The ATTRACT study: screening for the early identification of axial psoriatic arthritis in a cohort of Italian psoriatic patients

OBJECTIVE

There is growing interest in the early identification of patients with axial psoriatic arthritis (axPsA). We aimed to evaluate whether a dermatology-based screening strategy could help to identify axPsA patients.

METHODS

The dermatologist-centered screening (DCS) questionnaire was administrated by Dermatologists to consecutive patients fulfilling the inclusion criteria (1. age ≥ 18 years and 2. clinical diagnosis of psoriasis made by a dermatologist) to identify patients eligible (affirmative answers 1-3c of the DCS) for rheumatological evaluation. Clinical, laboratory, genetic, and imaging data were collected from all referred patients.

RESULTS

Among the 365 patients screened, 265 fulfilled the inclusion criteria and 124/265 (46.8%) were eligible for rheumatological referral. Diagnosis of axPsA, with or without peripheral PsA (pPsA), was made in 36/124 (29.0%) patients; pPsA without axial involvement was found in 21/124 (16.9%) patients. Back pain at screening was recorded in 174 (66%) patients, with 158 (60%) reporting a back pain duration longer than 3 months, and 140 (53%) reporting back pain onset before the age of 45. Active inflammatory and/or structural post-inflammatory changes in the sacroiliac joints and/or spine were observed in all axPsA patients.Patients with PsA showed a numerically longer duration of back pain and higher CRP levels in comparison with patients with Pso without PsA.

CONCLUSION

The DCS tool proved to be a valuable screening strategy for detecting and characterizing patients with axPsA in a real-life cohort of psoriasis patients in a dermatological setting and helped to identify a substantial number of patients affected by undiagnosed pPsA.

AMASI epidemiological study on children living in L'Aquila

AIM

The aim of the study is to observe the statistical relationship between children's habits, oral heath, pregnancy history and breastfeeding.

METHODS

A cross-sectional study was carried out on the pupils of the first and second grades of the primary schools of the "Silvestro" and "Amiternum" school districts of L'Aquila (Italy). The study population consisted of 496 (244 females and 252 males) students. The data were collected through anamnesis carried out by qualified health personnel before dental examination. According to the WHO criteria clinical teething examination standard, the presence of caries was determined by the dmft index (decayed-filled-missing deciduous teeth). Shapiro-Wilk test, Chi-square test and t test used. P values below 0.05 were considered statistically significant.

CONCLUSION

There is not enough evidence to advise against breastfeeding lasting more than one year due to the risk of tooth decay. Supportive practices need to be implemented to counteract risk factors. A larger sample is needed to study the role of human milk.

Atypical Scleroderma-like Chronic GVHD in a Liver Transplant Patient, Clinical and MRI Correlations

Dear Editor, cutaneous chronic graft versus host disease (cGVHD) is a pathological process consisting of donor-derived T-cells aimed at the antigens of the recipient. It exhibits a large range of clinical presentations resembling morphea and deep sclerosis/fasciitis, all characterized by both inflammation and progressive dermal and hypodermic fibrosis (1). Although classic scleroderma-like lesions in cGVHD are nummular or irregular plaques and linear bundles associated with hypo- or hyperpigmentation (2), we report an atypical case with ulcerative presentation. No other case-reports of morphea-like or scleroderma-like cGVHD with an ulcerated appearance after liver transplantation (LT) and magnetic resonance imaging (MRI) correlation have been found in the literature. CASE REPORT Ten months after LT due to an end-stage cirrhosis associated with multifocal hepatocarcinoma (HCC), a 61-year-old man on immunosuppressive therapy with Tacrolimus (1 mg) and Everolimus (10 mg) presented to our clinic for a skin lesion in the right scapular region. We observed a flat ulcerated plaque with areas of sclerosis, minimal necrosis, and well-defined slightly erythematous margins (Figure 1, a). On palpation, the plaque had a hard consistency and was slightly painful. The skin lesion had been preceded by subjective discomfort with stinging sensation for seven months before its onset. Gradually lesion developed starting from a small, flat, oval purplish plaque associated with a progressive increase in pain. Patient denied dysphagia, retrosternal heartburn, Raynaud's phenomenon, arthralgia, and dyspnea. A previous MRI (Figure 2, a,b) showed subcutaneous and muscle edema. Blood tests showed abnormal liver function indexes due to extrahepatic cholestasis, while C-reactive protein, erythrocyte sedimentation rate, and leukocytes were within normal ranges. Self-reactive antibodies were negative. Histological examination (Figure 1, b) identified rare dyskeratotic keratinocytes and basal lymphocyte infiltrate, a dermal dense fibrosis with the disappearance of the skin appendages, and large fibrous septa in the adipose panniculus. It led to the diagnosis of scleroderma/morphea, based on the patient's clinical history. The diagnosis of graft versus host disease scleroderma-like post liver transplant was established. The lesion was treated by topical application of 0.05% clobetasol once a day. We did not use systemic immunosuppressive therapy in order to prevent HCC recurrence. The patient is currently in clinical follow-up to identify worsening or neoplastic degeneration. CASE DISCUSSION Cutaneous cGVHD often presents clinically as an ulcerative evolution in the context of fibrosis and diffuse skin atrophy (2), but very rarely initially appears as a well-delimited ulcerated plaque. Only few cases of ulcer have been found in literature, all in patients undergoing hematopoietic stem cell transplantation (HSCT), which is associated with the highest risk of developing GVHD, 20-50% (3,4), while LT has quite low incidence, at 0.5-2% (5). To our knowledge, this is the first case report of a scleroderma-like cGVHD lesion with ulcer appearance in LT. Our patient underwent two MRIs during post-transplant follow-up, which allowed us to evaluate the deep disease evolution. The T2-weighted MRI (Figure 2, c,d) performed approximately 1 year after transplantation, demonstrated fibrous septa in the subcutaneous fat and fascial thickening, with associated muscle hypotrophy and edema. The previous MRI, performed seven months after transplantation, already showed subcutaneous tissues and fascial edema, highlighting active inflammation. This evidence suggests that MRI could identify the lesion location before clinical manifestations, providing an opportunity to intervene promptly. To the best of our knowledge, this is the first reported case of cGVHD with atypical scleroderma-like presentation in a liver transplant patient whose clinical and MRI correlations have been traced. Our suggestions are supported by the results of other previous studies (6,7) evaluating MRI performance for assessing disease extent and activity, as well as therapeutic response in HSCT.

