Showing papers in "Clinica Terapeutica in 1996"

[Adrenal myelolipomas: their magnetic resonance assessment].

Abstract: Adrenal myelolipomas are rare nonfunctioning neoplasias consisting of a variable mixture of mature fat and bone marrow tissue. In the present study MRI appearances of six adrenal myelolipomas are presented. MR exams of six patients in which a conclusive diagnosis of adrenal myelolipomas was reached by means of surgery (1 case), US-guided fine-needle biopsy (3 cases) and typical diagnostic imaging in association with stability on US follow-up for at least two years (2 cases) were retrospectively evaluated. MR sequences protocol included pre- and post-contrast (Gd-DTPA) SE T1-weighted images and SE proton density and T2-weighted images. Five adrenal masses were examined by means of combination of gadolinium administration with a SE T1-weighted modified three-point Dixon technique. Three different MR structural patterns were pointed out: a) homogeneous hyperintense masses on T1-weighted images with intermediate signal on T2-weighted images, suggestive for predominantly fat-containing lesions (2 cases); b) heterogeneous masses with fat intensity areas and hyperintense areas on T2-weighted images and on post-contrast T1-weighted images, suitable for mixed fatty and myeloid elements (2 cases); c) nodules hypointense to the liver on T1-weighted images and hyperintense on T2-weighted images and after gadolinium administration, suggesting tumors primarily composed of myeloid cells (2 cases). A precise determination of fatty and myeloid elements within the lesions was observed by means of "water" and "fat" images provided by modified three-point Dixon technique. In conclusion, MRI allows to determine the various structural components of myelolipomas and therefore appears to be a very reliable technique in the diagnosis and characterization of the different structural patterns of this rare adrenal pathology.

The efficacy and safety of glucosamine sulfate in the treatment of gonarthritis

Abstract: This study was performed to evaluate the therapeutic efficacy and tolerability of glucosamine sulfate in patients with gonarthritis. During the 12-month study period, the signs and symptoms of the disease were evaluated, as well as the dosage of the urinary pyridinoline. In this trial, we demonstrated that glucosamine sulfate has a chondroprotective activity, which was significant after the first 3 months of therapy. Moreover, this study showed that the side effects due to glucosamine sulfate were mild to moderate and did not require discontinuation of the drug.

[Motility of the gastric antrum and the gallbladder following oral administration of sulfate-bicarbonate].

Abstract: The authors evaluate the influence of a sulphate-bicarbonate mineral water on gastric emptying and cholecystic motility. Nine healthy volunteers drunk at settled intervals and with same procedures equal doses of mineral water and tap water on alternate days. Ultrasonographic evaluation of the gastric emptying and cholecystic volumes was performed before and after mineral water and top water drinks at settled intervals. The mean values of the gastric and the cholecystic volumes were calculated and compared at the single times. The results showed a significant colecystocinetic effect of the mineral water compared with tap water. No difference was observed in the gastric emptying with the mineral and tap water. Our work contributes to the knowledge of the pharmacodynamic effects of the mineral water employed and confirms its usefulness in the syndromes based on alterations in bile secretion and bile excretion in duodenum.

[Finasteride: a new drug for the treatment of male hirsutism and androgenetic alopecia?].

Abstract: Finasteride is a drug which inhibits the transformation of testosterone into its active metabolite, dihydrotestosterone, in the target organs, i.e. the skin, the scalp, the liver and the prostate. In the pathogenic mechanism of hirsutism and androgenetic alopecia, and important role is presumably played by alterations of the mechanisms which transform testosterone into dihydrotestosterone. In some conditions an increase in dihydrotestosterone has been demonstrated, due to increased activity of the enzyme 5 alpha-reductase. The effect of finasteride develops above all at the level of type II 5 alpha-reductase. Recent studies have evaluated the effect of finasteride in patients of both sexes with hirsutism and androgenetic alopecia. In women with various forms of hyperandrogenism, the use of the drug at the doses commonly used for the treatment of benign prostatic hyperplasia seems to have induced a significant reduction in the degree of hirsutism. Furthermore, both in animals and men with alopecia, the drug seems to have led to an increase in the number and an improvement in the shape of the follicles in the anagen phase, and a simultaneous decrease of dehydrotestosterone at the level of the scalp. This study represents a review of the main results obtained over the last two years and reports the prospects which the use of finasteride may have in this context.

