Intra-articular clodronate in patients with knee osteoarthritis non-responder to intra-articular hyaluronic acid - a case report series of 9 patients with 8-month follow-up.

Background: Osteoarthritis (OA) is a common disease in the elderly people, inducing pain and functional limitations. Clodronate (CLO) a first generation non-nitrogen containing bisphosphonate has been purposed as a treatment of OA, being effective on pain, inflammation, bone marrow oedema, osteophytosis and cartilage regeneration. Intra-muscular routes of CLO showed efficacy in the treatment of Knee OA (KOA) and erosive OA of the hand. In KOA intraarticular CLO at low doses (0.5-2 mg) showed efficacy as well as hyaluronic acid (HA), being able to improve the effectiveness if associated to HA. Methods: Nine Consecutive patients (4 female, 5 male, mean age 78,22) with KOA at 2nd or 3rd degree following Kellgren-Lawrance scale, non responder to HA and unintended to surgery. They were treated with intraarticular CLO at the weekly dose of 20 mg, plus lidocaine 1% in 5 cc of saline solution for a route of 5 weekly infil-trations, followed by a second route of 5 intraarticular infiltrations 3 months after the first course. Visual analog score (VAS) pain and Tegner-Lysholm Score (TLS) were used to assess changes following CLO treatment. Results: Baseline pain was 6,77/10, reduced to 1,09 at day 150 (after second course) and to 2,3/10 at day 240. TLS at baseline was 56,7/100, improved to 96,7 at day 150 and to 84,1 at day 240. At day 240 only 2 out of 9 patients had a negative judgement of the treatment and decided to stop it, while 7 were satisfied and available to a further course. There was no increase of consumption of anti-inflammatory or analgesic drugs. A short time lasting pain after the injections was registered in all patients. Conclusions: In a small cohort of patients affected by KOA, non responders to intraarticular HA a higher dose of intraarticular CLO in KOA showed good compliance, amelioration of pain and functionality.

Cellular fibroma in the Douglas cavity, mimicking a malignant neoplasia: fibroma, fibrosarcoma or mitotically active cellular fibroma?

INTRODUCTION: Ovarian fibroma is a benign stromal tumour composed of spindle/ovoid fibroblastic cells producing collagen. Approximally 10% of fibromas are densely cellular with small amount of collagen. In these cases, if mild nuclear atypia is present, they are best addressed as cellular fibroma. However cellular fibroma may show a greater mitotic activity and therefore they should be referred as mitotically active cellular fibromas. Mostly benign, it is necessary to differentiate them from malignant tumours such as fibrosarcomas. METHODS: We report a case of an unusual presentation of mitotically active cellular fibroma, detected in the Douglas cavity of a young woman, with normal appearing ovaries and uterus, mimicking a malignant neoplasia clinically and on imaging. In fact abdominal mass may be associated with acute pain, resulting in clinical emergency, really difficult to distinguish from a frank malignancy, before surgical procedure. RESULTS: We described the clinical, radiological and pathological characteristics of our case and we make a comparison of what previously described in literature. DISCUSSION: The differential diagnosis among those entities is based on the microscopic features such as atypia and the number of mitoses. However, according to their dimensions, it may be necessary to generously sample these tumours and sometimes, to perform a panel of immunohistochemical markers, in order to make a correct diagnosis, establish the best treatment and the right follow-up. In fact, the prognosis is not certain, due to the possible recurrence, especially if not completely excised.

Understanding bisphosphonates and osteonecrosis of the jaw: uses and risks.