Long-term efficacy and safety of apremilast in the treatment of plaques psoriasis: A real-world, single-center experience

Apremilast is a small molecule approved for the treatment of plaques psoriasis and adult psoriatic arthritis. Pivotal studies have demonstrated short and long term efficacy and safety of apremilast but few data in real life are still available. The aim of this study is to report the efficacy and safety results of apremilast in clinical practice in patients with moderate-to-severe plaque psoriasis, focusing on therapeutic results obtained after 24 and 52 weeks of treatment. From May 2018 to December 2018, 40 patients with plaques psoriasis have been enrolled. Psoriasis Area Severity Index (PASI), body surface area, Physician Global Assessment, and Dermatology Life Quality Index (DLQI) were performed at baseline at 24 (W24) and 52 (W52) weeks after treatment initiation. Primary endpoint was to evaluate the percentage of patient that achieved PASI 75, PASI 90 and PASI 100 at week 24 and 52 of treatment. Additional measure of efficacy was percentage of patients reaching the minimal disease activity (MDA = PGA0/1 and DLQI 0/1) after 24 and 52 weeks of treatment. As secondary endpoint, we evaluated the percentage of patient that achieved DLQI 0-1 at W24 and W52, and long-term safety of apremilast. The percentage of patients who achieved PASI75, PASI90 and PASI100 was 47.5%, 30% and 10% and 25%, 35% and 10% at W24 and W52 respectively. About the half of the reported patients reached MDA at W24 (n = 21) and at W52 (n = 20). The 60% of patients achieved and maintained DLQI 0-1 at W24 until W52. Diarrhea, nausea, headache, insomnia, and other AEs have been reported by 28 patients. Apremilast in real life experience confirmed the levels of efficacy and safety obtained in pivotal trials. In particular, the good initial response to the treatment is predictive of the maintenance or improvement of the outcome over W52. The efficacy is supported by an excellent safety profile even in frail patients.

Cutaneous Rosai-Dorfman disease in a 42-year-old woman: a rare case report

Rosai-Dorfman disease (RDD) is a histiocytic disorder that has only a skin implication in a very small percentage of cases. RDD is usually painless and accompanied by disseminated lymphadenopathy. We present a rare case of a female patient that complained of grouped skin papules localized on the left leg, associated with a palpable deep nodular lesion. Initially, this was clinically mistaken for a soft tissue sarcoma, but after a total body CT and surgical excision it was identified as a non-Langerhans cell benign histiocytosis known as RDD. The patient had neither recurrence nor systemic involvement after 7 months of follow-up.

Effects of in vivo application of an overnight patch containing Allium cepa, allantoin, and pentaglycan on hypertrophic scars and keloids: Clinical, videocapillaroscopic, and ultrasonographic study

Several therapeutic approaches have been described for their treatment of hypertrophic scars and keloids, but to date, the optimal treatment has not been established yet. Our in vivo study was conducted to evaluate the effect of a medical device consisting in an adhesive patch containing onion extract (Allium cepa) 10%, allantoin 1%, and pentaglycan 4% (Kaloidon patch) on hypertrophic scars and keloids. Thirty-nine patients with hypertrophic scars and seven patients with keloids were asked to apply an adhesive patch containing Allium cepa, allantoin, and pentaglycan once/day for at least 8 h consecutively, for 24 weeks. Patients were reevaluated 6 weeks (T6), 12 weeks (T12), and 24 weeks (T24) after starting the treatment through POSAS scale v 2.0, ultrasonographic, and videocapillaroscopic assessment. The investigated medical device was able to induce a significant improvement of POSAS starting from T12, with a positive amelioration trend until T24. However the patient-assessed POSAS sub-items showed improvement already after 6 weeks, whereas a significant improvement of the observer-assessed POSAS sub-items was observed only after 12 weeks (P < .001). Ultrasonography and intravital videocapillaroscopy confirmed a significant improvement of skin scars thickness (P < .001) and vascularization (P < .001) after 12 weeks of medical device application at least, with increasing improvement until T24. Applying an adhesive patch containing Allium cepa, allantoin, and pentaglycan once a day for at least 8 consecutive hours seems to be able to improve the clinical and morphological characteristics of the scars of the skin in 24 weeks.

Carotid Stenting and Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Tandem Occlusions: Antithrombotic Treatment and Functional Outcome

BACKGROUND AND PURPOSE

There is no consensus on the optimal antithrombotic medication for patients with acute ischemic stroke with anterior circulation tandem occlusions treated with emergent carotid stent placement and mechanical thrombectomy. The identification of factors influencing hemorrhagic risks can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to investigate the impact of medical therapy on functional and safety outcomes in patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions.

MATERIALS AND METHODS

A multicenter retrospective study on prospectively collected data was conducted. Only patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions of the anterior circulation were included. Univariate and multivariate analyses were performed on preprocedural, procedural, and postprocedural variables to assess factors influencing clinical outcome, symptomatic intracranial hemorrhage, stent patency, and successful intracranial vessel recanalization.

RESULTS

Ninety-five patients with acute ischemic stroke and tandem occlusions were included. Good clinical outcome (mRS ≤ 2) at 3 months was reached by 33 (39.3%) patients and was associated with baseline ASPECTS ≥ 8 (OR = 1.53; 95% CI, 1.16-2.00), ≤2 mechanical thrombectomy attempts (OR = 0.71; 95% CI, 0.55-0.99), and the absence of symptomatic intracranial hemorrhage (OR = 0.13; 95% CI , 0.03-0.51). Symptomatic intracranial hemorrhage was associated with a higher amount of intraprocedural heparin, ASPECTS ≤ 7, and ≥3 mechanical thrombectomy attempts. No relationships among types of acute antiplatelet regimen, intravenous thrombolysis, and symptomatic intracranial hemorrhage were observed. Patients receiving dual-antiplatelet therapy after hemorrhagic transformation had been ruled out on 24-hour CT were more likely to achieve functional independence and had a lower risk of symptomatic intracranial hemorrhage.

