Managing Adult-onset Still's disease: The effectiveness of high-dosage of corticosteroids as first-line treatment in inducing the clinical remission. Results from an observational study

To assess the effectiveness of the treatment with high dosage of corticosteroids (CCSs), as first-line therapy, in inducing remission in naïve Adult-onset Still's disease (AOSD) patients compared with low dosage of CCSs, after 6 months. To further evaluate the rate of patients maintaining the remission and the rate of CCSs discontinuation, after additional 12 months of follow-up.A retrospective evaluation of patients prospectively followed was designed to compare the rate of clinical remission in naïve AOSD patients treated with high dosages of CCSs (0.8-1 mg/kg/day of prednisone-equivalent) or low dosage of CCSs (0.2-0.3 mg/kg/day of prednisone-equivalent), after 6 months. An additional analysis was performed to compare the rate of monocyclic pattern between these groups, after further 12 months of follow-up.The clinical remission was achieved in a higher percentage of patients treated with the first-line treatment with high dosage of CCSs than treated the first-line treatment with low dosage of CCSs. At the end of 18 months of follow-up, a larger percentage of patients treated the first-line treatment with high dosage of CCSs was classified as monocyclic pattern and discontinued CCSs when compared with patients treated the first-line treatment with low dosage of CCSs. Patients defined as CCSs non-responder were treated with methotrexate (MTX)+CCSs or with combination therapy CCSs+MTX+biologic drug. The clinical remission was observed in a percentage of these patients.We showed the effectiveness of the first-line treatment with high dosage of CCSs in inducing clinical remission in naïve AOSD patients when compared with the first-line treatment with low dosage of CCSs. The first-line treatment with high dosage of CCSs was also associated with the achievement of monocyclic pattern and CCSs discontinuation, after 18 months of follow-up

Histopathology of salivary glands

Salivary gland (SG) biopsy is a technique broadly applied for the diagnosis of primary Sjögren's syndrome (pSS), lymphoma accompanying SS, sarcoidosis, amyloidosis, and IgG4-related disease The most peculiar feature of pSS on biopsy is focal lymphocytic sialadenitis. In the past, several histological scores have been reported in the literature to describe glandular involvement during pSS. However, the variability among centres in reporting glandular scores is one of the rationales behind the development of standardised consensus guidance. SGs as well as lacrimal glands are involved in up to 50% of patients with IgG4-related disease with 3 histopathological hallmarks such as dense lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. SGs can be also affected by amyloidosis with MSG biopsy being more sensitive than that of rectal mucosa or subcutaneous fat. SG involvement is a rare manifestation during sarcoidosis, and the presence of non-caseating granulomas needs to be differentiated from granulomas of other etiology. This review article provides an overview of normal and pathological SGs in the context of rheumatic diseases, identifying key elements in the tissue as diagnostic and prognostic biomarkers, useful in the current clinical practice