[Prevalence of obesity in school age: preliminary study on students from 2 Roman schools].

Abstract: The present study, aimed at the prevention of infantile obesity was carried out in two schools of Roma and regarded also the alimentary education 295 students 101 males and 194 females was considered; the result pointed out that 114 (386%) were found obese, 57 (193%) overweight and 124 (420%) normal weight The alimentary behaviour was the same of other students: usually three meals and often snacks use during the day, a lot of the student use to eat watching the television and the physical activity is done not so much The results of these paper are related to the literature data

[L-carnitine deficiency].

Abstract: After the introduction of the carnitinemia as routine analysis in the general practice, the authors could identify a pathologic table with L-carnitine deficiency. This pathologic form seems to compromise the myocardium function, until, in the old age, it will be the cause an irremediable cardiac circulatory insufficiency.

Disease states and changes in drug pharmacokinetics

Abstract: Given that pharmacokinetic data are mostly derived from studies in animals and healthy subjects, the authors highlight how diseases can modify one or more of its phases: absorption, distribution, metabolism and elimination (ADME). Although theoretically all diseases can modify these phases, the authors believe it worth and relevant to focus the discussion on major diseases for which information is available and which are frequent in the population and with the potential to affect more phases, i.e. cardiac, hepatic and renal failure. Therefore, the aim of the paper is to update the data available and to remind that the incidence of adverse reactions to drugs due to changes in their pharmacokinetics is frequent and often serious in these diseases.

[Normalization of the prolactin values during alfa-interferon therapy: the considerations with a female patient with anti-HCV-positive chronic hepatitis and prolactin-secreting hypophyseal microadenoma].

Abstract: We report the case of a 45-year-old woman suffering from anti-hepatitis C virus (HCV) positive chronic active hepatitis and amenorrhea-galactorrhea syndrome due to a prolactin-secreting pituitary microadenoma. She was repeatedly given alpha-interferon for hepatitis, and a concomitant normalization of plasma prolactin levels, with disappearance of the related symptoms, was observed during the treatment. Further experience is needed in order to verify the therapeutical effectiveness of alpha-interferon on prolactin-secreting tumors.

Drug surveillance and adverse reactions to drugs. The literature and importance of historical data

Abstract: The authors highlight the essential role of pharmacovigilance and the need for a simple, efficient and low-cost system of adverse reaction (AR) reporting which could cover the whole population and all marketed drugs, and suggest that the only one presently viable is based on spontaneous reporting. To support their proposal the authors provide a definition of AR and of the different monitoring system, and list as many drugs as possible to find in the literature that have been associated with a specific AR, together with the active molecule, the therapeutic indication, the features of the AR and the regulatory actions (withdrawal from the market, restriction of use). Moreover, by describing the "history" behind some of these drugs the authors highlight the contribution that pharmacovigilance and spontaneous reporting have had to the development of regulations for approval and marketing of new drugs. It is also highlighted how some of these unexpected events (thalidomide, DES) have had a significant and important contribution to pharmacological and toxicological knowledge.

Prevalence of Toxoplasma gondii infections in groups of individuals in Rome and its environment

Abstract: This study was aimed out to point out the prevalence of Toxoplasma gondii infections in Roma and in the province. The results pointed out that the percentage of antibodies positivity has been 45% this prevalence was the same of the prevalence reported by other authors in Italy. The presence of a lot of women without anti-Toxoplasma gondii antibodies shows that is necessary to continue the control of the young women especially at the beginning of the pregnancy.

[Low-dose combined estrogen-progestin oral contraceptives and pulmonary embolism: a case report]