OBJECTIVE: Bisphosphonates are chemically stable analogs of pyrophosphate compounds, which have been used to treat multiple disorders of calcium metabolism. Although bisphosphonates have been employed for many years and have demonstrated an excellent safety profile, severe osteonecrosis of the jaw (ONJ) has been described in patients with bone metastases who have been treated with bisphosphonates. METHODS: In this review we describe the reasons for ONJ and discuss the varying effects of different bisphosphonates on the development of ONJ. Bisphosphonates tend to accumulate in bone, subject to remodeling (such as the jaw) and can affect osteoclast-mediated bone resorption and osteoclast formation, leading to the osteonecrosistic phenomenon. RESULTS: Risk factors for previously -treated patients include the type of bisphosphonates (amino or non-amino), length of treatment and route of administration, the presence of co-morbidities and/or treatment with immune-suppressing drugs, and the presence of other risk factors in addition to the type of intervention required. In oncological patients currently in treatment with receiving intravenous bisphosphonates, greater consideration must be taken depending on the length of treatment already undertaken and concomitant therapies. In these patients, a preventive dental surgery visit and examination of the case would be advisable prior to beginning treatment with bisphosphonates. CONCLUSIONS: Practical approaches in the prevention of ONJ include thorough pre-treatment evaluation and performing any preventative procedures (treat periodontal conditions, extract loose teeth, provide protective and endodontic therapies); initiating amino-bisphosphonates only after any gum tissue damage has healed; establishing a regimented check-up schedule and hygieneic precautions the patient can take; and during bisphosphonate treatment conduct any dental procedures in the least invasive manner during bisphosphonate treatment.

Abnormalities in cortical gray matter density in borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a chronic condition with a strong impact on patients' affective, cognitive and social functioning. Neuroimaging techniques offer invaluable tools to understand the biological substrate of the disease. We aimed to investigate gray matter alterations over the whole cortex in a group of Borderline Personality Disorder (BPD) patients compared to healthy controls (HC). METHODS: Magnetic resonance-based cortical pattern matching was used to assess cortical gray matter density (GMD) in 26 BPD patients and in their age- and sex-matched HC (age: 38 ± 11; females: 16, 61%). RESULTS: BPD patients showed widespread lower cortical GMD compared to HC (4% difference) with peaks of lower density located in the dorsal frontal cortex, in the orbitofrontal cortex, the anterior and posterior cingulate, the right parietal lobe, the temporal lobe (medial temporal cortex and fusiform gyrus) and in the visual cortex (P<0.005). Our BPD subjects displayed a symmetric distribution of anomalies in the dorsal aspect of the cortical mantle, but a wider involvement of the left hemisphere in the mesial aspect in terms of lower density. A few restricted regions of higher density were detected in the right hemisphere. All regions remained significant after correction for multiple comparisons via permutation testing. CONCLUSIONS: BPD patients feature specific morphology of the cerebral structures involved in cognitive and emotional processing and social cognition/mentalization, consistent with clinical and functional data.

Solitary plasmacytoma of the tonsillar site associated with actinomyces infection: the possible role of IL-6.

ExtraMedullary Plasmacytoma (EMP) is a rare plasma cell tumor. It can occur in the upper aerodigestive tract and presents as a large nodule causing local compressive symptoms. A 79-year old woman presented to Otorhinolaryngology Department with progressive hearing loss and no other symptoms. Following PET/TC examination due to the suspicion of a lymphoproliferative disease, the patient underwent tonsillectomy and the diagnosis of solitary EMP was formulated. In addition to that, the histological examination of the tonsillar tissue revealed large colonies of filamentous bacteria, showing abundant sulphur granules and Splendore-Hoeppli phenomenon; these evidences indicating the presence of a chronic Actinomyces infection. Immunohistochemical analysis demonstrated a marked IL-6 immunoreactivity of the neoplastic plasma cells. Interestingly, a marked IL-6 immunoreactivity was also found in the tissue surrounding the Actinomyces colonies. In the present study we report for the first time a solitary EMP associated with Actinomycosis. It is tempting to speculate that the unsuspected and untreated Actinomyces infection, through chronic IL-6 production, could contribute to the neoplastic transformation of plasma cells.

Is HPV-DNA testing a useful tool in predicting low-grade squamous intraepithelial lesion outcome? A retrospective longitudinal study.

