Effects of Yoga in Daily Life program in rheumatoid arthritis: A randomized controlled trial.

OBJECTIVES: To explore the feasibility and effectiveness of a yoga program in improving health-related quality of life (HQOL), physical and psychological functioning in rheumatoid arthritis (RA) patients. DESIGN: Single-centre parallel-arms randomized controlled trial comparing yoga (n = 30) and education control group (n = 27). SETTING: Tertiary care University hospital. INTERVENTION: A 12-week yoga program, based on the Yoga in Daily Life system, included 2x weekly/90-minute sessions. The control group had 1xweekly/60-minute educational lectures on arthritis-related topics. MAIN OUTCOME MEASURES: Assessments were performed at baseline, 12 (post-intervention) and 24 weeks (follow-up). The primary outcome was change in The Short Form-36 (SF-36) HQOL at 12 weeks. Linear regression analysis was adjusted for baseline scores. RESULTS: No significant between-group differences were found for SF-36 (all p > 0.05). At 12 weeks the adjusted mean difference between groups favoured yoga for Functional Assessment of Chronic Illness Therapy-fatigue (5.08 CI 1.29 to 8.86; p = 0.009) and Hospital Anxiety and Depression Scale (HADS)-depression (-1.37 CI -2.38 to -0.36); p = 0.008) and at 24 weeks for HADS-anxiety (-1.79 CI -3.34 to - 0.23; p = 0.025), while the impact on fatigue was sustained (5.43 CI 1.33 to 9.54, p = 0.01). The program had no impact on RA disease activity. Feasibility outcomes included recruitment rate 16 %, retention 80.7 %, and adherence to yoga 87.5 vs 82.7 % for control. No serious adverse events were recorded. CONCLUSIONS: Yoga in Daily Life program was not associated with change in health-related quality of life of RA patients. Significant improvements in fatigue and mood were observed at postintervention and follow-up. This yoga program was found feasible and safe for patients and may complement standard RA treat-to-target strategy.

A comparison of blood and cerebrospinal fluid cytokines (IL-1ß, IL-6, IL-18, TNF-α) in neonates with perinatal hypoxia.

Perinatal hypoxia-ischemia is a specific and important pathological event in neonatal care practice. The data on relationship between the concentrations of cytokines in blood and cerebrospinal fluid (CSF) and perinatal brain injury are scarce. The aim of this study is to evaluate changes in interleukin (IL-1ß, IL-6, and IL-18) and tumor necrosis factor alpha (TNF-α) levels in newborns with perinatal hypoxia (PNH). CSF and serum samples of 35 term and near-term (35-40 weeks) newborns with PNH, at the age of 3-96 hours, were analyzed using enzyme-linked immunosorbent assay. Control group consisted of 25 non-asphyxic/non-hypoxic infants of the same age sampled for clinically suspected perinatal meningitis, but proven negative and healthy otherwise. The cytokine values in CSF and serum samples were determined in relation to initial hypoxic-ischemic encephalopathy (HIE) staged according the Sarnat/Sarnat method, and compared with neurological outcome at 12 months of age estimated using Amiel-Tison procedure. The concentrations of IL-6 and TNF-α in serum of PNH patients were significantly higher compared to control group (p = 0.0407 and p = 0.023, respectively). No significant difference between average values of cytokines in relation to the stage of HIE was observed. Significantly higher levels of IL-6 and IL-18 corresponded to a mildly abnormal neurological outcome, while higher levels of IL-6 and TNF-α corresponded to a severely abnormal neurological outcome, at 12 months of age. Elevated serum levels of IL-6 and TNF-α better corresponded with hypoxia/ischemia compared to CSF values, within 96 hours of birth. Also, higher serum levels of IL-6, TNF-α, and IL-18 corresponded better with abnormal neurological outcome at 12 months of age, compared to CSF values.