ROLE OF novel PKCs IN PLATELET PRODUCTION AND FUNCTION

Protein kinase C (PKC) is a family of serine-threonine kinase involved in many cellular function, including cell death, proliferation and differentiation (Corbalán-García S et al. 2006). In particular PKCε and PKCδ could be considered the yin and yang of novel PKCs, because of their antithetical role in many cellular mechanisms such as proliferation, apoptosis, tumor growth and cardioprotection. PKCε is largely considered as an oncogene because of its anti-apoptotic and pro-proliferation functions (Newton PM and Messing RO 2011), conversely PKCδ generally slows proliferation, induces cell cycle arrest and apoptosis (Steinberg SF 2004). In the heart, they are among the most widley expressed PKC isozymes and they play an antithetical role in the ischemic-reperfusion preconditioning process (i.e.: enhancing role forPKCε and inhibiting role for PKCδ (Chen L et al. 2001). Moreover, the importance of these two PKC isoforms in pathological conditions has been proven by clinical trials based on specific PKCε and PKCδ inhibitor peptides (Mochly-Rosen D et al. 2011). Platelets are the smallest blood cells with a primary physiological role in hemostasis. They are produced by megakaryocytes as anucleated cells that contain proteins and mRNA derived from megakaryocyte. Platelets retain also the protein synthesis machinery, therefore, platelet mRNAs can be efficiently translated during platelet life, during around 10 days. PKCs have been established as important regulators of several platelet functions. The physiological expression of the different PKC isoforms varies significantly in mature platelets, with relevant differences in humans and mice. Concerning novel PKC isoforms, it has been demonstrated that PKCδ is expressed in human platelets and regulates the activation response to GPVI agonists and adhesion to collagen (Hamm CW et al. 1987). This behavior of PKCδ in humans is similar to the one described for PKCε in mice, where it plays a relevant role in the activatory signaling cascade emanating from the GPVI receptor (Pears CJ et al. 2008). On the other hand, PKCε expression and function in human platelets is still very controversial (Crosby D and Poole AW. 2003; Muruggapan S et al. 2004; Beunsuceso S et al. 2005; Pears CJ et al. 2008). On these basis, during the first period of my doctoral fellowship, I focused my research on PKCε expression in human platelets, exploring whether its levels could be associated to platelet hyper-reactivity and related diseases (i.e. acute myocardial infarction), in order to clarify PKCε role in platelet function. The results of my research showed that the majority of HD-derived platelets did not express PKCε. This is in agreement with previous data (Gobbi G et al. 2007) describing the down-modulation of PKCε expression in in vitro human megakaryocytopoiesis from day 6 onward of TPO-driven MK differentiation of CD34 precursors. Platelets play a central role in the genesis and propagation of atherothrombosisis and the development of platelet thrombus is a critical, final phase in myocardial infarction. I demonstrated that in human platelets, PKCε is selectively de novo expressed in myocardial infarction, but not in stable coronary artery disease patients, and its expression returns negative after 15 days of follow-up after the acute event. Additionally, by functional experiments, I demonstrated that PKCε-transfected normal human platelets enhance their adhesion properties to collagen-coated surfaces under physiologically high shear forces. Myocardial infarction patients express PKCε mRNA at significantly higher frequency than healthy donors and stable coronary artery disease. Considering the dimensions of the first intronic sequence of the PKCε gene, that would virtually preclude the persistence of a potential PKCε pre-mRNA in the platelet, my findings suggest that platelet generations produced before the acute event of myocardial infarction might retain PKCε-mRNA that is not down-regulated during terminal MK differentiation. An alternative explanation would be an anticipated release of platelets, before physiological PKCε down-modulation. This possibility is however unlikely, as PKCε down-modulation takes place around day 6 of in vitro MK differentiation, that would be too early. Besides, the analysis conducted on the reticulated platelets of some myocardial infarction patients, randomly selected from the recruited cohort, did not show any difference in terms of PKCε expression as compared to mature platelets, excluding the possibility that the appearance of PKCε positive platelets in myocardial infarction patients could be selectively ascribed to newly formed platelets. These results suggest that the ectopic expression of PKCε in platelets could be used as a marker of probability to anticipate the acute event in patients at risk. Since many pathological conditions depend on an abnormal platelet function, the study of molecular mechanisms involved in platelet activation and thrombus formation, has always been a matter of great interest. On the other hand, many diseases are related to abnormal platelet production. Thrombocytopenia is a major clinical problem encountered across a number of conditions, including immune thrombocytopenic purpura, myelodysplastic syndromes, chemotherapy, aplastic anaemia, human immunodeficiency, virus infection, complications during pregnancy and delivery, and surgery. Patients with a low platelets number, are at increased risk of spontaneous bleeding or hemorrhage and, to prevent them, they are treated with platelets transfusion. However the use of apheresis-equivalent units derived from human donors, shows several limitations and challenges with platelet preparation and storage technologies , such as clinically significant immunogenicity, associated risk of sepsis and inventory shortages due to high and 5-days shelf life (Thon JN et al. 2014). On these basis, two strategy are possible: i) to potentiate an in vitro platelet producing system to obtain platelets for infusion and ii) to develop pharmacological treatment able to modulate in vivo megakaryocytopoiesis and platelet production. Therefore, a deeper understanding of molecular mechanisms that control megakaryocytopoiesis is a key element to regulate in vitro and in vivo platelet production for clinical applications. PKCε is involved in human and mouse megakaryocytopoiesis. In human CD34+-derived MKs, PKCε is down-modulated in the later phases of differentiation and its forced overexpression reduces cell polyploidization and platelet production via Bcl-xL up-regulation (Gobbi G et al 2007). Regarding to PKCδ although it is well established that PKCδ is present in human platelets regulating their function, little is known about its expression during megakaryocytopoiesis Given this background, during the second period of my doctoral fellowship I sought to demonstrate whether PKCδ expression in human platelet could be the expression of a specific modulation of this isoform during megakaryocyte differentiation, similarly to what described for PKCε. Using in vitro model of human megakaryocytopoiesis, I found that, conversely to PKCε levels, PKCδ is constantly expressed and its forced down-modulation results in reduced MKs differentiation and platelet release via Bcl-xL up-regulation and Bax down-modulation Finally, given the growing interest of the scientific community on ameliorating in vitro platelet production for transfusion purposes, I studied whether the modulation of PKCε/PKCδ balance could affect platelet production in vitro. The importance of PKCε and PKCδ balance in human thrombopoiesis is additionally proven by my findings in pathological conditions, ie. myeloproliferative disorders. Primary myelofibrosis is a chronic myeloproliferative neoplasm characterized by bone marrow hyperplastic MKs with an impaired capacity to generate proplatelets in vitro. Interestingly, I found that PMF-CD34+-derived megakaryocytes show an imbalance between PKCδ/ PKCε expression, with an increase in PKCε levels- in agreement with our more recently data (Masselli et al. In press) – and a decrease in PKCδ levels, than those from healthy subjects. Moreover, these expression levels of PKCs are associated with similar imbalance between their down-stream effectors Bcl-xL and Bax, respectively. Finally, using a pharmacological inhibitor and activator of PKCδ and PKCε function, I obtained a modulation of in vitro platelet production. The concomitant PKCδ inhibition and PKCε activation reduces platelet release; conversely, PKCδ activation associated with PKCε inhibition clearly demonstrates the possibility to potentiate platelet production. Collectively, these data suggest that novel PKCs i) should be adequately expressed in human circulating platelets and PKCε ectopic expression could be associated to cardiovascular deseases, suggesting its possible use as a risk marker; ii) have a crucial role during normal human megakaryocytopoiesis and platelet production, through a mechanism involving apoptotic pathway (specifically Bcl-xL and Bax); iii) might be modulated, as protein expression levels, during in vitro megakaryocytopoiesis and by modifying their rate is possible to revise platelet production, suggesting future strategy for platelet diseases theraphy and infusion-aimed platelet expansion