Abstract: A case study is presented of a 36-year-old woman who was referred to a University Hospital Department of Internal Medicine Rome Italy with symptoms of paroxysmal dyspnea pain in the left lower scapular area that was exacerbated by inhaling and accompanied by continuous fever of 38 degrees Celsius A few hours before the appearance of these symptoms painful tumefaction had appeared in her left calf The patient had started taking an oral contraceptive 15 days prior to admission (015 mg/day desogestrel + 002 mg/day ethinyl estradiol) for the treatment of a modest meno-metrorrhagia secondary to uterine fibromatosis Blood gas analysis demonstrated slight respiratory alkalosis with hypocapnia and slight hypoxemia A pulmonary scintiscan provided evidence of a perfusion defect corresponding to the medio-basal segment of the left lung with radiograph of the normal thorax Doppler meter examination of the venous circulation of lower arteries indicated a profound deep venous thrombosis at the level of the left femoral area Pelvic ecography demonstrated an enlarged uterus with a modestly inhomogeneous structure Hypochromic sideropenic anemia was present with slight augmentation of LDH AST ALT and indirect bilirubin with moderate hyperfibrinogenopenia and XDP values of between 499 and 800 ng/ml The blood coagulation test values were normal as were the activity of AT II protein C protein S alpha- 2 antiplasmin and plasminogen the spontaneous and induced platelet aggregability as well as the pure leukocyte aggregation The heparin therapy rapidly resolved the respiratory symptoms and markedly improved the clinical signs while the pulmonary perfusion defects disappeared and the deep venous circulation of the lower left artery was partially recanalized

Intrahepatic cholestasis in pregnancy

Abstract: Intrahepatic cholestasis of pregnancy (ICP) is a syndrome usually manifesting during the third trimester of pregnancy and disappearing after delivery. Multiple factors seem to be involved in pathogenesis of the syndrome; however, ICP appears to take place in women congenitally hypersensitive to estrogens. Typical is pruritus, which may be followed by jaundice and associated with other less common symptoms. The biochemical parameters are characteristically altered: an increase in the levels of aminotransferases (AST, ALT), total bile acids and alkaline phosphatase is observed; while serum GGT are normal. Maternal prognosis is benign. By contrast, a higher risk of acute fetal distress and prematurity has been reported. Various drugs are used in the treatment of ICP. We present the case of a patient treated with S-adenosyl-L-methionine (SaMe). SaMe therapy has proved to be effective in improving the altered biochemical parameters, whose normalization was obtained before delivery.

Endoscopic and histologic findings of gastric mucosa and Helicobacter pylori prevalence in patients suffering from chronic liver disease

Abstract: In this research we evaluated the prevalence of Hp in the gastric mucosa in patients suffering for chronic liver disease, either chronic hepatitis or liver cirrhosis. Sixty-three patients 27 with chronic hepatitis and 36 with liver cirrhosis, were examined by EGDS; of them we evaluated: endoscopic findings of stomach and duodenum, histology of gastric mucosa (antrum and corpus-fundus), presence of Hp in the histologic samples. We compared the positivity for Hp with the following parameters: presence of esophageal varices, macroscopic aspect of the gastric and duodenal mucosa, presence of hystological findings of gastritis, gastritis's activity, grading of the hepatic damage. In the our research we didn't point out greater prevalence of the Hp in the gastric mucosa with respect to hepatic damage, esophageal varices or macroscopic signs of gastric pathology. The Hp is significantly associated with histologic evidence of gastritis and also with the grade of gastritis's activity. The data of the present work don't suggest any correlation within the pathologic changes of the gastric mucosa caused from the liver cirrhosis and the presence or the growth of Hp.

The application of a new diagnostic protocol for stroke in the young

Abstract: Cerebral infarction before the age of 45 years accounts for 4-6% of all strokes. The etiology remains unexplained in a significant proportion of patients even after extensive investigations. The reported risk factors of this age group are cardiopathies, hypertension, smoking, hypercholesterolemia, reduction of anticoagulant proteins, hypercoagulable states, antiphospholipid antibodies primary syndrome, antiphospholipid antibodies secondary syndrome, some hemoglobinopathies, hyperviscosity syndromes, vasculitis, collagen vascular diseases, fibromuscular dysplasia, arterial dissections, migraine, myopathy encephalopathy lactic acidosis stroke like episodes, homocystinuria, familial amyloid angiopathy, microangiopathy with retinopathy encephalopathy and deafness, systemic lupus erythematosus, use of cocaine, traumas or manipulations of neck, AIDS. From 1/1/94 to 04/30/95 we observed 19 patients with cerebral infarctions and 9 patients with transitory ischemic attacks in young people. The aim of our study was to apply a diagnostic protocol by sequential tests of first level and second level. According to this protocol we found that the more common risk factors were ischemic cardiopathy, hypertension, smoking and hypercholesterolemia. Moreover we observed other independent risk factors, although less frequent, like the antiphospholipid antibodies, neurolupus, AIDS, deficit of protein S.