CONCLUSIONS

During carotid stent placement and mechanical thrombectomy for tandem occlusion treatment, higher intraprocedural heparin dosage (≥3000 IU) increased symptomatic intracranial hemorrhage risk when the initial ASPECTS was ≤7, and mechanical thrombectomy needs more than one passage for complete recanalization. Antiplatelets antiplatelets use were safe, and dual-antiaggregation therapy was related to better functional outcomes.

Bullous Sweet's syndrome in a patient with ulcerative colitis: a rare case report

Bullous Sweet's syndrome is an uncommon clinical presentation of classical Sweet's syndrome, often associated with various kinds of tumors, infections, and active inflammatory bowel diseases (IBDs), namely Crohn's disease and ulcerative colitis. Only a few cases of bullous Sweet's syndrome associated with ulcerative colitis are described in the literature. We report a case of a 62-year-old female patient with acute exacerbation of ulcerative colitis associated with infiltrating purple-erythematous skin plaques, which were partly vesicular, and oral ulcerative stomatitis. Biopsy was consistent with bullous Sweet's syndrome. Treatment with betamethasone sodium phosphate, starting at 5.5 mg, followed by gradual dose tapering for 12 weeks, resulted in improvement of the ulcerative colitis and disappearance of the cutaneous lesions. Bullous Sweet's syndrome most commonly occurs in the setting of hematologic malignancies, suggesting that physicians should perform long-term screening for early diagnosis of hematological and solid malignancies.

Effects of a cream containing 5% hyaluronic acid mixed with a bacterial-wall-derived glycoprotein, glycyrretinic acid, piroctone olamine and climbazole on signs, symptoms and skin bacterial microbiota in subjects with seborrheic dermatitis of the face

Objective: A new cream formulation containing hyaluronic acid 5%, complexed with a mix of a bacterial-wall-derived glycoprotein and peptide glycan complex (EDS), has been recently developed. We evaluated in a prospective, assessor-blinded, 6-week study the efficacy and tolerability of EDS in the treatment of facial seborrheic dermatitis (SD) and the effects on skin microbiota.

Subjects and methods: Seventy-five subjects (mean age 46; 60 men) with moderate-severe SD of the face were enrolled. EDS cream was applied twice daily. The primary outcome was the evolution of the Investigator Global Assessment (IGA) score, evaluating erythema, scale/flaking, grade of seborrhea and itch. Superficial skin bacterial microbiome at baseline and after treatment was assessed, using the 16S rRNA gene methodology, in affected and non-affected face areas. Local tolerability was evaluated checking self-reported side effects at each visit.

Results: Baseline IGA scores (mean±SD) was 10±3. The use of EDS reduced IGA score significantly by 70% at week 3 and by 88% at week 6. An increase in the abundance of Cutibacterium acnes genera associated with a significant drop of Staphylococcus genera presence was detected in affected areas. The ratio of relative abundance of genera Cutibacterium/Staphylococcus increased significantly after treatment in affected areas. The product was very well tolerated.

Conclusion: Treatment with EDS applied twice daily for 6 consecutive weeks was associated with a reduction of the signs and symptoms of SD. Furthermore, after EDS cream treatment, a reequilibrating effect on facial skin microbiota was observed. The product was very well tolerated.

Combined use of daily and hourly data sets for the source apportionment of particulate matter near a waste incinerator plant

A particulate matter (PM) source apportionment study was carried out in one of the most polluted districts of Tuscany (Italy), close to an old waste incinerator plant. Due to the high PM10 levels, an extensive field campaign was supported by the Regional Government to identify the main PM sources and quantify their contributions. PM10 daily samples were collected for one year and analysed by different techniques to obtain a complete chemical characterisation (elements, ions and carbon fractions). Hourly fine (<2.5 μm) and coarse (2.5-10 μm) aerosol samples were collected by a Streaker sampler for a shorter period and hourly elemental concentrations were obtained by PIXE. Positive Matrix Factorization (PMF) analysis of daily and hourly data allowed the identification of 10 main sources: six anthropogenic (Biomass Burning, Traffic, Secondary Nitrates, Secondary Sulphates, Incinerator, Heavy Oil combustion), two natural (Saharan Dust and Fresh Sea Salt) and two mixed sources (Local Dust and Aged Sea Salt). Biomass burning turned out to be the main source of PM, accounting for 30% of the PM10 mass as annual average, followed by Traffic (18%) and Secondary Nitrates (14%). Emissions from the Incinerator turned out to be only 2% of PM10 mass on average. PM10 composition and source apportionment have been assessed in a polluted area near a waste incinerator, by PMF analysis on daily and hourly compositional data sets.

Analysis of neoplastic skin complications in transplant patients: experience of an Italian multidisciplinary transplant unit

BACKGROUND

Transplant patients need to be strictly followed, since the immunosuppressive therapies they usually receive can increase the risk of skin complications. This study aims to evaluate the prevalence of neoplastic skin complications in transplant patients.

METHODS

We analyzed 256 liver or kidney transplant patients. The follow-up mean period was 7±3.5 years. It was also evaluated the prevalence of cutaneous neoplastic complications according to the immunosuppressive regimen received by patients as follows: cyclosporine, tacrolimus, steroids, mycophenolate mofetil or everolimus, in single, double or triple therapy.

RESULTS

The 18.36% of patients developed neoplastic complications, among these 9.37% actinic keratoses, 8.20% non-melanoma skin cancer, and 0.78% cutaneous melanoma. Among patients who developed non melanoma skin cancer, 61.90% had basal cell carcinoma, 23.81% squamous cell carcinoma, 52% Kaposi's sarcoma and 4.76%, Malherbe's epithelioma.

CONCLUSIONS

This study demonstrated the increased risk of skin cancer in transplant patients during the first 7 years of follow-up and made the dermatologists aware about the need of a regular cutaneous follow-up for this subset of patients.

