A telemedicine-based approach with real-time transmission of blood glucose data improves metabolic control in insulin-treated diabetes: the DIAMONDS randomized clinical trial

PURPOSE

To evaluate if a web-based telemedicine system (the Glucoonline^® system) is effective to improve glucose control in insulin-treated patients with type 1 and type 2 diabetes, as compared to standard of care.

METHODS

This was a prospective, randomized, controlled trial, carried out at three tertiary referral centers for diabetes in Italy. Adults with insulin-treated type 1 and type 2 diabetes, inadequate glycemic control, and no severe diabetes-related complications and/or comorbidities were eligible for this study. Patients were randomized to either perform telemedicine-assisted (Group A) or standard (Group B) self-monitoring blood glucose (SMBG) for 6 months. In Group A, patients received prompt feedback about their blood glucose levels and therapy suggestions from the study staff via phone/SMS, when appropriate. In Group B, patients had no remote assistance from the study staff between planned visits.

RESULTS

123 patients were included in the final analysis. After 6 months, patients achieved a significant reduction in HbA1c in Group A (-0.38%, p < 0.05) but not in Group B (+ 0.08%, p = 0.53). A significant difference in the percentage of patients with HbA1c < 7% between Group A and Group B was found after 3 months (28.6% vs 11.1%, p = 0.02). Also, fewer patients (p < 0.05) with HbA1c > 8.5% were found in Group A vs Group B, respectively, after both 3 months (14.3% vs 35.2%) and 6 months (21.8% vs 42.9%).

CONCLUSIONS

The use of the Glucoonline™ system resulted in improved metabolic control. Telemedicine services have potential to support diabetes self-management and provide the patients with remote, prompt assistance using affordable technological equipment. Trial registration This study was registered at clinicaltrials.gov (NCT01804803) on March 5, 2013.

Hypernatremia During Intravenous Treatment With Fosfomycin: A Retrospective Medical Record Review Study and an Analysis of Spontaneous Reports in the EudraVigilance Database

Background: Hypernatremia is a serious event that can occur during intravenous (IV) treatment with fosfomycin, and it can also be caused by a wrong drug preparation. Considering the clinical significance of hypernatremia, we decided to carry out two studies by using two different data sources with the aim to evaluate cases of IV fosfomycin-induced hypernatremia.

Methods: A retrospective medical record review was performed from June 2017 to June 2019 using data from two hospitals in Southern Italy. The information collected was related to the patients, the antibiotic treatment regimen, type of adverse drug reaction (ADR), hypernatremia severity classification, and drug withdrawal due to ADRs. Moreover, a pharmacovigilance study was performed from the date of the European marketing authorization of fosfomycin to October 11, 2021, using data reported on the European website of suspected ADRs. Information related to the patient characteristics, treatment, hypernatremia, and type of reporter was retrieved.

Results: From the retrospective medical record review, a total of 62 patients (48 men and 14 women) in treatment with fosfomycin were identified, of which 17 experienced ADRs. Specifically, 11 patients experienced hypernatremia. During the period from June 2017 to June 2018, a total of 63.7% of hypernatremia events were related to the wrong reconstitution of the drug. According to these results, a surveillance and training campaign about the correct drug reconstitution was managed. However, from June 2018 to June 2019, we still had four new hypernatremia cases. Drug withdrawal occurred in only one patient with hypernatremia. From the pharmacovigilance study, a total of 25 cases of IV fosfomycin-induced hypernatremia were retrieved. No substantial difference was found for patients’ distribution by sex. Most cases were classified as serious (68%) and reported “Recovered/resolved” as the outcome (44%). In the majority of cases, fosfomycin was the only suspected drug reported (72%).

Conclusion: Our results show that training campaigns on the correct drug preparation need to be strengthened to allow a reduction of hypernatremia cases. Moreover, when close monitoring and management is performed by the infectious disease (ID) specialist and hospital pharmacist, there also is a reduction in antibiotic withdrawal due to hypernatremia.

Economic evaluation of subcutaneous versus intravenous immunoglobulin therapy in chronic inflammatory demyelinating polyneuropathy: a real-life study

OBJECTIVES

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired peripheral neuropathy of immunological origin with a clinical presentation and course that are extremely variable. The therapeutic approach generally includes corticosteroid drugs, intravenous immunoglobulins (IVIGs) or plasmapheresis alone or in combination as first line therapy, and immunosuppressants. In 2014 the Italian regulatory agency included subcutaneous immunoglobulins (SCIGs) in the list of off-label drugs reimbursed by the national health service. Our aim is to compare costs and outcomes of IVIG versus SCIG therapy.

METHODS

Patients medical records and therapeutic plans were retrospectively analysed to collect data on IVIG treatments 1 year before the switch to SCIG, and after 1 year of treatment with SCIG. A budget impact analysis was conducted through resource identification and quantification, and healthcare and non-health care costs evaluation.

RESULTS

13 of 34 patients affected by CIDP who were referred to our neurophysiopathological unit and treated with IVIG were switched to home-based SCIG. After 1 year of receiving SCIG, 12 patients remained neurologically stable and reported good outcomes. Considering the cost of IVIG (€30.97/g) and adding to this the direct and indirect healthcare costs, the total cost of IVIG treatment for the 12 patients in a year was €371 417.06, compared with the cost of SCIG (€51.57/g) for a total annual cost of €631 745.16, not including indirect costs.

CONCLUSIONS

We observe a higher cost for SCIG treatment versus IVIG, which is not in line with data in the literature. However, SCIGs offer some important safety benefits and improvements in patient quality of life.

The addition of the MEP amplitude of finger extension muscles to clinical predictors of hand function after stroke: A prospective cohort study

BACKGROUND

Within the first 72 hours after stroke, active finger extension is a strong predictor of long-term dexterity. Transcranial magnetic stimulation may add prognostic value to clinical assessment, which is especially relevant for patients unable to follow instructions.

OBJECTIVE

The current prospective cohort study aims at determining whether amplitude of motor evoked potentials of the extensor digitorum communis (EDC) can improve clinical prediction after stroke when added to clinical tests.