Is the placebo still ethically acceptable and scientifically useful in clinical drug experimentation

Abstract: Here, the authors address the question whether the administration of placebo, in clinical trials of drugs to be registered or already registered, is ethically acceptable and/or scientifically useful. An important issue, particularly in view of the different opinions emerging in the international scientific community. Since many diseases are already treatable with established therapies and drugs, clinical trials should be performed mainly with placebo containing the appropriate active compound, in agreement with the Helsinki declaration. Active placebo should be employed when slightly modified compounds are tested and when trials are in phase 2/b, 3 or 4. The use of active placebo in these settings would be more correct from a scientific, ethical and economical point of view.

[Changes in cerebral vasomotor reactivity in relation to respiratory and metabolic stimuli: an analysis of its behavior in hypertensive and normotensive subjects].

Abstract: We know that increases in the arterial blood pressure determines changes in the behaviour of the cerebrovascular resistance and also the possible lack of vasomotor reactivity. In order to clarify the pathway of circulatory vasomotor reactivity in arterial hypertension, we carried out a study on a group of hypertensive subjects (20 patients) who were compared to a group of normotensive controls (18 patients). A transcranial doppler (TCD) study was performed with rebreathing tests (apnea and hyperventilation) and it was carried out in both groups of subjects. The TCD was repeated after an administration of sublingual pill of nitroglycerin. In both groups the hyperventilation caused a significant reduction in the velocity peak in the middle cerebral artery (norm.: 84.88 +/- 4.86 cm/sec 60 +/- 5.2 cm/sec; hyperten. 84.50 +/- 7.1 cm/sec 58.80 +/- 5.47 cm/sec) in contrast apnea induced a major increase in the velocities (norm.: 84.88 +/- 4.86 cm/sec 102.50 +/- 4.89 cm/sec; hyperten.: 84.50 +/- 7.1 cm/sec 101.59 +/- 10.6 cm/sec). We noticed a statistical significant difference between the velocities recorded in the different tests (Anova test p < 0.0001). The behaviour of the velocities in the rebreathing tests after nitroglycerin was similar when compared to the same test were performed without the drug. This study suggests that there is no difference in the behaviour of the cerebral reactivity between normotensives and the hypertensive subjects without vascular or cardiac compliance. Finally we would emphasize the role of TCD in the recording changes of cerebrovascular resistances due to pressure or metabolic causes.

Pharmacological preparation of the endometrium in surgical hysteroscopy

Abstract: Danazol, GnRH analogues (GnRH-A), progestins and gestrinone have been indicated for medical pre-treatment of surgical hysteroscopy, although only danazol and GnRH-A had some clinical evaluation. Pre-hysteroscopic pharmacological preparation is, in general, intended to reduce endometrial thickness, intraoperative bleeding and the need for endouterine distension with fluid media. In addition, in case of endometrial ablation, medical pre-treatment should facilitate the complete removal of endometrium, thus allowing better long-term results. The mechanism of action of progestins, danazol and gestrinone is partly indirect, through inhibition of ovulation and mild reduction in the synthesis of gonadotropins, and partly direct, through, first, decidualization of the endometrium, and then complete inactivation. On the other hand, GnRH-A have only an indirect, central mechanism of action of inhibition, through pituitary desensitization, of the synthesis of gonadotropins, thus inducing a profound hypoestrogenism. GnRH analogues appear to be more effective and rapid than danazol at the endometrial level and better tolerated. However, the effectiveness of pre-treatment versus no treatment needs to be clearly demonstrated in well-designed controlled studies. No significant difference, so far, has been found between danazol and GnRH analogues in terms of both surgical safety and long-term results.

The use of low doses of sodium aurothiomalate in the treatment of rheumatoid arthritis. Current trends in basic therapy

Abstract: We studied 20 patients suffering from rheumatoid arthritis treated with small doses of sodium aurothiomalate (20 mg/month, seldom 40 mg/month) for a mean time of 6.1 years (range 2.7-10.6). 16 subjects were women and 4 men; their mean age was 58 years (range 35-77). 9 patients (45%) were affected by seropositive RA; the mean duration of disease was 1.5 years (range 0.3-7.3). 14 patients achieved the grade 1 of disease activity, evaluated by Mallya and Mace's (1981) criteria: 9 subjects after 3-9 months and 5 subjects after 2-5 years. The mean length of this remission state was 4.3 years (range 0.9-9.9). Side dermatological effects (skin rashes, pruritus, exfoliative dermatitis) were observed in 3 patients (15%); 1 patient (5%) was withdrawn from the study. We have discussed the numerous advantages of low doses of sodium aurothiomalate monotherapy, although this therapy has to be employed only in patients selected by prognostic features. Moreover we briefly mention the actual opinions in R.A. therapy that discuss the traditional pyramidal approach in favour of more aggressive therapy with combination of various disease-modifying drugs in many R.A. patients.