TENS effects on salivary stress markers: A pilot study

Transcutaneous electrical nerve stimulation (TENS) is extensively used as pain relief through endorphins release. Moreover, recent findings showed a role in the activation of the autonomic nervous system (ANS); it was evidenced by modification in the heart rate variability and ANS-related marker. The objective of this pilot study is to evaluate salivary alpha amylase (sAA) as a marker of stress in two groups of healthy subjects, one receiving ultra-low frequency transcutaneous electrical nerve stimulation (ULF-TENS) and one without stimulation. Sixty healthy people were enrolled. The test group consisted of 30 participants (15 men, 15 women). The control group consisted of 30 participants (15 men, 15 women). Statistical analysis showed that sAA levels were statistically different between men and women independently from TENS; we hypothesize that treatment could influence sAA levels because it is thought to activate μ opioid receptors. The results of this study seem to indicate that the analysis of sAA, through a non-invasive saliva sample, could be an efficient aid for understanding the functions of the autonomic nervous system.

Efficacy and Safety of Topical Pidobenzone 4% as Adjuvant Treatment for Solar Lentigines: Result of a Randomized, Controlled, Clinical Trial

BACKGROUND/OBJECTIVE

This study aims at the evaluation of the efficacy and safety of a combination therapy based on pidobenzone 4% and fractional CO2 laser or cryotherapy in the treatment of solar lentigines and the prevention of eventual posttreatment hyperchromia.

METHODS

Efficacy was clinically evaluated by grading the pigmentation level with the Skin Tone Color Scale (STCS), and by grading patients' impression through a Visual Analog Scale (VAS).

RESULTS

Our study shows that the associated treatment was safe and that it improves the therapeutic results on solar lentigines and prevents postiatrogenic hyperpigmentation compared with physical therapy alone.

CONCLUSION

The combination of cryotherapy and pidobenzone 4% has been found to be the most useful treatment.

Biomass burning contributions estimated by synergistic coupling of daily and hourly aerosol composition records

Biomass burning (BB) is a significant source of particulate matter (PM) in many parts of the world. Whereas numerous studies demonstrate the relevance of BB emissions in central and northern Europe, the quantification of this source has been assessed only in few cities in southern European countries. In this work, the application of Positive Matrix Factorisation (PMF) allowed a clear identification and quantification of an unexpected very high biomass burning contribution in Tuscany (central Italy), in the most polluted site of the PATOS project. In this urban background site, BB accounted for 37% of the mass of PM10 (particulate matter with aerodynamic diameter<10 μm) as annual average, and more than 50% during winter, being the main cause of all the PM10 limit exceedances. Due to the chemical complexity of BB emissions, an accurate assessment of this source contribution is not always easily achievable using just a single tracer. The present work takes advantage of the combination of a long-term daily data-set, characterized by an extended chemical speciation, with a short-term high time resolution (1-hour) and size-segregated data-set, obtained by PIXE analyses of streaker samples. The hourly time pattern of the BB source, characterised by a periodic behaviour with peaks starting at about 6 p.m. and lasting all the evening-night, and its strong seasonality, with higher values in the winter period, clearly confirmed the hypothesis of a domestic heating source (also excluding important contributions from wildfires and agricultural wastes burning).

Helicobacter pylori infection in psoriasis: results of a clinical study and review of the literature

BACKGROUND

Data from the literature concerning the role of Helicobacter pylori (H. pylori) infection in psoriasis are still conflicting. This study was carried out to evaluate prevalence of H. pylori in patients with mild to severe psoriasis, correlation between H. pylori infection and severity of psoriasis, and effect of H. pylori eradication on the clinical course of psoriasis.

METHODS

Two hundred and ten patients with psoriasis and 150 healthy controls were screened for H. pylori through [(13) C] urea breath test at baseline (T0). All patients with psoriasis received standardized phototherapy treatment, and those infected by H. pylori were also treated with a 1-week triple therapy, then they were all re-evaluated four weeks later at the end of therapy (T5).

RESULTS

The prevalence of H. pylori was not higher in psoriasis than in the control group (20.27 vs. 22%; P > 0.05). Patients infected by H. pylori showed more severe psoriasis than uninfected patients (psoriasis area and severity index score 17.9 ± 7.1 vs. 13.7 ± 6.9; P = 0.04), and patients who received successful eradication of H. pylori infection showed a greater improvement of psoriasis than the others (psoriasis area and severity index score at T5 in patients infected by H. pylori was 8.36 ± 3.76, in uninfected patients was 10.85 ± 3.49; P = 0.006).

CONCLUSIONS

Patients with mild to severe psoriasis do not show a greater prevalence of H. pylori infection; however, H. pylori seems able to affect the clinical severity of psoriasis.

Homocysteine plasma levels in psoriasis patients: our experience and review of the literature

BACKGROUND

People with psoriasis are at higher cardiovascular risk. Plasma levels of homocysteine over the normal range have been recognized as marker of cardiovascular risk. Psoriasis patients express higher levels of plasma homocysteine than healthy people.

OBJECTIVE

Our study aims to investigate the correlation between homocysteinaemia, severity and duration of psoriasis and psoriasis arthritis, and to evaluate the effect of a 12-week administration of a target therapy for psoriasis on homocysteinaemia.

METHODS

Fifty-two psoriasis patients (study group) submitted to different kind of therapy for psoriasis (biological, systemic not biological and topical) and 24 healthy Italian subject (control group) were evaluated for their plasmatic homocysteine levels, both at baseline (T0) and 12 weeks after they a specific therapy for psoriasis.

RESULTS

A significant difference between the homocysteinaemia of psoriasis patients (mean 19.71 ± 11.16) and control group (13.90 ± 11.18), P < 0.05 (Fig. 1), was found at baseline (T0). The mean plasma levels of homocysteine were directly correlated with disease severity (P = 0.0401), but not with disease duration (P = 0.6018) or presence of arthritis (P = 0.6221) at baseline. None among the treatments administered to psoriasis patients caused a significant reduction in homocysteinaemia after 12 weeks of treatment.

CONCLUSION

Our results confirm that psoriasis patients with more severe disease, can have hyperhomocysteinaemia, without regard to disease duration or joint involvement. Hyperhomocysteinaemia is not influenced by a target therapy for psoriasis and it is as greater as psoriasis severity. However, limitation of our study is the relatively small number of cases. Homocysteine plasmatic levels should be advisable as a further independent risk factor for cardiovascular disease in psoriasis patients.