HPV-DNA testing has entered in clinical practice. Three important questions remain controversial: 1) which is the best HPV-DNA technology? 2) Which age group should be targeted? 3) Is HPV-DNA testing predictive of disease outcome? The answers to these queries represent the endpoints of this study. The population of this retrospective study consisted of 272 women, each one having: baseline cytological diagnosis of Low-grade Squamous Intraepithelial Lesion (LSIL); baseline HPV-DNA reports by Hybrid Capture 2 (HC2) and MY09/11 consensus primers PCR; follow-up duration over 3-years; cytological report of disease status at follow-up time. Firstly, we assessed the concordance and the performances of both HPV-DNA testing, then we correlated, respectively HPV-DNA results and age of patients to disease outcome. DNA testing methods agreed in 83.4 percent of cases (K=0.66). Baseline HPV-DNA result was not significantly associated to disease outcome (p=0.06). Within HPV-DNA positive group, we found no evidence of correlation between age and LSIL prognosis (p=0.89). Confining the analysis to age-stratified HPV-DNA negative women, the differences were statistically significant (p=0.01). In conclusion, HPVDNA testing gives no information about the real behaviour of cervical abnormalities. These findings suggest the demand for additive markers, reflecting the risk of progression, in prevention strategy and clinical approach.

Management and triage of women with human papillomavirus infection in follow-up for low-grade cervical disease: association of HPV-DNA and RNA-based methods.

Type-specific persistent infection with Human Papillomavirus (HPV) is a significant risk factor for the development of cervical diseases. Persistent infection could be further refined by a sequencing approach to detect early cervical lesions that are at high risk of developing an invasive squamous cervical cancer. The aim of the present study is to investigate the clinical utility of detecting mRNA transcripts of HPV oncogenes E6/E7 by using a Real-time NASBA technology (mRNA test) and to identify women with low-grade cytological disease but with an increased risk of developing high-grade cervical abnormalities or invasive squamous cervical cancer. Our preliminary results show that E6/E7 is detected in only a subset of HR-HPV-positive cases. Since viral persistence is considered to be the true precursor of neoplastic progression, only the detection of E6/E7 mRNA can identify the infection which is more likely to persist and induce neoplasia in future. For these reasons we believe that this test would be useful for the characterization of women with HR-HPV DNA positivity who should be effectively treated because at high-risk of developing a high grade cervical lesion or an invasive squamous cervical cancer.

Bisphosphonates and atherosclerosis: why?

The increasing knowledge on bone calcification processes has revealed some similarities with vascular tissue, where calcifications of arteries and cardiac valves contribute to several cardiovascular problems, such as heart failure, systolic hypertension, and myocardial and peripheral ischemic disease. Bisphosphonates have been used extensively for over two decades for the treatment of diseases associated with excessive bone resorption, i.e., osteoporosis, osteolytic bone metastasis, hypercalcemia and Paget's disease, by blocking osteoclastic function. Etidronate, pamidronate and clodronate has been shown to inhibit the development of experimental atherosclerosis, and proposed mechanisms for this action include inhibition of arterial calcification and lipid accumulation, degradation of atherogenic LDL-cholesterol and reduced foam cell formation. Bisphosphonates inhibit various enzymes involved in cholesterol biosynthesis and suppress macrophages in atheromatous lesions. The possibility of pharmacological agents that effectively treat both osteoporosis and atherosclerosis is attractive, however, current evidence is not conclusive and further research is necessary to confirm these actions in the clinical setting.

The expression of LEC/CCL16, a powerful inflammatory chemokine, is upregulated in ulcerative colitis.