METHODS

the amplitude of motor evoked potentials of the affected EDC muscle at rest was measured in 18 participants within 4 weeks after stroke, as were the ability to perform finger extension and the Fugl-Meyer Motor Assessment of the upper extremity (FMA_UE). These three determinants were related to the FMA_UE at 26 weeks after stroke (FMA_UE26), both directly, and via the proportional recovery prediction model. The relation between amplitude of the motor evoked potentials and FMA_UE26 was evaluated for EDC. For comparison, also the MEP amplitudes of biceps brachii and adductor digiti minimi muscles were recorded.

RESULTS

Patients' ability to voluntarily extend the fingers was strongly related to FMA_UE26, in our cohort there were no false negative results for this predictor. Our data revealed that the relation between amplitude of motor evoked potential of EDC and FMA_UE26 was significant, but moderate (rs = 0.58) without added clinical value. The other tested muscles did not correlate significantly to FMA_UE26.

CONCLUSIONS

Our study demonstrates no additional value of motor evoked potential amplitude of the affected EDC muscle to the clinical test of finger extension, the latter being more strongly related to FMA_UE26.

Complications after surgery for colorectal cancer affect quality of life and surgeon-patient relationship

AIM

This multicentric prospective study aimed to investigate how postoperative complications after surgery for colorectal cancer affect patients' quality of life and satisfaction with care.

METHOD

One hundred and sixteen patients operated on for colorectal cancer were enrolled in this study. Patients answered three questionnaires about generic (EORTC QLQ-C30) and disease-specific (EORTC QLQ-CR29) quality of life and treatment satisfaction (EORTC IN-PATSAT32) at the time of admission and at 1 and 6 months after surgery. Non-parametric tests and linear multiple regression models were used for statistical analysis.

RESULTS

Twelve patients had complications requiring further surgery (anastomotic leakage, abdominal bleeding, abdominal wall sepsis, wound infection). Patients with complications that required surgery reported a worse score of physical function, emotional function and anxiety than patients without such complications 1 month after surgery. These patients judged their general satisfaction with the quality of care and doctors' interpersonal skills, technical skills, information provision and availability to be worse than in patients without such complications. The presence of postoperative psychiatric complications and anastomotic leakage were independent predictors of quality of life (β = -0.30, P = 0.004, and β = -0.42, P < 0.001).

CONCLUSION

In patients undergoing surgery for colorectal cancer, complications requiring any kind of surgical management significantly affected patients' perception of all doctor-related items suggesting an impairment of the entire surgeon-patient relationship. Convincing patients that 'zero risk' cannot be achieved in surgical practice is therefore a priority.

Different subsets of circulating angiogenic cells do not predict bronchopulmonary dysplasia or other diseases of prematurity in preterm infants

Bronchopulmonary dysplasia (BPD) is a chronic lung disease occurring in very and extremely preterm infants undergoing mechanical ventilation. Given the altered lung vascular growth characterizing BPD, circulating angiogenic cells could be useful biomarkers to predict the risk. The objective of the study was to determine whether the percentages of circulating angiogenic cells (CD34+VEGFR-2+, CD34+CD133+VEGFR-2+, and CD45-CD34+CD133+VEGFR-2+ cells), assessed in the peripheral blood at birth by flow cytometry, could be used as markers for the risk of BPD. In one-hundred and forty-two preterm neonates (gestational age less than 32 weeks and/or birth weight less than 1500 g) admitted to our tertiary care Neonatal Intensive Care Unit between 2006 and 2009, we evaluated the percentages of circulating angiogenic cells at birth, at 7 days, and, in a subset of infants (n=40), at 28 days of life. The main outcome was the correlation between cell counts at birth and the subsequent risk of developing BPD. In our study, all the three cell populations failed to predict the development of BPD or other diseases of prematurity. We suggest that these cells cannot be used as biomarkers in preterm infants, and that research is needed to find other early predictors of BPD.

Immediate loading rehabilitation of a severe oligodontia: minimum impact on a young patient's social life

The purpose of this work was to illustrate the treatment of a severe oligodontia on a patient at the end of the growth through the use of immediately loaded dental implants. Deciduous teeth from 7.4 to 8.3 were extracted in a young patient suffering this severe oligondontia. In the same session five conical implants were inserted by the use of Piezosurgery inserts and traditional burs. The impression for the temporary restoration was then taken and an acrylic temporary restoration stabilized with a laser-welded titanium bar was delivered two days after. One year after loading the impression for the final restoration was taken and the screw retained final rehabilitation was then given to the patient. The radiographic, phonetic and esthetic tests showed an accurate fitting and very satisfactory esthetic integration. The functional and esthetic deficits that could possibly occur with a delayed function different method were minimized with an immediate loading technique. Probably the young patient received a less psycho-esthetic-functional impact then a delayed technique, that in a young age could heavily affect his social life. Although this work considers a single case is interesting how today it's possible to overcome a problem that has to be evaluated with a relational global view, not only dental or esthetic one.

Regeneration of mandibular osteoradionecrosis defect with platelet rich plasma gel

Osteoradionecrosis (ORN) of the mandible is a major complication of radiation therapy of head and neck cancer with a potential of occurrence ranging from 5 to 15% of the irradiated patients. Due to the gradual necrotic process, the mandibular bone becomes necrotic and looses its spontaneous regeneration ability. Containing an elevated content of mitogenic and osteogenic growth factors, the use of platelet rich plasma (PRP) from autologous source has been suggested to re-activate the healing process of osteogenesis. Autologous PRP gel was introduced into the ORN necrotic defect of a 44-year old patient previously treated for squamous cell carcinoma of the tongue, subsequent to proper surgical debridement. We report post-operative two-year follow-up demonstrated by panoramic X-ray which showed regain of the mandibular bone continuity with a complete repair of the necrotic defects. We conclude that this case illustrates an incident of successful regeneration of ORN critical-sized defect of the mandible by autologous PRP gel.

Localization of pathological gland's site in primary hyperparathyroidism: ten years experience with MIBI scintigraphy

BACKGROUND

Primary hyperparathyroidism (PHPT) is characterised by pathological hyperfunctioning of one or more of the parathyroid glands leading to excessive parathyroid hormone (PTH) secretion. The aim of this study was to assess the diagnostic capacity of scintigraphy with MIBI, considering the surgical findings and the level of agreement with the result of cervical ultrasonography.