Skin features in myotonic dystrophy type 1: an observational study

Poor data regarding skin involvement in Myotonic Dystrophy, also named Dystrophia Myotonica type 1, have been reported. This study aimed to investigate the prevalence and types of skin disorders in adult patients with Myotonic Dystrophy type 1. Fifty-five patients and one hundred age- and sex-matched healthy subjects were referred to a trained dermatologist for a complete skin examination to check for potential cutaneous hallmarks of disease. No difference in prevalence of preneoplastic, neoplastic, and cutaneous lesions was detected between the two groups. Among morphofunctional, proliferative and inflammatory lesions, focal hyperhidrosis (p < 0.0001), follicular hyperkeratosis (p = 0.0003), early androgenic alopecia (p = 0.01), nail pitting (p = 0.003), pedunculus fibromas (p = 0. 01), twisted hair (p = 0.01), seborrheic dermatitis (p = 0.02), macules of hyperpigmentation (p = 0.03) were significantly more frequent in patients compared with controls. In patients with Myotonic Dystrophy type 1 significant differences according to sex were found for: early androgenic alopecia, twisted hair and seborrheic dermatitis, whose prevalence was higher in males (p < 0.0001). Our preliminary results seem to rule out an increased prevalence of pre-neoplastic, and neoplastic skin lesions in Myotonic Dystrophy type 1. On the other hand, an increased prevalence of morphofunctional, inflammatory, and proliferative diseases involving adnexal structures seems to characterize adult patients with Myotonic Dystrophy type 1.

Role of small intestinal bacterial overgrowth and Helicobacter pylori infection in chronic spontaneous urticaria: a prospective analysis

The aim of this study is to assess the associations between chronic spontaneous urticaria (CSU), Helicobacter pylori infection and small intestinal bacterial overgrowth. Forty- eight patients with CSU were studied by scoring the urticaria activity and assesing the quality of life. Patients with H. pylori infection (n=11) or small intestinal bacterial overgrowth (n=13) were specifically treated for one week and clinically evaluated both before and 4 weeks after the eradication therapy. Eradication of H. pylori infection led to a significant improvement in CSU (p<0.002). In contrast, eradication of small intestinal bacterial overgrowth was not associated with any clinical improvement in CSU, despite the fact that these patients had statistically significant more urticaria activity at baseline. Thus there is no evidence to support the eradication of small intestinal bacterial overgrowth in CSU, but eradication of H. pylori infection may result in an improvement of the disease.

Advanced glycation end products: possible link between metabolic syndrome and periodontal diseases

On a planetary scale, Metabolic Syndrome (MetS)is the third cause of inability after malnutrition and nicotinism, even higher than water shortage and sedentariness. In the USA, the prevalence is estimated at over 25 percent of the population; in Italy, it involves approximately 25 percent of men and even 27 percent of women. These are very high figures, corresponding to approximately 14 million affected individuals. The prevalence is alarming and must not be underestimated, particularly in the dental field, where more than one patient out of four sitting in a dentist chair is affected. The etiology of periodontal disease has not yet been clarified, and recently the idea to consider it as a multifactor pathology has been developed. Cofactors such as the formation of free radicals of oxygen (ROS), oxidative stress, lipid peroxidation, and formation of glycation end-products (AGEs) probably play an important role in the onset of periodontal disease. The AGEs are compounds physiologically produced by the cells. However, they accumulate and cause pro-inflammatory conditions, when the cellular clearance fails, or in hyperglycemic and oxidative states. All these conditions can be clinically summarized as Metabolic Syndrome. The purpose of this literature review is to establish a relationship between two pathologies with very high prevalence: Metabolic Syndrome and Periodontal Disorder. The literature seems to have clarified that MetS involves a pro-oxidation status, which induces AGE formation. AGEs play a very important role in the course and severity of periodontal diseases.

Apoptosis in the kidneys of patients with type II diabetic nephropathy

The occurrence and extent of apoptosis in the kidneys of patients with diabetic nephropathy is largely unknown. We evaluated apoptosis in renal biopsies obtained from patients with early or advanced type II diabetic nephropathy. Apoptosis was about 6- and 3-fold higher, respectively, in glomeruli and tubules in kidneys of patients with early nephropathy than in the normal kidney and this was not further increased in advanced diabetic nephropathy. Glomerular apoptosis was related directly to hemoglobin A1(c) and systolic blood pressure, whereas tubular cell apoptosis correlated to diabetes duration and low-density lipoprotein-cholesterol. Fas, Fas ligand, and p38 mitogen-activated protein kinase expressions were enhanced in glomeruli and tubules; however, this did not correlate with apoptosis. In patients with proteinuria, apoptosis was associated with the subsequent loss of kidney function. When these parameters were subjected to multivariate analysis, only glomerular apoptosis retained a significant independent predictive value. Our findings suggest that apoptosis might be a clinically relevant mechanism of glomerular and tubular cell loss in proteinuric type II diabetic patients.

Neuromuscular diagnosis in orthodontics: effects of TENS on maxillo-mandibular relationship

AIM

This study was conducted in order to assess the changes in the occlusal position of the mandible after Ultra Low Frequency (ULF)-TENS relaxing procedure in children with diagnosed functional mandibular lateral deviation.

METHODS

This study was performed on 20 children, aged between 8 and 12 years, with a mean age of 10 years (SD 0.79) with functional mandibular lateral deviation, diagnosed by clinical and cephalometric evaluation, referred to the Dental Clinic for paediatric dental care. Diagnostic neuromuscular registrations were made for all children, and their casts mounted on articulator Galetti at the myocentric position and compared to casts provided of a wax bite registration in intercuspal position.

RESULTS

The alignment of the midline after TENS was not punctual (p >0.05). Compared with the existing intercuspal position, neuromuscular registration showed improvement in 10 (50%) patients, 6 patients (30%) showed no changes, while worsening of the tooth-midline discrepancy was assessed in the remaining 4 (20%). The molar relationship did not follow the same trend of the midline because of the three-dimensional changes in the maxillo-mandibular relationship induced by TENS. After TENS there was a significant correlation between midline and right side deviation (r >0.65), there was no correlation between midline and the left side (r <0.65). Furthermore, right molar movement showed no correlation with the contralateral molar (r <0.65). The posterior areas of the arch were moving in a very unpredictable way, resulting in the diagnosis and prognosis of mandibular lateral deviation as absolutely individual and unpredictable. Conclusion This study suggests that TENS recorded occlusion is an interesting diagnostic approach in orthodontics since it allows visualising the trends of the neuromuscular system.