Ulcerative colitis (UC) is a chronic inflammatory disease of unknown aetiology and pathogenesis. The presence in the colonic mucosa of reactive cells expressing proinflammatory cytokines and chemokines is associated with high levels of IL-10, an anti-inflammatory cytokine. Our aim was to investigate the role of IL-10 and the beta chemokine LEC/CCL16 selectively up-regulated by IL-10 in inflammatory cell recruitment and cytokine and chemokine production during UC. We studied histologically, immunohistochemically and ultrastructurally colonic biopsies from 20 active UC patients and 10 control specimens taken far from any macroscopically detectable lesion in age and sex-matched patients with noninflammatory bowel disease. In active UC, immature dendritic cells (DCs) in the LP are associated with IL-10 in the T cell rich area. Furthermore, most of the LP-infiltrating macrophages strongly expressed LEC/CCL16, a chemokine upregulated by IL-10. To evaluate if LEC/CCL16 plays a role in the inflammatory reaction present in UC, we performed morphological studies in mice injected s.c. with syngeneic tumor cells engineered to produce LEC/CCL16. We found that the LEC protein locally released by LEC-gene-transfected tumor cells is a potent proinflammatory chemokine that induces the recruitment of a reactive infiltrate, and an angiogenic process mirroring that in human UC.

Detection of Helicobacter pylori by PCR on gastric biopsy specimens taken for CP test: comparison with histopathological analysis.

The aims of the present study were: (i) to assess whether H. pylori could be successfully detected by PCR from the same biopsy sample used for CPtest; and ii) to evaluate CPtest comparatively to both PCR and histology for detection of H. pylori infection in dyspeptic patients. Three antral gastric biopsies were collected from each of 80 consecutive dyspeptic patients undergoing oesophago-gastroduodenoscopy. Two biopsies were for histology (gold standard), one for CPtest, scored at 20min, 1h and 24h for the presence of urease activity. Gastric biopsy was then removed from CPtest and used for ureC-targeted PCR. Fifty-five (68.7%) patients were positive for H. pylori infection by histology. CPtest yielded an overall diagnostic accuracy of 93.8% (95% CI: 91-96.4%), regardless of observation period. No erroneous categorization of H. pylori status occurred using PCR, yielding sensitivity, specificity, positive and negative predictive values, and overall diagnostic accuracy of 100%. Our results suggest that H. pylori can be detected by PCR in gastric biopsies previously taken for CPtest, so reducing the workload of the endoscopist by saving additional biopsies for culture analysis and susceptibility tests.

1,2-Dimethylhydrazine-induced colon carcinoma and lymphoma in msh2(-/-) mice.

BACKGROUND: Defective mismatch repair (MMR) in humans is particularly associated with familial colorectal cancer, but defective repair in mice is generally associated with lymphoma in the absence of experimental exposure to carcinogens. Loss of MMR also confers resistance to the toxic effects of methylating agents. We investigated whether resistance to methylation contributes to increased susceptibility to colorectal cancer in mice by exposing mice with defects in the MMR gene msh2 to a methylating agent. METHODS: Tumor incidence and time of death in msh2(+/+), msh2(+/-), and msh2(-/-) mice were analyzed after weekly exposure (until tumor appearance) to the methylating agent 1,2-dimethylhydrazine (DMH). Chemically induced and spontaneous tumors were characterized by frequency, type, and location. The tumor incidence in untreated and treated mice of each genotype was compared by a Mann-Whitney U test. Carcinogen-induced apoptosis in histologic sections of small and large intestines was also determined. All statistical tests were two-sided. RESULTS: Homozygous inactivation of the msh2 gene statistically significantly accelerated (P<.0001) death due to the development of DMH-induced colorectal tumors and lymphomas. Rates of death from DMH-induced colorectal adenocarcinoma were similar in msh2 heterozygous and wild-type mice, but only msh2 heterozygotes (msh(+/-)) developed additional, noncolorectal malignancies (notably trichofolliculoma [two of 21], angiosarcoma of the kidney capsule [two of 21], and lymphoma [one of 21]), suggesting that heterozygosity for msh2 slightly increases DMH susceptibility. DMH induced apoptosis in small intestinal and colonic epithelial crypts that was dependent on active msh2. CONCLUSIONS: Inactivation of msh2 allows the proliferation of gastrointestinal tract cells damaged by methylating agents. Furthermore, MMR constitutes a powerful defense against colorectal cancer induced by DNA methylation.

Effects of clodronate on synovial fluid levels of some inflammatory mediators, after intra-articular administration to patients with synovitis secondary to knee osteoarthritis.