The Genetic Makeup of Myeloproliferative Neoplasms: Role of Germline Variants in Defining Disease Risk, Phenotypic Diversity and Outcome

Myeloproliferative neoplasms are hematologic malignancies typified by a substantial heritable component. Germline variants may affect the risk of developing a MPN, as documented by GWAS studies on large patient cohorts. In addition, once the MPN occurred, inherited host genetic factors can be responsible for tuning the disease phenotypic presentation, outcome, and response to therapy. This review covered the polymorphisms that have been variably associated to MPNs, discussing them in the functional perspective of the biological pathways involved. Finally, we reviewed host genetic determinants of clonal hematopoiesis, a pre-malignant state that may anticipate overt hematologic neoplasms including MPNs

The time has come to look for metabolic dysfunction-associated fatty liver disease in adult patients with type 1 Gaucher disease

MAFLD is highly prevalent in Gaucher type 1 adult patients as well as in the general population and may worsen liver disease progression. Hepatic complications should be followed up. A healthy lifestyle and therapies of cardiometabolic risk factors should be recommended in Gaucher disease patients

SKIN, INFLAMMATION AND SULFUROUS WATERS: WHAT IS KNOWN, WHAT IS BELIEVED

One could argue that balneotherapy and mud therapy would have not lasted 2,000 years or so If they were not effective. No doubt a long history cannot be taken per se as scientific proof of efficacy. Some empiricism is still present in the field: the concept of spa itself is quite confounding, whereas spring waters are used for leisure purposes but also for non-acute patient therapy and late phases of clinical recovery. These confounding elements ultimately feed the opinion of those who aprioristically reject any potential beneficial effect of balneotherapy: instead, it should at least generate questions that deserve scientific answers. Clinical practices sequentially integrating pharmacological therapy with those natural principles for which a sufficient scientific demonstration is available, would probably cut the costs of public health, generating widespread advantages for the community. Recently, it has become evident that mineral waters may have intrinsic pharmacological properties. Of the numerous salts dissolved in thermal waters that might show pharmacological properties, for certain hydrogen sulfide (H2S) contained in sulfurous waters is the one that has obtained greater scientific attention, to which should be added the extensive scientific effort recently dedicated to H2S as a cellular gasotransmitter, independently from its natural sources. Dermatology and cosmetics are among the most studied applications of sulfurous waters, around which, however, some empiricism still confounds opinions: we therefore considered that a state-of-the-art focus on this topic might be timely and useful for future studies

Long-term bone outcomes in Italian patients with Gaucher disease type 1 or type 3 treated with imiglucerase: A sub-study from the International Collaborative Gaucher Group (ICGG) Gaucher Registry