Caries-risk assessment: the role of salivary tests

Although the incidence of caries has diminished dramatically over the past 3 decades, small groups of subjects remain highly susceptible and do not respond to conventional preventive programs. An accurate individual caries-risk assessment allows to identify the etiological factors responsible for the disease and design a rational approach to treatment, addressed to the specific needs of the patients. The use of appropriate caries-risk prediction models, which include the use of simple chairside caries-susceptibility salivary tests, is the most suitable and modern approach to the problem. A review of the literature on salivary tests, at present available, able to identify the factors contributing to caries susceptibility, is presented. Each test is accurately described, with regard both to its procedure and the interpretation of its results:

Visual input effect on EMG activity of masticatory and postural muscles in healthy and in myopic children

AIM

The purpose of this study was to evaluate the activity of Anterior Temporal, Masseter, Sternocleidomastoid and Anterior Digastric muscles in response to changes in visual input in subjects with defective vision by means surface electromyography.

METHODS

A total of 20 children, aged between 7 and 13 years, were evaluated. In the study group 10 children with myopic defects were enlisted, selected among patients afferent to the paediatric dentistry clinic. Ten subjects with normal vision, the control group, were chosen through the Pair Matching procedures, so that each myopic child had a matching age case control. Both study group and control group patients maintained mandible at rest with teeth apart and were submitted to a 15-sec electromyography (EMG) recording with closed eyes followed by a 15-sec EMG recording with open eyes.

RESULTS/STATISTICS

The Root Mean Square (RMS) values were elaborated to obtain means and standard deviation. Statistical analysis was undertaken using the Student's T-test for independent samples. Analysis of the results demonstrated a marked difference in tonic activity of temporal anterior muscles at open eyes between the myopic and the normal groups.

CONCLUSION

The findings suggest that in the evaluation of masticatory muscles tenderness, such as episodic tension type headaches, attention should be paid to vision defects.

Some tools for the identification of high caries risk individuals. A review

As a consequence of the polarisation of dental caries, which occurred over the last 3 decades in industrialised countries, the usefulness of risk assessment, both for individuals and for groups of subjects, became evident. At individual level, the early identification of high and medium caries-risk subjects allows to plan specific preventive measures for each subject's needs, based on the risk grade and the causally-directed diagnosis. At population level, risk assessment helps to increase the efficiency and to reduce the costs of caries preventive programmes. In this study, a review of caries-risk indicators is proposed: these indicators, collected through the analysis of relevant background data, clinical examination and salivary tests are indispensable to achieve a correct caries-risk assessment. A review of the studies on the attempts to produce prediction models for caries-risk assessment is presented: in view of the multifactorial nature of caries etiology and the complexity of the prediction of individual caries-risk, a multivariate approach is necessary. Finally, some suggestions on the clinical usefulness and on indications of caries-risk determination are given.

Relationship between mandibular deviation and ocular convergence

Recent studies have confirmed the relationship between head posture, mandibular position and visual focusing. A case-controlled study was conducted to assess the occurrence of ocular convergence defects between subjects with functional mandibular latero-deviation and healthy subjects in pediatric age. Sixty subjects (the study group) presented mandibular latero-deviation classified as functional according to the use of a clinical examination and frontal and basal tele-radiography. Sixty subjects without functional mandibular laterodeviation (control group) were selected randomly from all subjects seeking pediatric dental care and matched by gender and age to study group. All one hundred and twenty subjects were submitted to orthoptic tests performed by the same operator. These results seemed to confirm that in mandibular latero-deviation subjects ocular convergence defects occurred in greater frequency than in controls underlining the importance of role of pediatric dentistry among interdisciplinary cooperation.

Gender and the progression of chronic renal diseases: does apoptosis make the difference?

Several studies in patients with chronic kidney diseases have shown that men have a more rapid disease progression than women. Also, with ageing, men exhibit greater decrements in renal function and increased glomerular sclerosis than women. Data from meta-analysis studies indicate that women with several non-diabetic renal diseases such as membranous nephropathy, IgA nephropathy and polycystic kidney disease present a slower progression, but in diabetic renal disease this is not yet established. Thus, men appear to be at greater risk for renal injury than are women, but the underlying mechanisms are unknown. Sex hormones may mediate the effects of gender on chronic renal disease, through the interaction with the renin-angiotensin system, the modulation of nitric oxide synthesis and the downregulation of collagen degradation. New observations indicate that androgens may contribute to continuous loss of kidney cells though the stimulation of apoptotic pathways. Apoptosis is an unique type of programmed cell death which is activated in several chronic kidney diseases. Studies in vitro indicate that androgens prime a Fas/FasL dependent apoptotic pathway in kidney tubule cells. This apoptotic cell death pathway is receptor-linked and interacts with the mitochondrial pathway, which may be activated by other mechanisms, such as toxins and ischemia. Therefore, the mechanisms to cell death which are primed by androgens may interact with others occurring in several conditions leading to the loss of renal cells. These findings are consistent with a role for androgens to promote chronic renal injury in men.

[Complications of the nephrotic syndrome]

We described the case of a 27-year-old man presenting pulmonary embolism and hyperlipidaemia. Subsequent investigation revealed that he was affected by renal vein thrombosis and nephrotic syndrome due to membranous glomeruloephritis. Nephrotic syndrome complications are numerous and may represent the first sign of the syndrome. Among these complications we find thromboembolism, infections, negative nitrogen balance and renal failure. There are very few prognostic indicators that enable the prediction of nephrotic syndrome complications. Recent advances in the understanding of alterations in the metabolism of circulating and somatic proteins associated with proteinuria and hypooncotic condition have led to new insights into the pathophysiologic processes associated with the syndrome.

[Oral cancer]

Oral cancer (OC) is a rather frequent pathology representing about 30% of head and neck malignant neoplasms. After many years the incidence of the pathology shows constant values; the male:female ratio is continuously decreasing and at present, it is about of 2:1. The delay in diagnosis is the main cause of unsuccessful treatment and of the high values of poor outcome. OC shows three clinical aspects: exophytic, ulcerative and infiltrative; lips and margins of tongue are the most interested sites. For the diagnosis a correct clinical examination and a biopsy, possibly made with incisional criteria are necessary.