[GRANULOMATOSIS WITH POLYANGIITIS (GPA) LIMITED TO UPPER RESPIRATORY TRACT--A CASE REPORT]. / GRANULOMATOZA S POLIANGIITISOM (GPA) I LOKALIZIRANIM ZAHVACANJEM GORNJEGA DISNOG SUSTAVA PRIKAZ BOLESNICE.

Granulomatosis with polyangiitis (Wegener's granulomatosis) is one of the anti-neutrophil cytoplasmic anti-body-associated small vessel vasculitides. Upper and lower respiratory system and kidneys are most commonly affected. The disease is characterized by granulomatous inflammation of the respiratory tract and necrotizing vasculitis of small to medium-sized blood vessels. Most patients show involvement of more than one organ systems at the time of diagnosis, and constitutional symptoms may be present. In around a quarter of patients the disease is initially localised, with involvement of upper respiratory tract or lungs. We report a 21-year-old female patient with chronic rhinitis, saddle nose deformity and subglottic stenosis who presented with inspiratory stridor and impending respiratory failure. Initially, urgent tracheotomy was performed. The patient was diagnosed with granulomatosis with polyangiitis limited to upper respiratory tract. Treatment with glucocorticoids and methotrexate was followed by clinical improvement.

[ETIOLOGY AND PATHOGENESIS OF PAIN IN RHEUMATIC DISEASES].

Rheumatic diseases are chronic inflammatory disorders with ongoing inflammation that causes tissue damage. Inflammatory and damaged cells synthetize and release many diff erent intracellular substances which can activate highly specialized subsets of primary sensory neurons called nociceptors. Some of these proinflammatory mediators directly activate the nociceptor terminal and produce pain (such as hydrogen ion, adenosine triphosphate, and bradykinin), and others sensitize the terminal so that it becomes hypersensitive to subsequent and non-noxious stimuli (such as prostaglandin E2 and bradykinin). Acute pain has a protective role since it induces behavior that promotes healing and recovery, such as immobilization which limits tissue damage. Chronic pain is unhelpful pain that tends to be out of proportion to the actual tissue damage and persists long after the tissues have healed, so that the pain becomes the problem rather than the tissues of origin. Chronic pain affects the physical and mental status and causes impairment of quality of life as well as work disability. For rheumatologists the assessment and treatment of pain is a very important integral part of patient care, and understanding the etiology and pathogenesis of pain is necessary to fi nd adequate modalities of treatment to prevent suffering.

Scabies in a Patient with Rheumatoid Arthritis Treated with Adalimumab - A Case Report.

Rheumatoid arthritis is a chronic systemic inflammatory disease characterized by synovitis, erosions, and destruction of affected joints. If untreated, it leads to severe disability and premature mortality. Tumor necrosis factor alpha (TNF-α) inhibitors are biological drugs used in treatment of rheumatoid arthritis. Possible side effects include skin allergic reactions, which, if generalized, are the reason for discontinuation of the drug. We report the case of a 46-year-old female patient with rheumatoid arthritis who presented with pruritus and erythematous papular exanthema after administration of the second dose of adalimumab. At first, we suspected a drug hypersensitivity reaction. As the signs and symptoms persisted for 2 months after discontinuation of adalimumab and despite continuous administration of antihistamines and glucocorticoids, further work-up was performed, and scabies was diagnosed. The patient was treated with topical 10% crotamiton. The symptoms were persistent and additional applications of the preparation were needed. After clinical remission of scabies, treatment of active rheumatoid arthritis with adalimumab was restarted without any complications.

[Clinical manifestations of antineutrophil cytoplasmic antibodies associated vasculitis]. / Klinicka obiljezja vaskulitisa povezanih s antineutrofilnim citoplazmatskim protutijelima.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides are rare diseases, with the average of 30 new cases per million inhabitants per year. Their main characteristic is systemic involvement with necrosis of the vessel walls (histological changes showing necrosis of the media and inflammation of adventitia and intima). In some forms granulomas may be found surrounding the vessels. ANCA-associated vasculitides include granulomatosis with polyangiitis (GPA, previously called Wegener's), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA, previously called Churg-Straus). Honorific eponyms are now changing to a disease-descriptive or etiology-based nomenclature. ANCA-associated vasculitides are a distinctive group of vasculitides because they dominantly involve small sized vessels, sometimes even medium sized vessels, are associated with antineutrophil cytoplasmic antibodies with high risk of developing glomerulonephritis and respond well to immunosuppresion with cyclophosphamide.