[Atrial natriuretic factor (ANF) in massive pulmonary embolism: the effects of heparin treatment].

Abstract: We have determined, in a group of patients suffering from massive pulmonary embolism, the ANF basic levels and the changes noticeable in anticoagulant treatment. The heparin therapy, in six patients studied, has produced a considerable clinic and functional better conditions as testified by the gradual improving from hypoxemia. The PaO2, in fact, increases from a basic value of 68.7 +/- 17.65 mmHg to 74.68 +/- 7.16 mmHg on the 7th day (p: n.s.) and to 83.66 +/- 12.46 mmHg on the 14th day (p < 0.05 on the basic value) of treatment. At the same time it has been possible to note a decreasing of plasmatic ANF mean concentrations with decrease from a basic value of 250 pg/ml to 190 pg/ml (p: n.s.) after 7 days to 185 pg/ml (p: n.s.) after 14 days of therapy. However the presents of the high values after 14 days, could be considered as evidence of a persisting change of pulmonary arterious circulation. On the basis of such notes we have tied to compare the amount of ANF, in basic conditions, with the degree of scintigraphic alterations. Of the three patients whose PRA had been previously valued (n. 4, 5, 6), n. 4 and n. 5 showed, in basic condition, a suppression of PRA and only n. 5, at the end of treatment, reached a normal range of PRA. In those three patients there hasn't been relevant changes of plasmatic aldosterone concentration during the study.

Evaluation of the therapeutic activity of and gastric lesions due to new NSAID versus placebo in patients with osteoarticular diseases

Abstract: Oral amtolmetineguacyl 600 mg/day in a single blind comparative trial with placebo carried out in 24 patients suffering from rheumatic disorders of varying severity, reduced statistically all the symptomatology correlated to inflammation. Moreover our results indicate a lack of any gastric problem even in patient with a previous history of intolerance to other NSAIDs.

[The therapy of arterial hypertension: a comparison between ACE inhibitors and angiotensin-II-receptor antagonists].

Abstract: The efficaciousness of ACE inhibitors in arterial blood hypertension is well known. These drugs decreased the incidence of hypertension and myocardial infarction in population. However, they increase tissue levels of some kinines, that may be responsible of some adverse reactions (cough, etc.). Angiotensin-receptor antagonists can minimize the adverse reactions due to kinine accumulation and may increase the safety of the antihypertensive drug-treatment. Pharmacological and clinical aspects of angiotensin-receptor antagonists are discussed.

[Chronic viral hepatitis: diagnosis and treatment].

Abstract: HBV and HCV cause most of chronic hepatitis; the HDV is a co-infectious virus and it rend the help of HBV to duplicate; HAV and HEV do not induce chronic hepatitis. Etiology is not the same, without apparent reasons, in all the world and the distinction between persistent chronic hepatitis and active idiopathic chronic hepatitis is meaningless, because one can shift in the other. Diagnosis is possible using serologic tests and by determination of the DNA of the HBV and RNA of the HCV. Interferon is a good therapeutic tool either for B hepatitis than for C hepatitis in about 50% of case. On the contrary, the results obtained with liver transplantation are disappointing and those achieved with ribavirin have not been conclusive yet. The treatment with INF for more than one year and with full dosages, gives good results in about 50% of patients with hepatitis D. In the other patients it is not useful a second cycle with INF or the introduction of pure antiviral drugs alone or in association with INF.

[Crenotherapy in sports medicine: the state of the art].