The anxiety in bruxer child. A case-control study

BACKGROUND

The etiopathogenesis of bruxism in children is not clear although different authors would associate it with several factors, changes in dentition, malocclusions, certain parasomnias and most notably emotional stress. This study was performed to test the hypothesis that anxiety states measured by "Anxiety Scale for evolutive age" may affect the development of bruxism.

METHODS

A total of eighty-six children, aged between 7 and 1, were evaluated. In the study-group were enlisted forty-three children with bruxism selected among patients afferent to the paediatric dentistry clinic. The forty-three non bruxer children, the control group, were chosen through the Pair Matching procedures, so that each bruxer child had a matching age case control. The gravity of bruxism was scored by means of 0 to 3 graduated scale of dental wear. The psychological aspects were estimated by means of an Anxiety Scale for evolutive age. Statistical analysis was undertaken using the "Odds Ratio" on statistically significant values. The most significant level was evaluated by the Mc Nemar test.

RESULTS

Remarkable differences in anxiety levels were found among the children of the two groups; 72% of bruxers showed significant anxiety scores versus 12% of non bruxers. The results of Odds Ratio reveal that a bruxer child has a 16 times greater probability to be anxious than an non bruxer one.

CONCLUSIONS

The data provide support for the concept that anxiety state is a prominent factor in the development of bruxing behaviour in children.

The Chernobyl accident: EPR dosimetry on dental enamel of children

The radiation dose on tooth enamel of children living close to Chernobyl has been evaluated by EPR. The sample preparation was reduced to a minimum of mechanical steps to remove a piece of enamel. A standard X-ray tube at low energy was used for additive irradiation. The filtration effect of facial soft tissue was taken into account. The radiation dose for a group of teeth slightly exceeds the annual dose, whereas for another group the dose very much exceeds the annual dose. Since the higher dose is found in teeth whose enamel have much lower EPR sensitivity to the radiation, it can be suggested that for these teeth the native signal could alter the evaluation of the smaller radiation signal.

[Use of Electronic Spin Resonance in the study of dental enamel caries. Preliminary results]

BACKGROUND

By means of the Electron Spin Resonance technique (EPR) it is possible to detect carbonate-related paramagnetic centers in human tooth enamel. Several arguments indicate that the radicals formed after X-ray irradiation (CO2- and CO3(3-)) are ascribed to carbonate which is the most important constituent of hydroxyapatite. There is experimental evidence that the distribution of the orientation of these centers is related to microcrystal alignment in dental enamel, which might be responsible for caries susceptibility. The results reported in the literature, however, should be interpreted very carefully.

METHODS

In our own preliminary research we studied twenty-seven samples of dental enamel taken from the buccal face of upper molars. Fifteen were carious and the other ones were sound. We used the R-parameter and the S-parameter to convert our experimental results into numerical values. The R-parameters, as introduced by Cevc et al. (1976-1980) is the ratio of the amplitude for the high field and the low component of the EPR signal. The S-parameter is the ratio of the amplitude of the A2 component and the low one.

RESULTS

No significant difference was found between the R and S-value of carious and sound dental enamel samples. The degree of microcrystal alignment in enamel of clinically sound upper molar from their buccal site is very high. However, this result is not sufficient to evaluate the caries susceptibility or the caries resistance of tooth enamel.

CONCLUSIONS

Therefore, we can conclude that it is not sufficient to ascribe the caries susceptibility to the R-value, because other factors (such as etiological factors and the structure of the teeth) should be considered.

[Polishing of composite resins. Instrumental notes]

BACKGROUND

The polishing is the last procedure in the application of composite fillings. The surface morphology and the marginal seal, that are indispensable for integration of composite fillings with dental tissue and oral environment, are tightly dependent on polishing procedure.

METHODS

The authors tried out experimental therapeutic procedure in order to examine the surface of any composite resin polymerizated under matrix on a slide before and after polishing made by abrasive disease and finally after application of a new resin layer on a polished composite surface. These composite surfaces was examined with AFM and SEM.

RESULTS

The images prove that in the polished specimens there is a restoration of composite morphology surface because of the partial removal of organic part during the polishing. The polymerization of a new resin layer on polished surface make this one more regular and even as a substitute for partial removal of organic part during the polishing.

CONCLUSIONS

The experimental procedure prove that the ideal composite surface is that polymerizated under matrix because every treatment on this surface affect the composite filling's quality.

[Single-contrast enema after colon lavage in the elderly patient]

Double-contrast enema is often unsuccessful in elderly patients because of their poor cooperation and colon cleaning. This work was aimed at showing that a well-done single-contrast exam with simple colon lavage can make a very good alternative to double-contrast enema in elderly patients. Thus, 66 consecutive elderly patients (age range: 70-90 years) were submitted, over a 6-month period (June-December, 1994), to single-contrast enema, after colon cleaning with oral whole-gut lavage, using an osmotically balanced electrolyte solution (Isocolan, Bracco) containing polyethylenglycol (PEG 4000). We examined, in each patient: a) the tolerance to and effectiveness of bowel cleaning, according to the liquid volume drunk by each subject, needed to obtain clear diarrhea; b) radiograph quality. Successful colon cleaning was achieved with a mean (2.5-3 liters) and a large (3.5-4 liters) amount of solution, in 80% and 20% of our patients, respectively. Tolerance was good in the whole series except for 3 patients with emesis. Moreover, radiograph quality was good in 85% of the subjects. Finally, barium enema results, compared with endoscopic results, yielded 27 true positives, 3 false negatives (small neoplastic lesions) and 1 false positive. Therefore, in our opinion, these results confirm the role of single-contrast enema, combined with gut lavage, in elderly patients.