[From unexplained fever to visceral leishmaniasis--a case report]. / Od nejasne vrucice do visceralne lismenijaze--prikaz bolesnika.

Visceral leishmaniasis or kala-azar is a systemic infectious vector-borne disease caused by protozoa Leishmania donovani and Leishmania infantum that are transmitted to mammalian hosts by sand flies. It occurrs sporadically in endemic areas, including Mediterranean basin. Southern coastal territories of Croatia have been recognized as the foci of the disease. Dogs are the main reservoir of human infection. Clinical features include prolonged fever, malaise, hepatosplenomegaly, pancytopenia and inversion of albumin-globulin ratio. If left untreated, the disease causes death in majority of cases. We report a 47-year-old Croatian patient who was admitted to hospital with 2-month history of fever of unknown origin. Based on bone marrow aspirate findings and positive serological tests, the diagnosis of visceral leishmaniasis was established. We also considered secondary hemophagocytic lymphohystiocytosis in the differential diagnosis. After a 4-week treatment with sodium-stibogluconate clinical remission was achieved as well as complete recovery of hematopoesis. The aim of our case-report is to stress the importance of considering visceral leishmaniasis in patients with longstanding fever in endemic areas.

[Gluten-sensitive enteropathy: a disease to take into consideration - a case report]. / Mislimo li dovoljno na glutensku enteropatiju? - prikaz bolesnice.

Gluten-sensitive enteropathy or celiac disease is a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals. Although the disease may manifest itself at any age, it occurs mostly in either early childhood or in the third or fourth decade of life. Malabsorption syndrome as a typical clinical feature is commonly absent. Patients may exhibit minor gastrointestinal complaints, as well as numerous extraintestinal manifestations. We report a 43-year-old female patient with mi gratory arthralgias as the leading symptom, fatigue, sideropenic anemia and mild intermittent diarrhoea, who was diagnosed with gluten-sensitive enteropathy. Four months after introduction of gluten-free diet the patient reported no arthralgias, and complete clinical response was achieved. The aim of our case-report was to show that migratory arthralgias can be an extraintestinal manifestation of gluten-sensitive enteropathy. Unexplained articular complaints should raise clinical suspicion of celiac disease.

[Extra-articular manifestations of seronegative spondyloarthritides]. / Izvanzglobna obiljezja seronegativnih spondiloartritisa.

The term seronegative spondyloarthritides (SpA) is used to refer to a family of inflammatory rheumatic diseases characterised by inflammation of axial joints, asymmetric oligoarthritis and enthesitis, sometimes involving nonarticular structures, such as skin, heart, aortic valve, eye and kidney. The SpA consist of the following entities: ankylosing spondylitis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with IBD and undifferentiated spondyloarthritis. The prevalence of SpA in the population is 0,5-2%.

[Scleroderma renal crisis]. / Sklerodermijska bubrezna kriza.

Systemic sclerosis (SSc) is a multisystem disease whose clinical manifestations result from inflammation, vascular injury and obliteration, and cutaneous and visceral fibrosis. Scleroderma renal crisis (SRC) occurs in 5% of patients with particullary diffuse form of SSc. It is characterized by malignant hypertension and oligo/ anuric acute renal failure. SRC was once a uniformly fatal complication of SSc. The prognosis of SRC has significantly improved with the introduction of angiotensin-converting enzyme inhibitors (ACEi) as treatment. The treatment of SRC relies on tight control of blood pressure and aggressive treatment with ACEi, if needed in combination with other types of antihypertensive drugs.

