randomized trial, 57 patients and 57 controls with recurrent vulvovaginal candidiasis were assigned either to receive one-day monthly itraconazole prophylaxis for six months or no treatment. Clinical and mycologic evaluations were carried out 3, 6 and 12 months after enrollment.

RESULTS

During the first six months of follow-up, the rate of symptomatic recurrences was 36.4% (20/55) among the treated women and 64.2% (34/53) in the controls. The mean time +/- SEM to symptomatic recurrence was 149 +/- 6 days among patients receiving prophylaxis and 120 +/- 6 days in the controls (P = .003 by log-rank test). These differences disappeared almost completely after the cessation of intermittent prophylaxis. In fact, the proportion of patients still asymptomatic after one year of follow-up was 38.9% (21/54) among treated women and 28.8% (15/53) in the controls (P = .83 by Fisher's exact test).

CONCLUSION

One-day monthly, intermittent itraconazole prophylaxis reduced the rate of recurrence in patients with recurrent vulvovaginal candidiasis, but the beneficial effect of itraconazole was lost within a few months after cessation of prophylaxis.

Prevalence of and risk factors for fungal vaginitis caused by non-albicans species

OBJECTIVE

Our purpose was to evaluate the prevalence of symptomatic yeast vaginitis caused by non-albicans species among patients attending a vaginitis clinic over an 8-year period.

STUDY DESIGN

A retrospective study of 1263 patients with symptomatic yeast vaginitis confirmed by culture techniques was performed.

RESULTS

The prevalence of symptomatic fungal vaginitis caused by non-albicans species increased from 9.9% (10/101) in 1988 to 17.2% (36/209) in 1995 (chi 2 for trend = 9.33, p = 0.002). Non-albicans species were found more frequently in known human immunodeficiency virus-seropositive patients (23/102 vs 143/1161, odds ratio 2.07, 95% confidence interval 1.2 to 3.46) than in seronegative subjects or subjects of unknown status for the virus. Recurrent vaginal candidiasis was an additional risk factor for vaginitis caused by non-albicans species (odds ratio 2.47, 95% confidence interval 1.72 to 3.52). The increase in non-albicans isolates during the study period was confirmed in stratified analysis and in the subgroup of self-referred patients with no history of either human immunodeficiency virus infection or recurrent vaginal candidiasis.

CONCLUSION

The prevalence of fungal vaginitis caused by non-albicans species has increased sharply in the setting of a vaginitis clinic. The characteristics of risk factors suggest that fungal cultures should be done routinely in human immunodeficiency virus-seropositive subjects with suspected vaginal candidiasis and in patients with recurrent vaginal infection.

Schnitzler's syndrome: report of a new case and a review of the literature

Schnitzler syndrome is a rare condition characterized by chronic non-pruritic urticaria, recurrent fever, bone pain, osteocondensation, and monoclonal IgM gammopathy without features of lymphoproliferative disease. We describe the case of a 44-year-old man with an 8-year history of bone pain with hyperostosis and a 5-year history of chronic non-pruritic urticaria, associated with fever, hyperleukocytosis, hepatomegaly, serum monoclonal IgM-kappa. Systemic treatment with steroids was effective against bone pain but was ineffective in controlling the urticaria. We also review 35 cases. No adequate treatment has yet been found. The pathogenesis is unclear and the role of the IgM component in the induction of urticaria has not been established.

Epidermolysis bullosa of the Dowling-Meara type: clinical and ultrastructural findings in five patients

Clinical and pathologic features of five cases of epidermolysis bullosa simplex, Dowling-Meara type (EBS-DM), are described. Four patients were children, and two were related (father and daughter). Clinical history revealed blistering at birth in three patients; in all of them the signs and symptoms improved with age. Histopathologic and ultrastructural examinations showed cytolysis of the basal cells and clumping of the tonofilaments within the cytoplasm of keratinocytes. Two distinct types of clumps were observed: round (3 patients) and whisklike (2 patients). Two patients had both types of clumps. The presence of both types in the same patient suggests that subtyping of the disease is still premature.

[DSM IV and training: the limits]

Since its third edition, DSM has been considered to be an excellent tool for psychiatric research. The primary objective of this classificatory system was to put forward internationally accepted standard definitions. DSM diagnostic criteria are now indispensable for any publication in the scientific literature. It appears however that this work has gradually lost sight of its initial objective and is used as an educational tool for training of clinicians. What are the limits and risks of such a use? Can the DSM IV philosophy be reconciled with the objectives of training? Are the criteria in force for the selection of homogeneous patients groups identical to those which enable knowledge acquisition required for identification of disorders and their treatment? What is the heuristic value of enumerating symptoms and syndromes isolated from any theoretical context? Can symptoms be separated from the patient's history and personality? Is the excessive use of concurrent disorders not likely to be a source of conceptual and therapeutic inflation? Is a purely descriptive approach to psychiatric disorders not likely to run the risk of overestimating them? The points are discussed in succession by the authors.