[Fine needle aspiration in the cytologic diagnosis of swellings in the parotid and submandibular regions. Cytologic-histologic correlations in 49 cases]

Fine needle aspiration biopsy (FNAB) has been widely used for a number of years and offers considerable advantages in comparison to conventional surgical biopsy. A number of organs can be subject to this diagnostic procedure with good results, including the salivary glands. This paper aimed to compare the cytological diagnosis of biopsy material obtained using FNAB and the subsequent histological diagnosis formulated after surgery in 49 patients with swellings in the parotid or submandibular region who were referred to the Department of Anatomy and Pathological Histology in L'Aquila. Cytohistological concordance was present in 87.7% of the cases in this series, a percentage that is in line with that reported by other authors. The most frequent causes of diagnostic error may be ascribed to moderate nodule size and/or the scanty material obtained not suitable for diagnosis. In this series all cases of malignant neoplasia were correctly diagnosed. In spite of the limitations of this method, the authors consider that it plays an important role in the preoperative diagnosis of salivary gland pathologies.

[Epidermoid carcinoma of the oral cavity. Considerations of the role of the papillomavirus]

Human papilloma virus (HPV) may have an important role in oral carcinoma etiology. Our work compares the presence of HPV in the epithelium of oral mucosa of patients with oral carcinoma with other factors of risk (smoking, alcohol, chronic mucosal trauma). We studied 33 patients operated for oral cancer at St. Salvatore Hospital in l'Aquila, in January-December 1990. The presence of HPV was proved by a direct valuation of morphological signs (coilocytosis, nuclear inclusions, etc.) and by immunohistochemical technique with primary antibodies against structural virus antigens. Among the 33 patients 19 (57.6%) were positive for HPV and 14 (42.4%) were negative. Among the HPV positive subjects 13 were smokers, 11 usually assumed alcohol and 6 had chronic mucosal trauma. Among the HPV negative subjects 9 were smokers, 7 assumed alcohol and 3 had chronic mucosal trauma. The statistical evaluation of data showed the lack of significance of viral infection compared to other factors of risk. In spite of a few cases examined, we suppose that HPV doesn't play a primary role in oral cancerogenesis, but is a concomitant cause with other factors of risk.

Color Doppler sonography of salivary glands

OBJECTIVE

We used color Doppler sonography to evaluate the vascular anatomy of the salivary glands and to analyze physiologic changes that occur during salivary stimulation in normal subjects and the flow alterations that occur in diseased glands.

SUBJECTS AND METHODS

The vascular appearance of the three major salivary glands was examined in healthy volunteers (n = 24); in patients with chronic autoimmune diseases, including Sjögren's syndrome (n = 23) and salivary sarcoidosis (n = 2); and in a variety of benign (n = 49) and malignant (n = 13) nodules. Physiologic changes were assessed in healthy volunteers by means of a stimulation test with lemon and were quantified with color images and spectral analysis. Tumor vascularity was graded on a four-step analog scale of 0 to (+3) and classified as either peripheral or hilar, depending on the distribution of vessels.

RESULTS

In the control subjects, color Doppler imaging accurately reflected the complex vascular anatomy of the salivary glands and showed dramatic changes occurring in parenchymal vessels during lemon stimulation as a result of the intense hyperemia associated with the secretion of saliva. Sjögren's syndrome and sarcoidosis showed a diffuse hypervascular pattern when morphologic changes of salivary parenchyma were seen on gray-scale sonograms. Benign tumors showed a lower grade of vascularity than did malignant tumors. All but one of the hypovascular nodules graded as 0 (n = 8) and + (n = 23) were benign. Conversely, eight of 11 nodules labeled with the highest grade of tumor vascularity (+3) were malignant. When the pattern of tumor flow signals was peripheral, it could be considered specific enough to aid in diagnosing pleomorphic adenoma. Peak systolic velocities greater than 60 cm/sec were never detected in benign tumors and were seen in only 44% of malignant tumors.

CONCLUSION

Color Doppler sonography is a promising technique for analyzing the vascularity of the salivary glands and for characterizing some pathologic conditions. Our experience suggests that color Doppler sonography can provide additional diagnostic information in patients with chronic inflammatory diseases or suspected malignant tumors and can help in differentiating pleomorphic adenomas from other salivary gland tumors.

[Artifacts in echo-Doppler and color-Doppler]

It is well known that artifacts can be observed during US examinations; the same is true also for Doppler and color-Doppler images of blood flow. Recognizing these artifacts is important to avoid image misinterpretations and, when possible, to overcome them by modifying either techniques or unit settings, or both. This work was aimed at presenting the several artifacts which can be observed during Doppler investigations, at classifying them, and trying to understand the physical and/or technical principles underlying their origin. Doppler and color-Doppler artifacts can be divided into four large groups: 1) artifacts regarding evaluation of the presence of flow; 2) artifacts regarding evaluation of the direction of flow; 3) artifacts regarding determination of the velocity of flow; 4) artifacts affecting spatial location, on the screen, of the examined vessel. Each of the above can cause severe diagnostic misinterpretations, if not correctly recognized and interpreted. It must be kept in mind that an accurate analysis of unit settings during scanning, and the meticulous evaluation of the obtained color images are of the utmost importance for the proper use of this valuable but difficult diagnostic technique.

[Echography in laryngeal tumors]

During sonographic (US) studies of the neck for the nodal staging of patients with laryngeal neoplasms, the authors observed that, especially in advanced cases, also the primary lesion could be imaged with this method. Therefore, US capabilities were investigated in assessing the local stage of laryngeal neoplasms; the results were compared with clinical and surgical findings. Fifty normal subjects of various ages were previously examined to assess the normal US anatomy of laryngeal structures. The presence of calcifications within the thyroid cartilage is the major obstacle to US imaging of the larynx and is directly related to age; indeed, only 40% of subjects can be examined at the age of 70. Seventeen patients with advanced laryngeal tumors were examined by US. Laryngeal imaging was possible, either in part or completely, in 16 of 17 cases. The results were in agreement with clinical staging in 14 cases; in 2 cases US proved clinical understaging by detecting lesion spread to anterolateral perilaryngeal structures. To conclude, US is not suggested as the method of choice in patients with laryngeal neoplasms. However, in subjects with advanced tumors, also US can image the lesion directly, and even detect tumor spread to surrounding tissues, especially in the anterior and lateral directions. In a few cases, this can contribute to preoperative staging and to select the correct therapeutic approach.

[Papilloma of the palate. Clinical and histopathology]

An asymptomatic, exophytic and unusually large mass of hard and soft palate is presented. Its papillary surface architecture is characteristic of an oral squamous papilloma. The cause is unknown. Recurrent or malignant change, or both, are possible.