Psoriatic arthritis: treatment strategies using biologic agents.

The traditional management of psoriatic arthritis (PsA) includes NSAIDs, corticosteroids and DMARDs. Advancement in the knowledge of the immunopathogenesis of PsA has been associated with the development of biologic agents which have revolutionized the management of the disease. Among biologics drugs, there are the 4 currently available anti-TNFα blocking agents (etanercept, infliximab, adalimumab and golimumab) which are more effective than traditional DMARDs on symptoms/signs of inflammation, quality of life, function, and in inhibiting the progression of the structural joint damage. Despite of the high cost, TNF inhibitors are cost-effective on both the musculoskeletal and skin manifestations of psoriatic disease.

Entheseal involvement.

Enthesitis is a distinctive pathological feature of spondyloarthritis and may involve synovial joints, fibrocartilaginous joints, syndesmoses and extra-articular entheses. Extra-articular pain may often be present in rheumatoid arthritis patients. This review focuses on peripheral enthesitis which is a clinical hallmark of spondylarthritis, by comparing the same findings in rheumatoid arthritis.

Persistent normalization of serum levels of uric acid in a gouty patient after administration of cyproterone acetate.

In this article we describe a gouty caucasian male patient who had high levels of serum uric acid since 1970s. Serious adverse reactions to allopurinol discouraged its administration. We prescribed cyproterone acetate (CA) because of severe prostatic hypertrophy, associated with a suspect small cancer. The administration of this drug obtained persistent normalization of serum uric acid levels. Our observation, that needs to be confirmed in other cases, could suggest a possible new treatment for gout in male patients with prostatic disorders.

Aortic involvement in ankylosing spondylitis.

Patients with ankylosing spondylitis (AS) may develop cardiovascular manifestations ranging from asymptomatic forms to life threatening conditions. The most important cardiovascular manifestation of AS is aortitis, which frequently involves the aortic root and the ascending aorta leading to valvular insufficiency. The extension of the subaortic fibrotic process into the interventricular septum may cause conduction abnormalities that represent the second common cardiovascular manifestations occurring in AS patients. More rarely, an involvement of coronary arteries and of thoracic and abdominal aorta could be present. Rheumatologists managing AS patients should carefully consider, both in late and in early phases of the disease, the occurrence of an aortic involvement in order to promptly administer adequate treatment.

HCV infection: pathogenesis, clinical manifestations and therapy.

Chronic hepatitis C virus (HCV) infection is a worldwide public health problem with a global prevalence of 2-3%. It is believed that about 170 million people are currently infected (about 3% of the world's population), and a further 3-4 million are infected each year. HCV is the main reason for liver transplantation in the developed world, and the main cause of liver-related morbidity and mortality in a number of countries, including Italy. It is not only a frequent cause of chronic liver diseases such as hepatitis, cirrhosis and hepatocellular carcinoma, but is also involved in the pathogenesis of various autoimmune and rheumatic disorders (arthritis, vasculitis, sicca syndrome, porphyria cutanea tarda, lichen planus, nephropathies, thyroid diseases, and lung fibrosis), as well as in the development of B-cell lymphoproliferative diseases. Furthermore, patients suffering from C hepatitis tend to produce rheumatoid factor, cryoglobulins and a large series of autoantibodies (ANA, anti-SSA/SSB, SAM, ATG, aCL). The use of glucocorticoids or immuno-suppressant agents in HCV infected individuals, which are needed to treat autoimmune and rheumatic disorders, leads to a risk of worsening the clinical outcome of HCV. Under these conditions, the viral infection often needs to be treated with antiviral agents, mainly pegylated interferon combined with ribavirin. However, cyclosporine A seems to be safe and effective in patients with autoimmune disease (AD) and concomitant chronic HCV infection as is documented by the reduction in viremia and transaminases, particularly in patients with high baseline levels. Finally, HCV is the main trigger of mixed cryoglobulinemia. An attempt at viral eradication is therefore indicated in most patients, and is particularly effective in the case of mild or moderate manifestations. In severe cases, rituximab is an apparently safe and effective alternative to conventional immunosuppression and, specifically, it controls B-cell proliferation.