PATIENTS AND METHODS

In the period January 1996 to January 2006, 84 cases with PHPT were included in the study, in which scintigraphy with MIBI was used in addition to cervical ultrasonography. All were hospitalised as "short stay surgery" patients and then seen as outpatients at follow-up visits (at 7, 14 and 30 days), during which calcium, phosphorus and PTH values were measured.

RESULTS

In 55 cases (65.5%), the site of the pathology was suspected on the basis of the cervical ultrasonography. Scintigraphy with MIBI was positive in 76 cases (90.4%) and negative in the other eight (9.6%). In six of these eight cases the site had been detected by the cervical ultrasonography. In the remaining two cases (2.4%), neither of these examinations gave positive diagnostic findings. In 58 patients we proceeded with the removal of a single adenoma, in 19 cases with the removal of two out of the four glands, and in seven cases with the removal of three out of the four glands, the single formations removed not showing clearly-defined macroscopic characteristics; in two of the seven patients in whom three of the four glands were removed, the preoperative diagnostic examinations had not shown any evidence of gland pathology.

CONCLUSIONS

We regard scintigraphy with MIBI as a preoperative diagnostic examination that has modified the surgical approach to PHPT, inclining surgeons towards a mini-invasive surgical procedures. We consider CT, MRI and SPECT techniques to be indicated only in cases of relapse of PHPT, possibly associated with ectopic localisation of the parathyroid gland not identified in the course of previous surgical procedures.

Laparoscopic Donor Nephrectomy: Short Learning Curve

INTRODUCTION

The learning curve of laparoscopic donor nephrectomy (LDN) may represent a great technical challenge at centers with low volume of living donors. The number of LDNs required to overcome the learning curve is still unclear. Here we report the modality of approach to LDN at a low-volume living donor transplant center.

MATERIALS AND METHODS

We reviewed the records of two groups of donors operated by two different surgeons between January 2002 and October 2005. We compared donor hospital stay, operative time, presence of multiple renal arteries, blood loss, operative details, and complications.

RESULTS

The first six operations (group A) were performed by a well-trained laparoscopic surgeon (A.P.) with a consolidated experience in the LDN procedure, attended by our training surgeon (R.D.V.) who conducted the other six cases (group B). No conversion to an open procedure was necessary and there were no major minor complications. Mean operative time was 267.5 (+/-55.9) minutes in group A and 300 (+/-43.4) minutes in group B (P = .28). Mean warm ischemia time was 125 (+/-61.6) seconds in group A and 189.2 (+/-18.6) seconds in group B (P = .035). Mean hospital stay was 5.3 days in group A and 5.6 days in group B.

CONCLUSIONS

LDN can be performed safely and efficiently in transplant centers with initial experience. A collaborative approach to this difficult procedure with a surgeon skilled in donor nephrectomy minimizes the risk to the donor and reduces the learning curve.

Successful solitary pancreas transplantation with portal-enteric drainage following unsuccessful islet cell transplantation

BACKGROUND

There are no data regarding the outcome of solitary pancreas transplantation (SPT) with portal venous drainage (PVD) following unsuccessful islet transplantation (ITx) after multiple islet injections into the portal vein. We herein describe the outcome of three SPTs with PVD performed after failed ITx.

METHODS

Between October 2002 and December 2003, three SPTs with PVD were performed following unsuccessful ITx with multiple intraportal islet injections (mean 2.3 injections: range 2 to 3 injections) in two women and one man, aged 26, 49, and 60 years. Panel reactive antibody titer was 0% in all recipients. Immunosuppression was based on induction with either basiliximab (n = 2) or thymoglobulin (n = 1); maintenance therapy included steroids, mycophenolate mofetil, and tacrolimus. During the recipient operation, the absence of venous hypertension was established by direct measurement of portal pressure, before making the final decision to drain the pancreas into the portal vein.

RESULTS

Portal pressures were 16 cm H2O, 14 cm H2O, and 13 cm H2O. Pancreas grafts were reperfused after a period of cold preservation of 638, 695, and 835 minutes, respectively. All grafts showed immediate endocrine function, maintaining their recipients insulin-independent for longest follow-ups of 8, 21, and 23 months, respectively. One recipient developed a nonocclusive venous thrombus that resolved with intravenous heparin infusion.

CONCLUSIONS

Our experience showed that unsuccessful ITx with multiple intraportal injections does not necessarily preclude the possibility of subsequent successful SPT with PVD. Further experience is needed to define contraindications and possible complications of SPT with PVD following ITx.

High circulating levels of biologically inactive IL-6/SIL-6 receptor complexes in systemic juvenile idiopathic arthritis: evidence for serum factors interfering with the binding to gp130

We previously demonstrated that high levels of IL-6/sIL-6R complexes are present in sera of patients with systemic juvenile idiopathic arthritis (s-JIA) and that the amount of IL-6 estimated in the IL-6/sIL-6R complexes is markedly higher than that measured by the B9 assay. Here, we show that two additional bioassays, employing human myeloma XG-1 cells and human hepatoma Hep3B cells, detected serum IL-6 levels similar to those measured by the B9 assay and approximately 10-fold lower than the IL-6 levels estimated to be present in the IL-6/sIL-6R complex. Using an assay for the measurement of the amount of circulating IL-6 complexed with the sIL-6R and available for binding to gp130 (gp130 binding activity), we show that the IL-6/gp130 binding activity is similar to that detected by the bioassays and again significantly lower than that estimated to be present in the IL-6/sIL-6R complex. Addition of recombinant human IL-6 (rhIL-6) to sera of patients or controls results in a markedly lower increase in the gp130 binding activity in patients than in controls. Moreover, sera from s-JIA patients inhibited in a dose dependent manner the gp130 binding activity assay. These results show that sera from patients with s-JIA contain a factor, or factors, that inhibit(s) the binding of the IL-6/sIL-6R complex to gp130. This inhibitory activity does not appear to be due to soluble gp130, C-reactive protein or autoantibodies to IL-6.

Activation-induced cell death and Fas-induced apoptosis in patients with systemic or pauciarticular juvenile idiopathic arthritis

OBJECTIVE

To investigate the functionality of the Fas-induced apoptotic pathway in peripheral blood mononuclear cells (PBMC) from patients with systemic or pauciarticular juvenile idiopathic arthritis (JIA).