Abstract: The existing relationship linking thermal and sport medicine has developed with time. This is shown by the established beneficial effects of thermal treatments (mineral waters, mud baths, balneotherapy, aerosol applications) in a wide range of sport and non-sport related injuries. The muscle fatigue syndrome is a condition particularly worrisome for sports practising individuals. This condition impairs the cardiovascular system, as well as hematologic, renal and gastrointestinal functions, acting via biochemical and metabolic modifications of the organism, which have effects also on the psyche of the subject. The treatment of this syndrome includes the use of specific mineral waters, which underscores that the correct hydration of the organisms is a precondition to achieve high performance levels. Traumas involving muscles and skeletal segments, and precocious arthrosis occur with higher frequency in sportsmen after continuous and intense stresses. Within the scope of rheumatology, mud-baths and balneotherapy have curative and rehabilitative potentials leading to a reduction, and often a disappearance, of pain with a faster recovery of the locomotory system. The gastrointestinal system is a target of psychic as well as physical stresses displaying symptoms or diseases which may be favourably addressed with the aid of mineral waters. This treatment has proved effective in secretory and motility dysfunctions of the biliary tree allowing a rapid functional recovery. Mineral water treatments are successfully employed in the treatment of urologic disturbance and ORL and dermatological pathologies, where local applications such as mud baths, balneotherapy, showers and aerosols, play a critical role.

Prevalence of congenital cardiopathies among newborn infants in a department of pediatric cardiology

Abstract: This study consists of a prevalence congenital heart disease (CHD) registered in the Pediatric Cardiology Department of Umberto I General Hospital in Rome between January 1st 1992 and December 31-th 1993. Cases recorded in this period have been taken part of a larger study called Italian Multicentric Study for recording and follow-up of congenital heart disease (IMS-CHD); the purpose is to determine the prevalence of CHD in Italy and discover the outcome of affected children. In this duration, 187 new cases have been recorded, in which 63.6% had a single defect while 36.4% had multiple defects. These isolated defects were most frequently occurred (51.9%) following the stenosis of the pulmonary artery (15.5% and the defects of the interatrial septum (15%).

[Gastric neoplasms: their characterization, assessment of the degree of parietal infiltration and check on recurrence. The potentials and limits of CT, endoscopic US and MR].

Abstract: In this report we reviewed the role of CT, of endoscopic ultrasonography and of MR in the study of the gastric wall, to assess the degree of parietal infiltration to characterize gastric neoplasms. Finally we assess the CT role to check gastric carcinoma recurrences.

[Evaluation of the coagulation and fibrinolysis system in 54 patients with type 2 diabetes mellitus: correlations with lipid metabolism and blood glucose control].

Abstract: Diabetic patients have increased morbidity and mortality attributable to myocardial infarction, cerebrovascular disease and peripheral vascular disease, due to a high incidence of premature atherosclerosis. Abnormalities of hemostasis have been reported in many studies on diabetes over almost thirty years, but unfortunately the results have often appeared contradictory. The hemostatic alterations could lead to increased risk of vascular disease in diabetic patients. We have studied some coagulation factors (Fibrinogen, Factor II, Factor VII) and coagulation inhibitors (Protein C, Protein S), and plasminogen in fifty-four type 2 diabetic patients. The possible relationship between coagulation factors and coagulation inhibitors and parameters for glyco-metabolic control (glycosylated hemoglobin, fructosamine) and disturbed lipid metabolism (cholesterol, triglycerides) have ben analyzed. Our results show increase of fibrinogen, correlated with the metabolic control of the disease, positive correlation between plasminogen, factor II, protein S and hypertriglycerides, decreased levels of protein C correlated neither with metabolic control of disease neither with disturbed lipid metabolism.

Physiopathology of cerebral circulation

Abstract: Autoregulation of the cerebral circulation is the key mechanism that keeps CBF constant within wide limits of arterial pressure. The mechanism for autoregulation and the influence of arterial hypertension and extracranial carotid stenosis are discussed. Brain function and metabolism are critically dependent on sufficient CBF and oxygen supply. Cerebral ischemia occurs when flow drops below about 10-15 ml/100 g/min. Metabolic and therapeutic aspects of acute cerebral ischemia are discussed.

Polymyalgia rheumatica associated with myelodysplasia

Abstract: In this paper we describe a patient, female 76 years aged, who showed typical symptomatic, haematologic and instrumental findings of polymyalgia rheumatica The patient also showed myelodysplastic syndrome and peripheral signs of vasculitis, which some authors refer in association with PMR The improvement obtained with steroidal therapy confirmed the clinical picture of case