Hepatitis C virus infection in Italian patients with fibromyalgia.

We evaluated the prevalence of hepatitis C virus (HCV) infection in Italian patients suffering from fibromyalgia (FM), in comparison with patients affected by non-HCV related rheumatic degenerative disorders. Consecutive patients with FM and a statistically comparable group of patients suffering from peripheral osteoarthritis (OA) or sciatica due to L4-L5 or L5-S1 herniated disc were tested for HCV infection with a third-generation microparticle enzyme immunoassay (MEIA). In the positive cases, a third-generation recombinant immunoblot assay (RIBA) confirmatory test and serum HCV-RNA test were performed. Fisher's exact test was performed to compare the prevalence of HCV infection (MEIA- and RIBA-positive results) obtained in the two enrolled groups. Enrolled were 152 subjects suffering from FM and 152 patients with peripheral OA or sciatica. Anti-HCV antibodies were found in 7/152 (4.6%) patients suffering from FM and in 5/152 (3.3%) of control subjects. No statistically significant differences in HCV prevalence were detected between cases and controls. Our present report does not confirm previous data indicating an increased prevalence of HCV in FM patients and does not seem to support a significant pathogenetic role of HCV under this condition.

Acute myositis in a patient with systemic sclerosis after the administration of darbepoetin alpha.

We first describe the onset of acute myositis in a patient suffering from systemic sclerosis after the administration of darbepoetin alpha for renal failure-related anemia. Therapeutic implications and risks are discussed.

Non-rheumatoid erosive arthritis associated with type I hereditary angioedema.

Hereditary angioedema (HAE) is an autosomal dominant disease that causes recurrent attacks of non-pitting edema of soft tissues, without pruritus. This disorder can also affect internal organs. The cause of HAE consists in quantitative or qualitative defective production of C1 inhibitor (C1-INH). Many autoimmune diseases such as systemic lupus erythematosus (SLE) (or SLE-like syndromes), Sjögren's syndrome, scleroderma, thyroiditis, glomerulonephritis, and inflammatory bowel disease have been described in patients suffering from HAE. A concomitance with pure arthritis was previously reported only in two adult patients. Here, we describe for the first time the association between HAE and a non-rheumatoid erosive oligoarthritis involving hips and wrists.

Communicating hydrocephalus in a patient with mixed cryoglobulinemia and chronic hepatitis C.

This report describes a case of communicating hydrocephalus (CH), associated with mixed cryoglobulinemia (MC), which complicated chronic hepatitis C. The possible role of MC vasculitis and plasma hyperviscosity in the pathogenesis of CH is also discussed. Furthermore, we suggest screening MC patients for CH and to search for cryoglobulins in CH patients whose etiology is unknown.

[A clinical case of restrictive myocardiopathy associated with polyneuropathy]. / Un caso clinico di miocardiopatia restrittiva associata a polineuropatia.

A case of somatic and autonomic polyneuropathy associated with restricive myocardiopathy is reported. No etiology was identified although the presence of amyloid substances was excluded. Several diagnostic hypotheses are discussed including a possible evolution towards Loeffler's myocardiopathy.

Vertical dimension. Part 1: comparison of clinical freeway space.

This study was conducted in order to compare the clinical freeway space measurements using three simple methods commonly used by dentists in their practices. The study was performed in 15 young healthy subjects with natural dentition and bilateral molar support. Artificial landmarks (adhesive tape) were placed on the more prominent parts of the nose and chin of each subject. Vertical dimension of occlusion (VDO) was measured in the intercuspal position. Postural vertical dimension (PVD) was measured in the following functional conditions: after swallowing saliva, after pronouncing the word "Mississippi", and in a relaxed postural mandibular position (RPMP). Then, the clinical freeway space value in each functional condition was obtained by subtracting VDO from PVD value. Significant differences among clinical freeway space values using three different methods were observed (ANOVA). A significantly higher clinical freeway space value was found using phonetics method than after swallowing and with the mandible in a relaxed postural position (Bonferroni multiple comparison test). No significant differences between swallowing and relaxed methods were found. These results seem to suggest that the measures of clinical freeway space depend upon the method used.