METHODS

PBMC from 12 patients with systemic and 6 with pauciarticular JIA were activated with anti-CD3 and rhIL-2 and then incubated in the presence or absence of the anti-Fas MoAb CH11 inducing activation of the Fas apoptotic pathway. Apoptosis was evaluated by flow cytometry and fluorescence microscopy.

RESULTS

The percentage of apoptotic cells following triggering of Fas did not differ between patients with systemic JIA (12.5 +/- 9.5%) or pauciarticular JIA (18.7 +/- 8.9%) and controls (16.1 +/- 6.8%). Evaluation of activation-induced cell death (AICD) in the absence of exogenous triggering of Fas showed that 44% (8/18) of the patients with JIA, compared to none of the controls (0/16), had a percentage of apoptotic cells higher than the mean + 2 SD of controls. The increased AICD was neutralized by the addition of an anti-TNF-alpha antibody.

CONCLUSION

Patients with systemic or pauciarticular JIA do not show a defect in the Fas-dependent apoptotic pathway of T cells. The increased AICD present in some patients with JIA appears to be at least in part related to the inflammatory cytokine TNF-alpha.

Circulating levels of soluble E-selectin, P-selectin and intercellular adhesion molecule-1 in patients with juvenile idiopathic arthritis

OBJECTIVE

To measure circulating levels of soluble E-selectin (sE-selectin), sP-selectin, and soluble intercellular adhesion molecule-1 (sICAM-1) in patients with active juvenile idiopathic arthritides (JIA), and to evaluate their correlation with disease activity variables and cytokine levels.

METHODS

Serum levels of sE-selectin, sP-selectin, and sICAM-1 were measured by ELISA in 42 patients with JIA and in 15 healthy controls.

RESULTS

Circulating levels of sE-selectin and sICAM-1, but not sP-selectin, were significantly elevated in patients with active systemic JIA. In patients with active polyarticular or pauciarticular JIA serum levels of sE-selectin. sP-selectin, and sICAM-1 were comparable to those of controls. In patients with systemic JIA, levels of sE-selectin and sICAM-1 were significantly correlated with levels of soluble tumor necrosis factor receptor 2 (sTNFR2), but not with those of interleukin 6 (IL-6) or IL-1beta.

CONCLUSION

Patients with active systemic JIA have elevated circulating levels of sE-selectin and sICAM-1. The correlation with sTNFR2, together with previous data on the TNF system in systemic JIA. suggests that TNF activated endothelial cells are the source of sE-selectin and sICAM-1 in this disease.

Conformational dynamics of the beta2-microglobulin C terminal in the cell-membrane-anchored major histocompatibility complex type I

We have recently described an anti-beta2-microglobulin (beta2-m) monoclonal antibody (mAb 14H3) capable of recognizing the epitope 92-99 of the protein in the monomeric native state as well as in the fibrillar polymeric state, but not in the major histocompatibility complex type I (MHCI) anchored to the cell membrane. In the present study, we investigated the molecular basis for the inaccessibility of the C-terminal end of beta2-m in the MHCI complex, and demonstrated that mAb 14H3 binds the soluble fraction of the MHCI complex with a Kd of 0.3 microM. An interaction between the complex and the membrane protects beta2-m from immunological recognition at the MHCI level. This protection from antibody recognition can be weakened by procedures such as heat shock or gamma irradiation that perturb the membrane structure and commit the cell to the apoptotic pathway. mAb 14H3 can recognize MHCI in a transient state that most likely precedes beta2-m shedding and may be proposed as a useful tool for dynamic analysis of MHCI conformational modifications.

[Retroperitoneal tumors]

The retroperitoneal tumors are seldom met in their several histological expressions. Authors totally considered 27 patients with retroperitoneal tumors and they were observed from 1975 to 1996: 21 of them were primitively cured in this Institute whereas 6 were affected with relapse or metastasis after a surgical approach which had been performed by other structures. Their operability resulted of 100% with an 87% resectability rate. The surgical mortality resulted nil while the morbidity rate was of 44%. The global survival resulted of 60% to 5 years while the disease-free interval was of 35%. The outliving to 5 years resulted of 65% with a 60% disease-free interval only in the patients who were treated in first instance. The surgical therapy represents the only treatment which can modify the clinical history of such neoplasms. Exeresis should be aggressive enough in order to obtain a total extirpation of the mass and grant a right margin of safety of sound tissue. Such radical proceeding should also be pursued in the treatment of relapses and metastases. The therapeutical efficacy is always linked to the precocity the diagnosis. A strict follow-up of the patients who underwent a surgical operation for retroperitoneal neoplasm is therefore necessary. A minority of the instances was only subjected to a complementary radio and/or chemotherapic treatment. Such protections did not significantly modify the outliving.

Parietal seeding of unsuspected gallbladder carcinoma after laparoscopic cholecystectomy

Laparoscopic cholecystectomy (VALC) represents the treatment of choice for the symptomatic gallstones. However the occurrence of an adenocarcinoma of the gallbladder results a controindication for this surgical technique. We present a case of a 52 years old woman who underwent a VALC; histology revealed a gallbladder adenocarcinoma. For this reason the patient underwent a second operation that is right hepatic trisegmentectomy. Six months later the patient presented with a parietal recurrence at the extraction site of the gallbladder. We discuss the possible mechanism responsible for carcinomatous dissemination during laparoscopic surgery and we raccommend the use of some procedures in order to limit the risk and eventually to treat a neoplastic parietal seeding. These complications suggest the problem about the utility and the future played by video assisted laparoscopic surgery in the diagnosis and treatment of intraabdominal malignancies.

Serum soluble CD23 levels and CD23 expression on peripheral blood mononuclear cells in juvenile chronic arthritis

OBJECTIVE

To assess the CD23 status in patients with juvenile chronic arthritis (JCA), as defined by serum soluble CD23 (sCD23) and the expression of CD23 on peripheral blood mononuclear cells.

METHODS

Serum sCD23 levels were measured by ELISA in 22 patients with systemic JCA (s-JCA), in 40 patients with antinuclear antibody positive pauciarticular JCA (ANA+ p-JCA), and in 38 healthy controls. CD23 expression on T cells, B cells, and monocytes was determined by flow cytometry analysis of double fluorescence staining.

