Alberto Lo Gullo

Is colour duplex sonography-guided temporal artery biopsy useful in the diagnosis of giant cell arteritis? A randomized study

OBJECTIVE The aim of this study was to assess the usefulness of colour duplex sonography (CDS)-guided temporal artery biopsy (TAB) for the diagnosis of GCA in patients with suspected GCA. METHODS From September 2009 through December 2012, 112 consecutive patients with suspected GCA were randomized to undergo CDS-guided TAB or standard TAB. All patients underwent temporal artery physical examination and temporal artery CDS prior to TAB. CDS of the temporal artery was performed by the same ultrasonographer, who was unaware of the patients clinical data, and all TABs were evaluated by the same pathologist. Seven patients in whom biopsy failed to sample temporal artery tissue were excluded from the analysis. RESULTS Fifty patients were randomized to undergo CDS-guided TAB and 55 patients to standard TAB. Except for a younger age in patients who underwent standard TAB (P = 0.026), no significant differences were observed between the two groups. There were no significant differences in the frequencies of positive TAB for classic transmural inflammation (28% vs 18.2%) or for periadventitial small vessel vasculitis and/or vasa vasorum vasculitis (6% vs 14.5%) between the two groups. No significant differences in the frequency of positive TAB in the two groups were observed when we excluded the patients treated with glucocorticoids and when we stratified the patients of the two groups for the presence or absence of the halo sign. CONCLUSION Our study showed that CDS-guided TAB did not improve the sensitivity of TAB for diagnosing GCA.

Left coronary artery fistula to right ventricle complicated heart failure in a patient on hemodialysis

Coronary artery fistulas (CAF) are rare, and are most often diagnosed by echocardiography or by coronary angiography. The incidence of this disease is very low, with a more frequent occurrence of fistulas originating in the right coronary artery. There is a higher incidence of CAF to right heart chambers, with CAF to the left ventricle (LV) being rare. Treatment can be surgical or percutaneous [1]. This report describes a case of CAF to the right ventricle (RV) resulting in severe pulmonary hypertension, in a patient with end-stage renal disease (ESRD) on hemodialysis and rheumatoid arthritis [2]. The patient had a history of hypertension for over 30 years [3]. Computed tomographic pulmonary angiography ruled out pulmonary embolism, but it suggested a coronary fistula to the RV cavity. A 61-year-old woman was referred for cardiac evaluation for chest pain and worsening dyspnea. The patient was on maintenance hemodialysis for the prior 2 years owing to ESRD. Clinical examination revealed tachycardia, crackles at both bases with no wheezes, rhonchi, or other adventitious sounds, a blood pressure of 160/70 mmHg. The patient had a radio-cephalic fistula constructed at the left wrist between the radial artery and the cephalic vein, using end-to-end anastomosis. An electrocardiogram showed evidence of a right bundle branch block, and signs of ventricular overload. Cross-sectional echocardiography with Doppler interrogation revealed a left ventricular ejection fraction of 55 %, and there was evidence of diastolic dysfunction, without important calcification or regurgitation of the valves.

Vitamin D Status in Rheumatoid Arthritis: Inflammation, Arterial Stiffness and Circulating Progenitor Cell Number

Background and Aims Suboptimal vitamin D status was recently acknowledged as an independent predictor of cardiovascular diseases and all-cause mortality in several clinical settings, and its serum levels are commonly reduced in Rheumatoid Arthritis (RA). Patients affected by RA present accelerated atherosclerosis and increased cardiovascular morbidity and mortality with respect to the general population. In RA, it has been reported an impairment of the number and the activity of circulating proangiogenic haematopoietic cells (PHCs), including CD34+, that may play a role in endothelial homeostasis. The purpose of the study is to investigate the association between vitamin D levels and PHCs, inflammatory markers, and arterial stiffening in patients with RA. Methods and Results CD34+ cells were isolated from 27 RA patients and 41 controls. Vitamin D levels, C-reactive protein (CRP), fibrinogen, pulse wave velocity (PWV), and carotid intima-media thickness (cIMT) were also evaluated. CD34+ count and vitamin D levels were lower in RA patients as compared to controls, while fibrinogen, CRP, PWV and cIMT were higher in RA patients. CD34+ cell number appeared to be associated with vitamin D levels, and negatively correlated to fibrinogen and early atherosclerosis markers (PWV and cIMT); vitamin D levels appear also to be inversely associated to fibrinogen. Conclusions RA patients with moderate disease activity presented with low vitamin D levels, low CD34+ cell count, increased PWV and cIMT; we found that vitamin D deficiency is associated to CD34+ cell reduction in peripheral blood, and with fibrinogen levels. This suggests that vitamin D might contribute to endothelial homeostasis in patients with RA.