Body position effects on EMG activity of the temporal and suprahyoid muscles in healthy subjects and in patients with myogenic cranio-cervical-mandibular dysfunction.

This study was conducted in order to determine the effects of body position on integrated electromyographic (IEMG) activity of anterior temporal and suprahyoid muscles. The study was performed on 15 patients with myogenic cranio-cervical-mandibular dysfunction (CMD) and 15 healthy subjects. IEMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the anterior temporal and suprahyoid muscles in the following body positions: standing, seated, supine, and lateral decubitus position. Insignificant changes in IEMG activity of both muscles were observed upon variations in the body position. Insignificant differences in IEMG activity were observed between patients with myogenic CMD and healthy subjects. A pattern of higher IEMG at rest and during swallowing of saliva was observed in the suprahyoid muscles than in the anterior temporal muscles, whereas during maximal clenching activity, an opposite pattern was observed. Results of the present study seem to suggest that for the anterior temporal and suprahyoid muscles there is no specific body position that could be relevant to initiate and/or to perpetuate a craniomandibular dysfunction.

Body position effects on EMG activity of sternocleidomastoid and masseter muscles in patients with myogenic cranio-cervical-mandibular dysfunction.

This study was conducted in order to determine the effects of body position on integrated electromyographic (IEMG) activity of sternocleidomastoid and masseter muscles in 17 patients with myogenic cranio-cervical-mandibular dysfunction. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the sternocleidomastoid and masseter muscles (contralateral to the habitual side of sleeping of each patient), in the following body positions: standing, seated, supine, and lateral decubitus position. Significant higher EMG activities were recorded in the sternocleidomastoid muscle in the lateral decubitus position and in the supine position (except during swallowing), whereas a significant higher EMG activity was recorded in the masseter muscle during maximal voluntary clenching in standing and seated positions. The EMG pattern observed suggests that the presence of parafunctional habits and body position could be closely correlated with the clinical symptomatology in the sternocleidomastoid and masseter muscles at wakening and during waking hours, respectively, in patients with myogenic cranio-cervical-mandibular dysfunction.

Body position effects on sternocleidomastoid and masseter EMG pattern activity in patients undergoing occlusal splint therapy.

This study was conducted in order to determine the effects of body position on electromyographic (EMG) activity of sternocleidomastoid and masseter muscles, in 15 patients with myogenic cranio-cervical-mandibular dysfunction undergoing occlusal splint therapy. EMG activity was recorded by placing surface electrodes on the sternocleidomastoid and masseter muscles (contralateral to the habitual sleeping side of each patient). EMG activity at rest and during swallowing of saliva and maximal voluntary clenching was recorded in the following body positions: standing, supine and lateral decubitus. In the sternocleidomastoid muscle significant higher EMG activities at rest and during swallowing were recorded in the lateral decubitus position, whereas during maximal voluntary clenching EMG activity did not change. In the masseter muscle significant higher EMG activity during maximal voluntary clenching in a standing position was observed, whereas EMG activity at rest and during swallowing did not change. The opposite pattern of EMG activity supports the idea that there may exist a differential modulation of the motor neuron pools of the sternocleidomastoid and masseter muscles, of peripheral and/or central origin. This suggests that the presence of parafunctional habits and body position could be closely correlated with the clinical symptomatology in these muscles in patients with myogenic craniomandibular dysfunction.

Body position effects on EMG activity of sternocleidomastoid and masseter muscles in healthy subjects.

This study was conducted in order to determine the effects of body position on integrated electromyographic (IEMG) activity of sternocleidomastoid and masseter muscles in 20 healthy subjects. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the sternocleidomastoid and masseter muscles (contralateral to the habitual side of sleeping of each subject), in the following body positions: standing, seated, supine, and lateral decubitus position. Significant higher EMG activities were recorded in the sternocleidomastoid muscle in the lateral decubitus position, whereas significant lower EMG activities were recorded in the masseter muscle in the supine position. This finding supports the idea that there may exist a differential modulation of the motor neuron pools of the sternocleidomastoid and masseter muscles of peripheral and/or central origin. Significant differences in the EMG pattern as well as in the levels of EMG activities upon variations in body positions were observed between healthy subjects and patients with myogenic craniomandibular dysfunction reported by Palazzi, et al.