RESULTS

Serum sCD23 levels were increased in both ANA+ p-JCA and s-JCA; no relation with disease activity or severity was found. In patients with ANA+ p-JCA, serum sCD23 levels were correlated with an increased percentage of B cells expressing CD23, while in patients with s-JCA the serum sCD23 levels were correlated with an increased percentage of monocytes expressing CD23.

CONCLUSION

Serum sCD23 levels are elevated both in systemic and ANA+ pauciarticular JCA: different cell subset CD23 expression in s-JCA and ANA+ p-JCA (i.e. monocyte or B cell, respectively) suggests that in pauciarticular JCA CD23 may be implicated in B cell activation and autoantibody production, while in systemic JCA may be involved in monocyte activation and in the release of inflammatory mediators.

p53 exon 7 mutations as a predictor of poor prognosis in patients with colorectal cancer

We have studied 61 resected colorectal adenocarcinomas in order to investigate p53 mutations as a prognostic factor for this pathology. Mutations in exons 5-9 of the p53 gene were analyzed by the polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) technique followed by sequencing. Our data indicate that p53 exon 7 mutations were prevalent in the latest stages of colorectal carcinogenesis and patients bearing this alteration had the worst prognosis. Therefore, according to our results, mutations affecting exon 7 of the p53 gene could be considered as a useful marker of biological aggressiveness for colorectal cancer.

Membrane CD22 defines circulating myeloma-related cells as mature or later B cells

Circulating clonally related earlier cells are present in multiple myeloma (MM) and may be involved in the dissemination of this disease, its recurrence, and chemoresistance. The nature, stage of differentiation, and size of this cell population remain uncertain. Unlike other B-cell markers, CD22 membrane expression is limited to the late differentiation stages comprised between mature B cells (CD22+) and plasma cells (PC; CD22-) and may thus be useful in delimiting the maturational state of circulating early myeloma cells. Peripheral blood clone-related cells were detected by anti-idiotypic (Id) monoclonal antibodies and found to express CD22 (92% to 95%), monotypic light and heavy chain (100%), and CD38 (45%), whereas bone marrow PC were CD22-negative. CD22 expression was also documented on functional myeloma PC precursors, defined as peripheral blood cells capable of in vitro cytokine-driven monotypic PC differentiation, because up to approximately 70% inhibition of this process was obtained in 10 myeloma patients through the use of biospecific antibodies (BsAb) that deliver the plant toxin saporin to CD22+ cells. As further evidence of CD22 on circulating abnormal cells, it was found that in the only patient analyzed for DNA content, a portion of the peripheral blood CD22+ cells killed were hyperdiploid. Collectively, these findings indicate that most peripheral blood myeloma PC precursors are mature or later B cells presenting membrane CD22. The pattern of CD22 expression suggests the existence in MM of a differentiation process analogous to the normal antigenic response, in which CD22+ B cells migrate to the bone marrow and lose CD22 with PC differentiation. In addition, the sensitivity of myeloma PC precursors to the cytotoxic effects of the anti-CD22 BsAb and the possibility of interfering with their differentiation have potential therapeutic relevance.

Differences in synovial fluid cytokine levels between juvenile and adult rheumatoid arthritis

OBJECTIVE

To evaluate quantitative or qualitative differences in synovial fluid (SF) cytokine levels among patients with systemic juvenile rheumatoid arthritis (JRA), antinuclear antibody positive pauciarticular JRA, or adult RA.

METHODS

SF levels of interleukin 1alpha (IL-1alpha), IL-1beta, IL-1 receptor antagonist (IL-1Ra) IL-11, tumor necrosis factor-alpha (TNF-alpha), soluble TNF receptor 1 (sTNFR1), leukemia inhibitory factor (LIF), all measured by immunoassays, and of IL-6, measured with a bioassay using B9 cells, were evaluated in 11 patients with systemic JRA, 24 with pauciarticular JRA, and 22 adult patients with RA.

RESULTS

SF IL-6 levels were significantly higher in patients with systemic JRA than patients with pauciarticular JRA (p = 0.003) or RA (p = 0.002). IL-1alpha was detectable in 12/24 SF samples from pauciarticular JRA, in 2/22 SF from RA, and in no sample from systemic JRA (p = 0.004 vs RA; p = 0.005 vs systemic JRA). SF IL-11 levels were significantly higher in patients with RA than patients with systemic JRA (p = 0.012) or pauciarticular JRA (p = 0.005). We found no significant differences in SF levels of IL-1beta, IL-1Ra, TNF-alpha, sTNFR1, or LIF.

CONCLUSION

In systemic JRA, SF levels of IL-6 are significantly higher than in pauciarticular JRA or in RA; IL-1alpha is present in a significant proportion of patients with pauciarticular JRA, but not in those with RA or systemic JRA.

Soluble tumour necrosis factor receptor levels reflect coagulation abnormalities in systemic juvenile chronic arthritis

The objective was to evaluate tumour necrosis factor (TNF) status in patients with systemic juvenile chronic arthritis (s-JCA). Plasma levels of TNF-alpha, and serum levels of soluble TNF receptor 1 and 2 (sTNFR1 and sTNFR2) were measured using specific immunoassays in 20 patients with s-JCA, 10 with polyarticular JCA and 15 with pauciarticular JCA, and in 20 controls comparable for age. In patients with active s-JCA, circulating levels of TNF-alpha, sTNFR1 and sTNFR2 were significantly (P < 0.001) higher than those of controls. The levels of sTNFR1 and sTNFR2, but not those of TNF-alpha, were associated with the persistence and severity of systemic symptoms and were significantly correlated with prolongation of partial thromboplastin time and decrease in prothrombin activity. In two patients evaluated during a s-JCA-associated macrophage activation syndrome, a marked increase in sTNFR1 and sTNFR2 was found. Our results suggest that in s-JCA, TNF is involved in systemic manifestations, in the subclinical coagulation abnormalities, and in the development of the macrophage activation syndrome.