Background: Gaucher disease (GD) is a lysosomal storage disorder. We evaluated the “real-world” effectiveness of first-line imiglucerase on long-term bone outcomes in Italian patients in the International Collaborative Gaucher Group (ICGG) Gaucher Registry. Methods: Patients treated with imiglucerase for ≥2 years and with bone assessments at baseline and during follow-up were selected. Data on bone pain, bone crises, marrow infiltration, avascular necrosis, infarction, lytic lesions, Erlenmeyer flask deformity, bone fractures, mineral density, and imiglucerase dosage were evaluated. Results: Data on bone manifestations were available for 73 of 229 patients (31.9 %). Bone crises frequency decreased significantly from baseline to the most recent follow-up (p < 0.001), with some improvement observed in bone pain prevalence. Bone pain and bone crises prevalence decreased significantly from baseline at 2 to <4 and 4 to <6 years (all p < 0.05). A low median (25th, 75th percentile) baseline imiglucerase dosage was identified in patients reporting bone pain or bone crises (15.0 [13.7, 30.0] and 22.8 [17.5, 36.0] U/kg once every 2 weeks, respectively). Conclusion: Our study suggests that the management of GD in Italy, with regards to imiglucerase dosage, is suboptimal and confirms the need for clinicians to monitor and correctly treat bone disease according to best practice guidelines

Blocking CD248 molecules in perivascular stromal cells of patients with systemic sclerosis strongly inhibits their differentiation toward myofibroblasts and proliferation: A new potential target for antifibrotic therapy

Background: Fibrosis may be considered the hallmark of systemic sclerosis (SSc), the end stage triggered by different pathological events. Transforming growth factor-β (TGF-β) and platelet-derived growth factor BB (PDGF-BB) are profibrotic molecules modulating myofibroblast differentiation and proliferation, respectively. There is evidence linking CD248 with these two molecules, both highly expressed in patients with SSc, and suggesting that CD248 may be a therapeutic target for several diseases. The aim of this work was to evaluate the expression of CD248 in SSc skin and its ability to modulate SSc fibrotic process. Methods: After ethical approval was obtained, skin biopsies were collected from 20 patients with SSc and 10 healthy control subjects (HC). CD248 expression was investigated in the skin, as well as in bone marrow mesenchymal stem cells (MSCs) treated with TGF-β or PDGF-BB, by immunofluorescence, qRT-PCR, and Western blotting. Finally, in SSc-MSCs, the CD248 gene was silenced by siRNA. Results: Increased expression of CD248 was found in endothelial cells and perivascular stromal cells of SSc skin. In SSc-MSCs, the levels of CD248 and α-smooth muscle actin expression were significantly higher than in HC-MSCs. In both SSc- and HC-MSCs, PDGF-BB induced increased expression of Ki-67 when compared with untreated cells but was unable to modulate CD248 levels. After CD248 silencing, both TGF-β and PDGF-BB signaling were inhibited in SSc-MSCs. Conclusions: CD248 overexpression may play an important role in the fibrotic process by modulating the molecular target, leading to perivascular cells differentiation toward myofibroblasts and interfering with its expression, and thus might open a new therapeutic strategy to inhibit myofibroblast generation during SSc

Hypertriglyceridaemia and low plasma HDL in a patient with apolipoprotein A-V deficiency due to a novel mutation in the APOA5 gene

APOA5 encodes a novel apolipoprotein (apo A-V) which appears to be a modulator of plasma triglyceride (TG). In apoA5 knock out mice plasma TG level increases almost fourfold, whereas in human APOA5 transgenic mice it decreases by 70%. Some SNPs in the APOA5 gene have been associated with variations in plasma TG in humans. In addition, hypertriglyceridaemic (HTG) patients have been identified who carried rare nonsense mutations in the APOA5 gene (Q139X and Q148X), predicted to result in apo A-V deficiency. In this study we report a 17-year-old male with high TG and low high density lipoprotein cholesterol (HDL-C), who at the age of two had been found to have severe HTG and eruptive xanthomas suggesting a chylomicronaemia syndrome. Plasma postheparin LPL activity, however, was normal and no mutations were found in LPL and APOC2 genes. The sequence of APOA5 gene revealed that the patient was homozygous for a point mutation (c.289 C>T) in exon 4, converting glutamine codon at position 97 into a termination codon (Q97X). Apo A-V was not detected in patient's plasma, indicating that he had complete apo A-V deficiency. The administration of a low-fat and low-oligosaccharide diet, either alone or supplemented with ω-3 fatty acids, started early in life, reduced plasma TG to a great extent but had a negligible effect on plasma HDL-C. Loss of function mutations of APOA5 gene may be the cause of severe HTG in patients without mutations in LPL and APOC2 genes