Visual input effect on EMG activity of sternocleidomastoid and masseter muscles in healthy subjects and in patients with myogenic cranio-cervical-mandibular dysfunction.

This study was conducted in order to determine the input visual effect on electromyographic (EMG) activity of the sternocleidomastoid and masseter muscles in the supine and lateral decubitus positions. The study was performed on 22 patients with myogenic cranio-cervical-mandibular dysfunction (CMD) and 18 healthy subjects. EMG activity at rest and during swallowing of saliva and maximal voluntary clenching was recorded in the supine and lateral decubitus positions in the following conditions: 1. with eyes open; and 2. with eyes closed after 5 minutes in a dark room. A significant decrease of EMG activity at rest with closed eyes in both groups was observed in the sternocleidomastoid (lateral decubitus position) and in the masseter muscle (supine position). During swallowing of saliva a significant decrease of EMG activity with closed eyes was observed only in the sternocleidomastoid muscle (lateral decubitus position) in healthy subjects. During maximal voluntary clenching any significant differences were observed upon variation in the visual input. The significant change in EMG activity, mainly observed at rest, suggests that the visual input effect is weak. The absence of a significant change in EMG activity during maximal voluntary clenching upon variation in the visual input could be clinically relevant in patients with myogenic CMD who habitually brux.

Effects of two types of pillows on bilateral sternocleidomastoid EMG activity in healthy subjects and in patients with myogenic cranio-cervical-mandibular dysfunction.

This study was conducted in order to determine the effects of two types of pillows on bilateral electromyographic (EMG) activity of the sternocleidomastoid muscles. The study was performed on 15 patients with myogenic cranio-cervical mandibular dysfunction (CMD) and 15 healthy subjects. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the right and left sternocleidomastoid muscles. EMG activity was recorded in the supine position and in the lateral decubitus position (according to each individual's normal resting habit), with their eyes closed and with the head supported by means of: 1. a Sleep Easy Pillow (Interwood Marketing Groups, Concord, Ontario, Canada) and 2. a Standard Pillow (INDUVET). In the lateral decubitus position a significantly higher contralateral than ipsilateral EMG activity at rest in the sternocleidomastoid muscles was observed with both types of pillows in all the sample studied (ANOVA and Duncan's Multiple-Range Test). Asymmetrical bilateral EMG activity in the lateral decubitus position with both types of pillows in healthy subjects and in patients with myogenic CMD, suggests that if this body posture is prolonged, it could be important in the genesis of sternocleidomastoid hyperactivity.

[Reactive arthritis: advances in diagnosis and treatment]. / Artriti reattive: attualità in tema di diagnosi e terapia.

Reactive Arthritis (ReA) is an aseptic synovitis developing after a primary infection distant from the joint, mainly localized in the gastrointestinal (Enteroarthritis) or genitourinary tract (Uroarthritis). Because of either the asymmetric joint involvement, the possibility of involvement of the spine and enthesis, and the HLA-B27 association ReA is considered one of the spondylarthropathies. Recently, bacterial components or viable bacteria were found in joints during ReA. For this reason, the limits between ReA itself and infectious arthritis are now less definite. Generally accepted diagnostic and classification criteria are still lacking but the improvement in techniques for detection of bacteria increase the possibility to identify the triggering agents. Several studies have examined the role of antimicrobial drugs in ameliorating the natural course of ReA, with some positive results for Uroarthritis only. However, more conventional treatments based on NSAIDs, sulfasalazine and steroids are effective in many cases.

[Primary grafting for septic non-union (author's transl)]. / La greffe d'emblée dans les pseudarthroses septiques des os longs.

A one step operation is described as treatment of the septic non-union of the long bones. It consists in decortication, plus external fixation plus grafting with cancellous bone of the iliac crest. In the tibial cases the resection of the fibula is compulsory. 31 cases have been operated and all consolidated between 2 1/2 and 10 months. The etiology has been: open fracture 4 cases, osteomyelitis 1 case and iatrogenia.