Clinical strain of Staphylococcus aureus inactivates and causes efflux of macrolides

Searching through a collection of 124 Staphylococcus aureus clinical strains, we found one isolate, strain 01A1032, that inactivates 14- and 16-membered macrolides. The products of inactivation were purified from supernatant fluids of cultures exposed to erythromycin for 3 h and were found to be identical to products of inactivation from Escherichia coli strains that encode either an EreA or EreB esterase. Further, strain 01A1032 was shown to be resistant to azithromycin, a 15-membered macrolide, by an alternate mechanism, efflux. Thus, strain 01A1032 harbors determinants encoding an esterase activity that hydrolyzes 14- and 16-membered macrolides and a macrolide efflux system.

The AGROBOT project

The aim of this paper is to illustrate the AGROBOT project. This project was initiated to develop a complete robotic system for the production cycle of tomato plants in a greenhouse environment. The robot architecture is based on a vehicle carrying the picking arm (a six degrees of freedom anthropomorphic arm with a gripper/hand), the head with the two micro cameras (for the color stereoscopic vision system) and the VME rack for the complete control of the system. The head was purposely developed to permit complete visibility of the overall area. The vision system drives the head to point the path during navigation or to explore the plants looking for the work objects. The robot will be able to navigate between rows of plants, stop near each plant and identify the relevant objects (fruits or flowers) so as to be able to pick ripe tomatoes or spray anticryptogamic substances on flowers. Due to its flexible architecture, the system can be suited to operate on other kinds of cultivation or could be modified to perform other kinds of operations such as transplanting or packaging. Also the field of action could be different from greenhouses: changing from a wheeled locomotion system to a tracked system, the robot will be able to operate on particularly irregular surfaces. These features make this robotic system particularly adapted to replace human from tiring and harmful tasks or operating within adverse environment.

Circulating levels of interleukin 1 beta and of interleukin 1 receptor antagonist in systemic juvenile chronic arthritis

OBJECTIVE

To measure circulating interleukin 1 beta (IL-1 beta) and IL-1 receptor antagonist (IL-1Ra) levels in patients with systemic juvenile chronic arthritis (JCA) and to evaluate their correlation with disease activity.

METHODS

IL-1 beta and IL-1Ra levels were measured by ELISA in 45 patients with JCA (20 systemic, 10 polyarticular and 15 pauciarticular) and in 15 healthy controls.

RESULTS

Plasma IL-1 beta levels were undetectable in the majority of patients with systemic JCA, and detectable levels were not associated with different treatments or with parameters of disease severity. Serum IL-1Ra levels were markedly increased in patients with systemic JCA and significantly correlated with the persistence of systemic features, the extent and severity of joint involvement, and with C-reactive protein concentrations. Serum IL-1Ra levels were also significantly correlated with IL-6 levels.

CONCLUSION

These results argue against a relevant role of IL-1 in systemic JCA. The increase in IL-1Ra levels does not appear to reflect an increase in IL-1 production, but may rather be induced by IL-6.

Elevated circulating interleukin-7 levels in patients with systemic juvenile rheumatoid arthritis

OBJECTIVE

Since interleukin-7 (IL-7) has been shown to induce monocyte production of IL-1, IL-6, IL-8, and tumor necrosis factor-alpha, we investigated plasma and synovial fluid levels of IL-7 in patients with juvenile rheumatoid arthritis (JRA).

METHODS

IL-7 levels were measured using an ELISA in 60 patients with JRA and in 25 patients with other rheumatic disorders (ORD).

RESULTS

In patients with systemic JRA, but not in patients with polyarticular or pauciarticular JRA or with ORD, plasma IL-7 levels were significantly higher (p < 0.0001) than those of healthy controls. IL-7 was undetected in all synovial fluid tested. Among patients with systemic JRA, those with persistent systemic symptoms had IL-7 levels significantly higher (p < 0.01) than those of patients in which systemic symptoms subsided.

CONCLUSION

Plasma IL-7 levels are elevated in patients with systemic JRA and are associated with the presence and severity of systemic symptoms.

[Emergency surgical treatment in cancer of the colon]

The diagnostic delay which accompanies the colon-rectum neoplastic desease makes that complications are often the first signal. This work means to prove, according to our experience, that the incidence of these complications is high and that only in a few patients undergoing emergency treatment is possible a one-stage procedure with radical purpose. In our survey, since Genuary 1975 to December 1993, 473 patients (255 males and 218 females) affected of colon-rectum cancer were treated: among these 54 (11.5%) underwent emergency surgery. The neoplasm was located: in the rectosigmoid junction in 25 cases (46.3%) in the caecum or in the right colon in 10 cases (18.6%), in the left colon and in the hepatic flexure in 6 cases (11.1%), in splenic flexure in 4 cases (7.4%), and in the trasversum colon in 3 cases (5.5%). According to Astler & Coller classification 22 patients (40.8%) were C2, 17 (31.5%) were D, 11 (20.4%) were B2, 3 (5.5%) were A, and only 1 patient (1.8%) was C1. 16 patients (29.7%) underwent a one-stage procedure, 8 (14.9%) had a first stage with a colostomy added together with resective procedure, and 3 (5.5%) patients had a Hartmann procedure. In 27 (50%) patients was possible only a palliative procedure. Finally, 10 patients (18.5%) had post-operative complications such as anastomotic fistula, wound's leakage or subphrenic abscess, and 11 patients (20.4%) died for cardiac insufficiency, ARDS, renal failure or cerebral stroke.

Lack of temporal association of iridocyclitis with IgG reactivities to core histones and nucleosome subparticles in pauciarticular juvenile chronic arthritis

This study aimed to measure IgG reactivities to DNA-free nucleosome subparticles (H2AH2B, H3H4) and nucleosome subparticles (H2AH2B-DNA, H3H4-DNA) and to evaluate the temporal relation of these reactivities, as well as those to single core histones, with iridocyclitis (IC) in patients with antinuclear antibody positive (ANA+) pauciarticular juvenile chronic arthritis (JCA). Reactivities to nuclear substrates were determined by enzymatic immunoassays in 120 sera from 45 children with ANA+ pauciarticular JCA. Significantly elevated IgG levels to H3 and H4, to DNA-free nucleosome subparticles, and to the nucleosome subparticle H3H4-DNA were present in patients with ANA+ pauciarticular JCA; no evidence of recognition of conformational epitopes was found. In both horizontal and follow-up studies, no relation between the reactivities studied and the development, presence, or history of IC was found. Our results show the absence of a relation of antibodies to histone molecules or to nucleosome subparticles with IC in patients with ANA+ pauciarticular JCA.