Canakinumab in a case of Adult onset Still's disease: Efficacy only on systemic manifestations

Joint Bone Spine - In Press.Proof corrected by the author Available online since jeudi 23 janvier 2014

Occlusal and MRI characterizations in systemic sclerosis patients: A prospective study from Southern Italian cohort

OBJECTIVES The aim of the present study was to assess the prevalence of temporomandibular joint (TMJ) symptoms, clinical and magnetic resonance imaging (MRI) findings in a cohort of Southern Italian patients with SSc. METHODS Twenty-seven patients with SSc (12 diffuse, 15 limited, mean age 53.9, SD±1.2) and 28 healthy subjects (mean age 54.8, SD±4.2) were enrolled in this observational cohort study. In all patients, clinical examination for assessing the presence of TMJ sounds, pain in the TMJ area, tenderness of masticatory muscles, limited mouth opening, pain assessment, MRI scan and Anamnestic and Dysfunctional Index were performed. RESULTS The test groups reported more clinical and MRI findings of TMJ symptoms and dysfunction than control group. The frequency distributions of symptoms were significantly different (P<0.05), in the test groups for TMJ sounds, pain during mandibular movement and difficulty in the maximum mouth opening. There was also a significant decrease (P<0.001), in the test groups, in the mean of leftward, rightward laterotrusion and protrusion. Correlation analysis allowed to affirm that maximum opening leftward laterotrusion, protrusion and click were significantly correlated to Modified Rodnan Skin Score. The mean duration of disease was significantly correlated, ever in total SSc group, only for the maximum mouth opening value. CONCLUSION This study demonstrates that TMJ involvement is common in SSc patients and is correlated with a length and involvement of disease and supports the notion that TMJ examination should be encouraged in the rheumatology setting and clinicians should provide a right pain management and patient support.

Venous thromboembolism and cerebrovascular events in patients with giant cell arteritis: A population-based retrospective cohort study

Objective To investigate the incidence of venous thromboembolism (VTE) and cerebrovascular events in a community-based incidence cohort of patients with giant cell arteritis (GCA) compared to the general population. Methods A population-based inception cohort of patients with incident GCA between January 1, 1950 and December 31, 2009 in Olmsted County, Minnesota and a cohort of non-GCA subjects from the same population were assembled and followed until December 31, 2013. Confirmed VTE and cerebrovascular events were identified through direct medical record review. Results The study population included 244 patients with GCA with a mean ± SD age at diagnosis of 76.2 ± 8.2 years (79% women) and an average length of follow-up of 10.2 ± 6.8 years. Compared to non-GCA subjects of similar age and sex, patients diagnosed with GCA had a higher incidence (%) of amaurosis fugax (cumulative incidence ± SE: 2.1 ± 0.9 versus 0, respectively; p = 0.014) but similar rates of stroke, transient ischemic attack (TIA), and VTE. Among patients with GCA, neither baseline characteristics nor laboratory parameters at diagnosis reliably predicted risk of VTE or cerebrovascular events. Conclusion In this population-based study, the incidence of VTE, stroke and TIA was similar in patients with GCA compared to non-GCA subjects.

Histopathologic Findings of Patients With Biopsy-Negative Giant Cell Arteritis Compared to Those Without Arteritis: A Population-Based Study.

To evaluate whether there are histopathologic features of negative temporal artery biopsy (TAB) that allow differentiation between patients with giant cell arteritis (GCA) and those without.

