Late cardiac assessment in children diagnosed with post-streptococcal reactive arthritis: a long term study.

OBJECTIVES: Unlike rheumatic fever (RF), the association of post-streptococcal reactive arthritis (PSRA) and carditis is controversial. The American Heart Association recommends anti-streptococcal prophylaxis for PSRA for one year, repeating echocardiogram and discontinuation of prophylaxis if normal. In this study the possibility of late cardiac involvement was investigated in a cohort of children with PSRA. METHODS: Children diagnosed with PSRA and followed at the Paediatric Rheumatology Units at two medical centres in Israel had echocardiography carried out by a paediatric cardiologist, at least 1 year following diagnosis. RESULTS: 146 patients with PSRA met the study criteria. Of these, 69 had undergone echocardiography 1-6.9 years (mean 3.6 years ± 1.5 years) after diagnosis. All had normal major parameters. Twenty (29.0%) patients had minimal cardiac findings, including 5 (7.2%) mild mitral insufficiency, 12 (17.4%) minimal mitral insufficiency, 2 (2.9%) mild tricuspid insufficiency and one patient (1.4%) had very mild, aortic insufficiency. Of the 77 patients who did not have echocardiography, 31 were randomly excluded from the initial study list, 26 refused to undergo echocardiography, and 20 were lost to follow-up. All were asymptomatic according to their medical record or telephone questionnaire. There were no significant differences in clinical or demographic data between those with or without echocardiography. CONCLUSIONS: No late cardiac involvement was found in our paediatric PSRA patients. Therefore, different approaches to antibiotic prophylaxis for PSRA and ARF are probably suggested. A prospective, controlled study is needed to definitively assess the necessity of prophylaxis in PSRA.

The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general.

OBJECTIVE: To evaluate new classification criteria for peripheral spondyloarthritis (SpA) in patients with SpA with peripheral manifestations only. METHODS: In this Assessment of SpondyloArthritis international Society (ASAS) study, two prespecified sets of criteria were compared against the European Spondylarthropathy Study Group (ESSG) and Amor criteria in newly referred consecutive patients with undiagnosed peripheral arthritis, and/or enthesitis, and/or dactylitis that usually began before 45 years of age. The clinical diagnosis (SpA vs no SpA) made by the ASAS rheumatologist served as reference standard. RESULTS: In all, 24 ASAS centres included 266 patients, with a final diagnosis of SpA being made in 66.2%. After adjustments a final set of criteria showed the best balance between sensitivity (77.8%) and specificity (82.9%): arthritis and/or enthesitis and/or dactylitis plus (A) one or more of the following parameters: psoriasis, inflammatory bowel disease, preceding infection, human leucocyte antigen B27, uveitis, sacroiliitis on imaging, or (B) two or more other parameters: arthritis, enthesitis, dactylitis, inflammatory back pain in the past, family history of SpA. The new criteria performed better than modified versions of the ESSG (sensitivity 62.5%, specificity 81.1%) and the Amor criteria (sensitivity 39.8%, specificity 97.8%), particularly regarding sensitivity. In the entire ASAS population of 975 patients the combined use of ASAS criteria for axial SpA and ASAS criteria for peripheral SpA also had a better balance (sensitivity 79.5%, specificity 83.3%) than the modified ESSG (sensitivity 79.1%, specificity 68.8%) and Amor criteria (sensitivity 67.5%, specificity 86.7%), respectively. CONCLUSIONS: The new ASAS classification criteria for peripheral SpA performed well in patients presenting with peripheral arthritis, enthesitis and/or dactylitis.

[Expert assessment of patients with seronegative spondyloarthropathies]. / Begutachtung von Patienten mit seronegativen Spondylarthropathien.

Besides rheumatoid arthritis, seronegative spondyloarthropathies are one of the most common inflammatory musculoskeletal diseases. The main clinical manifestations are spondylitis and sacroiliitis, but peripheral arthritis and involvement of other organ systems are known as well. The typical ankylosis of the spine is resulting in a marked loose of the functional capacity. During the course of disease, work disability is progressing and finally the patient may become permanent disabled. Patients with ankylosing spondylitis can be viewed by experts for several reasons. To guarantee an objective medical expert view, a detailed clinical examination and use of clinical indices are mandatory.

Development of a disease activity index for the assessment of reactive arthritis (DAREA).

OBJECTIVES: The objectives of this study were to investigate and validate individual variables and to develop a composite score for disease activity measurement in patients with reactive arthritis (REA). METHODS: In the first cross-sectional part, the clinical and laboratory evaluation of 45 patients was used to elaborate the most important individual disease activity measures. In the second prospective part, these variables as well as a composite score for disease activity measurement of REA were prospectively validated in 23 patients at two points in time. RESULTS: The following variables emerged as the most useful for the composite measure: number of swollen and tender joints, patient's pain and global assessment, and C-reactive protein. The score was calculated by simple addition of the individual figures. CONCLUSION: DAREA constitutes a reliable score which can easily be assessed on a day-to-day office work basis.

James Joyce: steps towards a diagnosis.

Authors whose scholarship is in the golden realm of English literature have not hesitated to make pronouncements on James Joyce's health. A publication in this genre claims he had tabes dorsalis. One feels that an authoritative comment, accepting or rejecting a diagnosis of neurosyphilis, should be provided by the Journal of the History of the Neurosciences.

[Questionable gonarthritis--assessment and therapy]. / Unklare Gonarthritis--Abklärung und Therapie.

The differential diagnosis of gonarthritis is widespread due to the fact that the knee participates in diseases ranging from infections to autoimmunopathies and metabolic disorders. The analysis of the synovial fluid provides important information and has to be performed without delay, if septic arthritis is suspected. Characteristics, symptoms and signs of underlying diseases help in the diagnostic work-up. Whereas radiologic examination is primarily done to document the evolution of the process, ultrasonography may add substantial morphological information. Therapy is based on drug treatment and physical measures. The primary goals of physiotherapy are analgesia and rehabilitation.

Epidemiologic aspects, clinical features, and management of ankylosing spondylitis and reactive arthritis.

The generally reported prevalence of 0.1% to 0.2% for ankylosing spondylitis in the white population is probably too low, because it is based almost entirely on hospital records. The incidence and clinical presentation of ankylosing spondylitis have not changed during the past few decades. For reactive arthritis, the list of microbes recognized as triggering agents is continuously increasing. Reactive arthritis is divided into urogenic, enterogenic, respiratory tract-associated, and idiopathic arthritides. In addition, several microbial diseases may be accompanied by reactive arthritis, even though the identity of the causative agent is not always known. In the diagnosis of the spondyloarthropathies, definite progress has been made in developing classification criteria. Intensive research is going on to evaluate new therapies, with special attention to the use of antimicrobial agents for the treatment of reactive arthritis.