Circulating levels of interleukin-6, interleukin-8, and tumor necrosis factor-alpha in children with autoimmune hepatitis

Circulating levels of the proinflammatory cytokines interleukin-6 (IL-6), IL-8, and tumor necrosis factor-alpha (TNF-alpha) were measured in 13 children with autoimmune hepatitis (AIH) (seven with type 1 and six with type 2). In untreated children with type 1 AIH, TNF-alpha, IL-6, and IL-8 levels were elevated when compared to those of healthy controls (p < 0.005, p < 0.02, p = 0.06, respectively), whereas in children with type 2 AIH, cytokine levels were normal in all except one sample. A significant decrease in circulating IL-6, IL-8, and TNF-alpha was observed when patients were evaluated during a subsequent remission. We found no significant correlation of cytokine levels with alanine aminotransferase (ALT) activity, total serum gamma-globulins, or prothrombin activity. In patients with cirrhosis, serum IL-8 and IL-6 levels were higher (significantly in the case of IL-8) than those of patients without cirrhosis. In conclusion, activation of the in vivo production of the proinflammatory cytokines IL-6, IL-8, and TNF-alpha appears to be associated with type 1 but not with type 2 AIH.

Serum soluble interleukin 6 (IL-6) receptor and IL-6/soluble IL-6 receptor complex in systemic juvenile rheumatoid arthritis

By using a sandwich ELISA, soluble human IL-6 receptor (sIL-6 R) levels were measured in the sera of 20 healthy children and of 25 patients with systemic juvenile rheumatoid arthritis (JRA). In patients with systemic JRA, serum sIL-6 R levels (114.6 +/- 37.7 ng/ml) were significantly lower (P < 0.01) than those of healthy children (161.2 +/- 45.5 ng/ml). Serum sIL-6 R levels were negatively correlated (r = -0.610, P < 0.001) with serum IL-6 levels measured with the B9 cells. The serum IL-6/sIL-6 R complex was detected using an ELISA based on a monoclonal antibody to IL-6 for capture and on a monoclonal antibody to human sIL-6 R for detection. Healthy controls had little, if any, detectable serum IL-6/sIL-6 R complex (OD 0.024 +/- 0.027), while the majority of patients with systemic JRA presented measurable serum IL-6/sIL-6 R complex (OD 0.492 +/- 0.546). IL-6 levels estimated in the circulating IL-6/sIL-6 R complexes were in the range of nanograms per milliliter and approximately 20-fold higher than those measured by the B9 cells. Since serum C-reactive protein concentrations were much more correlated with serum levels of IL-6/sIL-6 R complexes (r = 0.713, r2 = 0.51, P < 0.0001) than with the serum IL-6 levels measured with the B9 cells (r = 0.435, r2 = 0.19, P = 0.05), the large quantities of serum IL-6 present in IL-6/sIL-6 R complexes appear to be biologically relevant in vivo, at least as far as the induction by IL-6 of acute phase protein production.

Hypocomplementemic urticarial vasculitis syndrome with severe systemic manifestations

We describe two children with clinical and laboratory features of hypocomplementemic urticarial vasculitis syndrome. Both patients had severe, life-threatening manifestations: rapidly progressive glomerulonephritis (patient 1) and pulmonary hemorrhage (patient 2). We conclude that this syndrome may be a potentially severe multisystem disease.

Immune responses to the Escherichia coli dnaJ heat shock protein in juvenile rheumatoid arthritis and their correlation with disease activity

Patients with juvenile rheumatoid arthritis frequently have abnormal immune responses to the hsp65 class of bacterial heat shock proteins. However, lymphocytes from children with other inflammatory diseases may also recognize hsp65, and the role of these antigens in juvenile rheumatoid arthritis remains controversial. We have studied humoral and cellular immune responses to a distinct, recently described bacterial heat shock protein, designated dnaJ. The Escherichia coli dnaJ gene was cloned and expressed, and the purified recombinant protein was used as an antigen. Neither normal children nor children with various chronic inflammatory diseases had lymphocyte proliferative responses to recombinant dnaJ. However, lymphocytes from patients with polyarticular, pauciarticular, and systemic manifestations of juvenile rheumatoid arthritis responded strongly to the antigen. Cellular immune responses to dnaJ were higher in synovial fluid than in blood and higher in children with active disease than in children in remission. These data show that increased immune reactivity to dnaJ is characteristic of juvenile rheumatoid arthritis and that the magnitude of the immune response is linked to disease activity. The results suggest that an abnormal immune response to antigens on commensal gut bacteria may contribute to the generation of chronic inflammation in juvenile rheumatoid arthritis.

Anti-double stranded DNA, anti-histone, and anti-nucleosome IgG reactivities in children with systemic lupus erythematosus

In this study we evaluated the presence of anti-nucleosome reactivity in children with systemic lupus erythematosus (SLE), and assessed its clinical correlations in comparison with anti-dsDNA and anti-histone IgG levels. Reactivities to nuclear substrates were determined by enzymatic immunoassays in 80 sera from 22 children with SLE, and solid phase adsorption experiments were performed. In children with active SLE, the anti-dsDNA, anti-histone, and anti-nucleosome IgG levels were elevated, and were significantly correlated with disease severity; during remission anti-histone (but not anti-dsDNA and anti-nucleosome) antibodies, although reduced, were still significantly elevated. The results of adsorption studies showed that anti-dsDNA antibodies contributed to anti-nucleosome reactivity, while anti-histone antibodies did not. The recognition of the H3H4-DNA nucleosome subparticle, rather than H2AH2B-DNA, may be related to the nucleosome reactivity. In children with SLE anti-nucleosome reactivity is present; it is in part due to anti-dsDNA antibodies and in part to antibodies recognizing conformational epitopes that may be related to the H3H4-DNA nucleosome subparticle. Its clinical significance for diagnosis is not greater than that of the anti-dsDNA antibodies.