[Anti-ischemic therapy in patients with STEMI or NSTEMI treated at county and university hospitals]. / Antiishemijska terapija bolesnika sa STEMI ili NSTEMI u zupanijskoj i klinickoj bolnici.

The objective of prehospital care of patients with acute coronary syndrom (ACS) [acute ST segment elevation myocardial infarction (STEMI), acute non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA)], is prompt diagnosis of the acute myocardial infarction, patient's risk assessment, drug administration in order to reduce patient's pain and fear, and prevention or treatment of heart failure. In hospital treatment therapeutic procedures include reperfusion therapy, limitation of infarction zone, treatment of complications (heart failure, life-threatening arrhythmias), prevention of reinfarction, heart failure and eventually prevention of sudden cardiac death. Acute therapeutic procedures include revascularization, anti-ischemic and antithrombolytic treatment, possible surgical revascularization and treatment of complications (arrhythmias, heart failure). The patients with STEMI that present within 3-12 hours from the onset of chest pain should undergo primary percutaneous coronary intervention (PCI). In case of presentation within 3 hours from the occurrence of chest pain, the administration of thrombolytic therapy in this period is equally efficient as PCI. Regardless of reperfusion regimen, the anti-ischemics administered including nitrates (nitroglycerin); intravenous analgesics (morphine-sulfate); O2 2-4 L/min; beta-adrenergic blockers; calcium channel blockers; angiotensin converting enzyme inhibitors (ACE-I); magnesium and glucose-insulin-potassium have proved to be efficient as shown by study results and clinical experience. The mechanism of action of anti-ischemics includes reduction in myocardial oxygen consumption achieved by a decrease of heart frequency, reduction of systemic blood pressure and reduction in myocardial contractility by vasodilatation and consequent better myocardial oxygen supply. The outstanding results of major clinical studies are presented, and main guidelines for anti-ischemic therapy of ACS adopted by the international professional associations are set forth.

Cyclic adenosine 5'-monophosphate in synovial fluid of rheumatoid arthritis and osteoarthritis patients.

The relationship between synovial fluid (SF) cAMP level and IL-18 and PGE2 SF levels in rheumatoid arthritis (RA) and osteoarthritis (OA) patients, and between SF cAMP level and disease as well as inflammatory activity in RA were investigated in 17 RA and 19 OA patients. Erythrocyte sedimentation rate (ESR), serum (S) C-reactive protein (CRP) level and SF IL-18 level were higher in RA than in OA patients. SF PGE2 level was similar in both groups. SF cAMP level was higher in OA than in RA patients. In RA patients, SF cAMP level showed negative correlation with Disease Activity Score including a 28-joint count and S CRP, ESR and SF IL-18 level. The results suggest that cAMP promotes anti-inflammatory response in RA and OA patients, which is higher in the latter. Promotion of anti-inflammatory response by cAMP elevating agents might be useful in the treatment of RA.

Vasodilatory prostaglandins in perinatal hypoxic brain damage.

Prostaglandin (PGE2 and PGI2) synthesis was determined in the cerebrospinal fluid (CSF) and serum of 19 hypoxic neonates at the age of 5-96 hours by using Enzyme Linked Immunosorbent Assay (ELISA) method. Control group consisted of 8 children of the same age whose samples were taken due to initial suspicion of neonatal meningitis. The prostaglandin concentrations in CSF were correlated with initial hypoxic-ischemic encephalopathy (HIE) stage and neurological findings of patients at the age of 12 months. The values of PGE2 and PGI2 in the CSF of children with perinatal hypoxia (PNH) were significantly higher than in the children from the control group. The values of PGI2 in serum were significantly higher than in "CSF" of patients with PNH. Although average values of PGE2 and PGI2 in the liquor were higher in children with advanced stage of HIE, the differences between different stages were not statistically significant. We did not find any significant correlation between average concentrations ofprostaglandins and neurological findings of the 12-month-old children.