Circulating progenitor cells in hypertensive subjects: Effectiveness of a treatment with olmesartan in improving cell number and miR profile in addition to expected pharmacological effects

CD34+ circulating progenitor cells (CD34+CPCs) are a population of multipotent cells which can delay the development of atherosclerosis and cardiovascular disease (CVD) in conditions of increased CV risk. MicroRNAs (miRs) 221 and 222 modulate different genes regulating angiogenesis and inflammation; moreover, miR221/22 have beenshown to participate in differentiation and proliferation of CD34+CPCs, inhibiting cell migration and homing. miR221/222 in CD34+CPCs from hypertensive subjects are also increased and associated with CD34+cell number and reactive oxygen species (ROS). We evaluated CD34+CPC number, intracellular miR221/222 and ROS levels, arterial stiffness (AS)and echocardiography indices at baseline (T0).Then, after a six-month treatment with olmesartan, 20 mg/day (T1), in 57 hypertensive patients with left ventricular hypertrophy (LVH) and with no additional risk factor for CVD, and in 29 healthy controls (baseline),fibrinogen, C-reactive protein (CRP), glucose and lipid profiles were also evaluated.At T1, blood pressure values, CRP and fibrinogen levels, ROS and miR221/222 were significantly decreased (all p <0.001), as were AS indices and LV mass index (p<0.001), while cell number was increased (p<0.001). Olmesartan is effective in reducing miR and ROS levels in CD34+CPCs from hypertensive subjects, as well as in increasing CD34+CPC number, providing multilevel CV protection, in addition to its expected pharmacological effects.

CD34+ cell count predicts long lasting life in the oldest old

Circulating progenitor cells (CPCs) represent a pool of cells capable of differentiating into mature cells of different organs and systems, promoting tissue maintenance and repair. Among CPCs, CD34+cells (CD34+CPCs) seem to predict outcome in CV disease, also in elderly people. A decline in CD34+CPCs was reported with advancing age. Moreover, aging is associated with a state of chronic inflammation, influencing life expectancy. Our purpose was to investigate a 10-year predictive ability of CD34+CPCs, inflammatory marker levels, classic CV risk factors (CVRFs), and Framingham Risk Score (FRS) in a population of healthy, self-sufficient octogenarians. We found that baseline CD34+CPCs was strongly associated with mortality, showing a significant difference in CD34+CPC numbers between deceased and living patients. Moreover, by dividing our patients into tertiles based on age reached, this difference was more remarkable the higher the age reached. Regressive analyses suggested that the chances of reaching an older age depend on higher CD34+CPCs at baseline and are not significantly affected by inflammatory markers levels, FRS, CVFRs, or HDL-C levels. We found that higher CD34+CPCs predict longer life also in the oldest old, providing additional insights on the predictive role of CD34+CPCs in subjects aged 80 years or more.

Vitamin D Status and the Relationship with Bone Fragility Fractures in HIV-Infected Patients: A Case Control Study

HIV-infected patients show high risk of fracture. The aims of our study were to determine the prevalence of vertebral fractures (VFs) and their associations with vitamin D in HIV patients. 100 patients with HIV infection and 100 healthy age- and sex-matched controls were studied. Bone mineral density was measured by quantitative ultrasound at the non-dominant heel. Serum osteocalcin and C-terminal telopeptide of collagen type 1 served as bone turnover markers. Bone ultrasound measurements were significantly lower in patients compared with controls (Stiffness Index (SI): 80.58 ± 19.95% vs. 93.80 ± 7.10%, respectively, p < 0.001). VFs were found in 16 patients and in 2 controls. HIV patients with vertebral fractures showed lower stiffness index (SI) (70.75 ± 10.63 vs. 83.36 ± 16.19, respectively, p = 0.045) and lower vitamin D levels (16.20 ± 5.62 vs. 28.14 ± 11.94, respectively, p < 0.02). The majority of VFs (87.5%) were observed in HIV-infected patients with vitamin D insufficiency, and regression analysis showed that vitamin D insufficiency was significantly associated with vertebral fractures (OR 9.15; 95% CI 0.18–0.52, p < 0.04). VFs and are a frequent occurrence in HIV-infected patients and may be associated with vitamin D insufficiency.