Recent studies have outlined the role of bisphosphonates, and particularly clodronate, as potential therapeutic agents for inflammatory and degenerative joint diseases. On this basis, we carried out an open, non comparative pilot trial to evaluate the effects of clodronate on synovial fluid concentration of some inflammatory mediators (prostaglandin E2, leukotriene B4 and tromboxane B2) after intra-articular, repeated administrations in 20 patients (7 males and 13 females) with synovitis secondary to knee osteoarthritis. At the end of the treatment period, statistically significant reductions (p < 0.05) of spontaneous pain and pain on active movement, evaluated by means of a 100 mm visual analogue scale (VAS), were reported. Linear regression analysis showed that the decrease of pain was correlated with the bisphosphonate induced reduction of prostaglandin E2 levels. These results, in spite of the limitation due to the open design of the trial suggest a possible role of bisphosphonates in the treatment of knee osteoarthritis.

In vitro effects of different formulations of bovine collagen on cultured human skin.

Irritant effects and cytotoxicity of three different products based on collagen were investigated: a sponge formulation and a thin film composed by Type I collagen from bovine Achille's tendon, and a membrane prepared from bovine derma. The test system was a three-dimensional human skin model, developed by Advanced Tissue Science, La Jolla, CA, USA. Squares of dermal tissue (11 x 11 mm) were cultured in suitable media and exposed to the products under study. Dimethyl sulphoxide was used as the chemical control of tissue responsiveness to irritating substances. After 24 and 48 h the prostaglandin E2 (PGE2) concentration and the lactate dehydrogenase (LDH) activity in the culture medium were measured, as indexes of early inflammatory response and cell membrane breakdown, respectively. In addition, cell morphology was examined by light microscopy. The highest PGE2 concentrations were observed after cell exposure to the collagen sponges. The intensity of the inflammatory response changed accordingly to the collagen dose in use. However, it was never followed by an increased rate of cell death, as revealed by LDH activity measurement and microscopy. These findings suggest that hydrolysis of exogenous collagen starts shortly after it is kept in contact with tissues and evokes a local inflammatory response whose intensity depends on the pharmaceutical formulation in use.

[The prevention of adhesions in surgery. A clinical review and experimental contribution]. / Prevenzione delle aderenze in chirurgia. Revisione clinica e contributo sperimentale.

BACKGROUND: The well-known soft tissue healing properties in some rat models as well as the modulating fibroblasts activity of heterologous collagen led us to the hypothesis that it is possible to prevent the peritoneal adhesions in the rat by interposition of the collagen after peritoneal surgery. METHODS: In this study, the use of Type I heterologous collagen in different physical forms (1% gel, lyophilized sponge, dehydrated film) for the postoperative peritoneal adhesions prevention has been evaluated. In the second part of the experiment; the 1% gel heterologous collagen including the recombinant tissue plasminogen activator (rtPA) has been applied. RESULTS: The results of both the experiments don't show any improvement in the number and the quality of the adhesions. CONCLUSIONS: It is cannot be excluded that, increasing the rtPA concentration it is possible to obtain better results, but the great cost and its potential systemic toxicity are limiting factors for its widespread use in order to prevent peritoneal adhesions.

Interleukin 1alpha and interleukin 6 promote the in vitro growth of both normal and neoplastic human cervical epithelial cells.