Association of methotrexate treatment with a decrease of double negative (CD4-CD8-) and gamma/delta T cell levels in patients with juvenile rheumatoid arthritis

OBJECTIVE

It has been suggested that double negative (CD4-CD8-) (DN) and gamma/delta T cells may be involved in some autoimmune diseases. We investigated peripheral blood DN and gamma/delta T cell levels in patients with active juvenile rheumatoid arthritis (JRA).

METHODS

DN and gamma/delta T cell levels were measured in 42 patients with active JRA and in 10 healthy controls comparable for age by an immunofluorescence double staining procedure.

RESULTS

All 3 JRA onset types had DN and gamma/delta T cell levels not significantly different from those of controls, although a wide scattering of data was present. No correlation was found between DN or gamma/delta T cell levels and erythrocyte sedimentation rate values or the number of active joints. When patients were divided according to treatment, we found that DN and gamma/delta T cell levels were significantly lower (p = 0.001, p = 0.02, respectively) in patients receiving methotrexate (MTX) than in patients not receiving MTX. The association of MTX treatment with a decrease in DN and gamma/delta T cell levels was also confirmed in a followup study of individual patients. Among patients not receiving MTX, patients with systemic JRA presented DN T cell levels significantly higher than those of controls. In 5 patients with pauciarticular JRA DN and gamma/delta T cell levels were higher in synovial fluid than in the peripheral blood.

CONCLUSIONS

We found an increase in peripheral blood DN T cell levels in systemic JRA; treatment with MTX appears to be associated with a decrease in DN and gamma/delta T cell levels.

Skin thickness score in systemic sclerosis: an assessment of interobserver variability in 3 independent studies

OBJECTIVE

Using data from 3 independent studies, to quantify the interobserver reliability of semi-quantitative skin scoring methods (the original and the modified Rodnan skin thickness scores) used to assess the degree and extent of cutaneous thickening in systemic sclerosis (SSc).

METHOD

Interobserver variability of the original Rodnan skin thickness score method (cutaneous thickness assessed in 26 body surface areas using a 0-4 scale) was evaluated in one study. The modified Rodnan method (cutaneous thickness assessed in 17 body surface areas using a 0-3 scale) was evaluated in 2 studies. In all 3 studies, each patient's skin thickness was assessed by 6 or 7 observers in a blinded fashion.

RESULTS

The overall within patient standard deviations were not statistically different in all 3 studies (5.4, 4.6 and 4.6) irrespective of the overall mean skin thickness scores (26.6, 18.3 and 17.7). With the original Rodnan technique, the within patient standard deviation tended to be higher in patients with higher skin thickness scores. In the 2 studies which used the modified technique, no significant differences in within patient standard deviation were noted between high and low skin thickness scores.

CONCLUSIONS

Three independent studies demonstrate that the Rodnan skin thickness scoring techniques are reproducible among different observers (the within patient standard deviation being consistently about 5 units). Our data provide valuable information needed for sample size calculations for SSc trials in which skin thickness score is an outcome variable.

Nucleosome-specific antibody from an autoimmune MRL/Mp-lpr/lpr mouse

OBJECTIVE

To characterize the binding properties and variable-region sequences of LG4-1, a monoclonal antibody from an autoimmune MRL/Mp-lpr/lpr mouse that reacts specifically with nucleosome core particles and represents a new antinuclear antibody specificity.

METHODS

The reactivity of the antibody against various nuclear substrates was determined using an enzymatic immunoassay, and the variable-region genes were sequenced from messenger RNA, using the dideoxy chain termination method.

RESULTS

LG4-1 was found to react with nucleosome core particles but not with individual histones and DNA, or with various histone-histone and histone-DNA complexes. It was demonstrated that this antibody is encoded by a combination of variable-region genes and gene segments that have undergone few somatic mutations.

CONCLUSION

The nucleosome core particle expresses a unique conformational autoepitope(s) resulting from the ordered association of histones and DNA.

CD5-positive B cells in type 1 (insulin-dependent) diabetic children

We have measured CD5+ B cell levels in the peripheral blood of 35 type 1 (insulin-dependent) diabetic children, aged 1.1-21.2 years (10.7 +/- 4.6 years). Patients were divided into two groups according to disease duration (group I < 6 months and group II > 1.5 years). Group I included 18 patients and group II 17 patients. Thirty-nine healthy subjects, comparable for age and sex, served as controls. CD5+ B cells were identified by double immunofluorescence staining with rhodamine-conjugated rabbit anti-human immunoglobulin and with a mouse anti-CD5 monoclonal antibody revealed by a fluorescein-conjugated goat anti-mouse immunoglobulin. We found that CD5+ B cell levels (expressed as percentages of peripheral blood B lymphocytes) were significantly higher in group I (median 24; range 4-48) than in controls (median 14; range 0-36, P < 0.001) and in group II (median 4; range 0-20, P < 0.001). A follow-up study of 12 group I patients showed a significant decline in CD5+ B cell levels. The data obtained in our diabetic patients suggest that CD5+ B cells are expanded in the early phase of type 1 diabetes mellitus and may play a role in the autoimmune process of the disease.

Serum interleukin-6 levels and joint involvement in polyarticular and pauciarticular juvenile chronic arthritis

We measured serum and synovial fluid interleukin 6 (IL-6) levels in patients with polyarticular-onset and pauciarticular-onset juvenile chronic arthritis (JCA), using the hybridoma cell line B9. During active disease, but not during remission, serum IL-6 levels were significantly elevated in patients with polyarticular (p < 0.0001 vs controls) and in patients with pauciarticular JCA (p < 0.01 vs controls). In patients with active polyarticular disease (polyarticular and extended pauciarticular) serum IL-6 levels correlated with the extent and severity of joint involvement (p < 0.05), with erythrocyte sedimentation rate values (p < 0.005) and with C reactive protein concentrations (p < 0.05). In patients with persistent pauciarticular JCA, serum IL-6 levels correlated with the joint swelling score (p < 0.05). Synovial fluid IL-6 levels, measured in 5 patients with pauciarticular JCA, were markedly elevated (range 600-24,000 HGF U/ml). In conclusion, our data suggest that IL-6 is an important pathogenic mediator in polyarticular and pauciarticular JCA.