Interleukin 1alpha (IL-1alpha), Interleukin 6 (IL-6) and epidermal growth factor (EGF) were tested for their ability to regulate epithelial cervical cell cytokine production and secretion and to induce proliferation of human normal and neoplastic epithelial cervical cells. IL-1alpha, and IL-6 enhanced tumour and normal cell growth by 20-120%. The interleukins efficacy was similar to that of EGF for some cell lines but not for normal esocervical cells. The stimulatory effects of the interleukins were observed in both human papilloma virus (HPV)-infected and HPV-non-infected cervical cells. Normal cells constitutively expressed IL-1alpha, IL-6 and EGF mRNA. All cell lines except C33A expressed IL-1alpha mRNA. CaSki, C-4II and HT-3 expressed mRNA for IL-6. IL-1alpha induced or increased IL-6 mRNA levels in the Me-180 and HT-3 lines and in normal cervical cells. IL-6 induced: (1) the expression of its own mRNA only in Me-180 cells that constitutively lacked IL-6 mRNA; (2) the expression of IL-1alpha mRNA in C-33A and increased IL-1alpha mRNA level in the case of Me180 cells. Increased amounts of IL-6 mRNA were found in normal cells when treated with IL-1alpha. In spite of the pattern of mRNA expression, only HT-3 and normal cervical cells constitutively secreted IL-6, and only normal cells were able to produce IL-1alpha protein. A significant IL-1alpha-dependent increase of IL-6 secretion was found in Me-1 80, HT-3 and normal cells. IL-1alpha- and IL-6-driven cell proliferations were almost completely inhibited by the addition of neutralizing anti-IL-6 antibodies. Taken together, these data suggest that interleukins play a role in cervical carcinogenesis as autocrine and/or paracrine stimuli.

Effects of orally administered bisphosphonates on bone loss in a disuse osteopenia model involving the rat.

OBJECTIVE: This study was carried out to evaluate the effectiveness of two newly synthesized bisphosphonates (BPs) [Alendronate (4-amino-1-hydroxybutylidene-1, 1-bisphosphonic acid (AHBuBP)) and Neridronate (6-amino-1-hydroxyhexylidene-1,1-bisphosphonic acid (AHHexBP)], administered orally, in reducing experimentally induced bone loss. METHODS: Unilateral sciatic nerve section was performed on the Sprague-Dawley rat to induce osteopenia in one of the hind limbs. Histomorphometric measurements of the tibial trabecular bone and femur ash content determinations were effected to assess the degree of osteopenia. For comparison Chlodronate (dichloromethylene-1-bisphosphonic acid (Cl2MBP) was employed as the reference drug. CONCLUSIONS: The results of this investigation show that both BPs were significantly active in reducing the osteopenic process in the involved limb and were more active than Chlodronate.

[Use of new forms for the evaluation of the clinical apprenticeship of nursing students]. / L'uso di nuove schede per la valutazione del tirocinio clinico degli studenti infermieri.

The development of forms oriented to the evaluation of the practical training of nursing students is described. The activities of the nursing students were listed and the relevant activities for each practical training period were identified. The level of difficulty of the activity, the skills needed and the performance level to be reached by the end of the practical training period was agreed on and clearly stated for each activity. Criteria for evaluating the socio-affective and relational skills were also identified. The 28 forms developed were used for the evaluation of the practical training of 254 students. Some critical reflections and suggestions for improvement are presented.

Depletion of stromal and intraepithelial antigen-presenting cells in cervical neoplasia in human immunodeficiency virus infection.

Human immunodeficiency virus-positive (HIV+) women have an increased risk of lower genital tract dysplasia and neoplasia, and studies of the central lymphoid system suggest that impaired immunosurveillance plays a role in the development of their cervical tumors. Intraepithelial and stromal immunocompetent cell counts were compared in cervical specimens from 50 HIV+ and 50 appropriately matched HIV-women (controls) with low and high grade squamous intraepithelial lesions (SIL), or carcinoma. Each histological class of HIV+ women displayed fewer intraepithelial Langerhans' (S100+) cells (LC) (as already known), and also fewer stromal LC and both intraepithelial and stromal (CD68+) macrophages. LC and macrophages were reduced in all HIV+ patients, whereas reduction of cervical T lymphocytes was found in only immunocompromised subjects (peripheral blood CD4+ T-cell count < 500/microL). A mucosal quantitative deficiency of antigen-presenting cells (APC) thus precedes that of T cells. HIV infection appears to lead to early impairment of mucosal immunoreactivity mainly because of defective antigen presentation. This impairment may be one mechanism underlying the increased frequency of cervical dysplasia/neoplasia, and the enhanced aggressiveness of invasive cancers in HIV+ women.