[Psoriatic arthritis: epidemiological and clinical aspects in a cohort of 1.306 Italian patients]. / Artrite psoriasica: aspetti epidemiologici e clinici in 1.306 pazienti afferenti a 37 strutture reumatologiche italiane.

Because there is the impression that psoriatic arthritis is a composite disorder with mild forms close to more severe and aggressive ones, we conducted a multicenter study with the aim of characterizing disease expression in a large cohort of Italian patients. One-thousand-three-hundred-six patients fulfilled inclusion criteria and were analyzed in this study. Psoriasis antedated the onset of arthritis in the majority of the cases (67.7%). More rare was inverse or simultaneous onset which occurred in 17.3% and 15.0% of the cases, respectively. Peripheral articular involvement (mono-oligo or polyarthritis) was recorded in 88.7% of the cases while spondylitis occurred in 11.3%. Peripheral enthesopathies were found in 28.1% of the cases with a marked occurrence in patients with axial involvement (64.5% vs 35.5% in oligo or polyarthritis). Abnormal levels of ESR and CRP respectively occurred in 52.2% and in 52.6% of the cases, while rheumatoid factor was detected in 5.0% of the cases. On the basis of distribution of joint involvement, symmetry and presence of peripheral enthesopathies we recognized three clusters of arthritis. Patients included in Cluster 1 and Cluster 2 showed a severe form of polyarthritis in most of the cases (82.9%), with increased serum levels of inflammatory indices in more than 85% of the cases. Almost all the hospitalized patients (97.1%) were included in this two clusters. They markedly assumed steroids and methotrexate or another DMARD. About half of the patients (51.1%) included in Cluster 3 showed mono-oligo articular involvement. Serum inflammatory indices were increased in 20.8% of the cases while hospitalization occurred only in 2.9% of the cases and NSAIDs were the treatment of choice. The evidence in our country of a large prevalence of severe forms of arthritis needing specific and aggressive approach outlines the requirement of an intense educational action aimed at increasing the awareness of this condition.

Sonographic imaging of the distal phalanx.

OBJECTIVE: To investigate the potential role of ultrasonography (US) with very high frequency transducers in assessing distal phalanx involvement in some rheumatic diseases. METHODS: We performed sonographic evaluation with an Esaote AU-4 Idea (Esaote Biomedica, Genoa, Italy) equipped with a 13-MHz linear transducer. The images were obtained in asymptomatic healthy subjects and representative patients with psoriatic arthritis, osteoarthritis of the distal interphalangeal joint (Heberden's nodes), erosive osteoarthritis, gout, rheumatoid arthritis, systemic sclerosis, and posttraumatic synovial cyst. RESULTS: US with very high frequency transducers allowed a careful identification of the following anatomic details: joint space, extensor and flexor tendons, bone margin, periarticular and peritendinous soft tissues, nail, and blood vessels. Several pathological changes were depicted in different rheumatic disorders. These included joint space widening, tendon sheath widening, dislocation of the joint surfaces, irregularity of the bone margin, and urate and calcium deposits within periarticular soft tissues. CONCLUSIONS: Very high frequency US is able to depict the anatomic substrate of distal phalanx involvement in several rheumatic diseases, adding useful information to clinical examination of the hand.

Sonographic imaging of normal and osteoarthritic cartilage.

OBJECTIVES: This study was undertaken to describe representative sonographic features of normal and osteoarthritic cartilage. METHODS: Sonographic evaluation was performed with real-time ultrasound equipment, using 7.5-, 10-, 13-, 15-, and 20-MHz transducers. Normal and osteoarthritic cartilage has been studied in healthy subjects and in patients with osteoarthritis. RESULTS: Ultrasonography allows a safe, quick, and careful evaluation of both normal and osteoarthritic cartilage. A spectrum of images ranging from loss of cartilage transparency to marked narrowing of the cartilage layer can be depicted clearly in patients with osteoarthritis. Loss of clarity of the cartilaginous band and loss of the normal sharpness of the synovial space-cartilage interface are the earlier features of cartilage damage. CONCLUSIONS: Although the value of ultrasonography in the evaluation of articular cartilage remains to be determined, this imaging method can be regarded as a useful bedside procedure for initial diagnostic screening of osteoarthritic femoral condylar cartilage.

Sonographically guided procedures in rheumatology.

OBJECTIVE: To provide some representative examples of sonographically guided arthrocentesis and intralesional injection therapy. METHODS: Sonographic evaluation was performed with high-frequency linear (13 MHz) and mechanical sector (20 MHz) transducers. The images were obtained in representative patients with rheumatoid arthritis and posttraumatic subacromial bursitis. RESULTS: Sonographically guided intralesional injection is a rapid and reliable procedure, especially in patients with arthritis, tenosynovitis, and bursitis. After target localization, needle placement can be performed under continuous sonographic monitoring. Sonographic guidance is particularly useful when fluid collections are small (less than 5 mm) and deep or when the inflammatory process is adjacent to anatomic structures that could be seriously damaged by the injection. CONCLUSIONS: Over the last few years, the rapid technologic advancements in ultrasonography have dramatically increased the potential applications of sonographically guided procedures. The simplicity and reliability of the technique might warrant rheumatologists to undergo sonographic training.

Microvascular involvement in systemic sclerosis: capillaroscopic findings.

OBJECTIVE: To show the most representative capillaroscopic findings in patients with systemic sclerosis (SSc). METHOD: Capillaroscopic evaluation was performed with a videomicroscope at 100 times and 200 times magnification. Representative images of the nailbed microcirculation were obtained in 20 healthy subjects and in 75 patients with SSc. RESULTS: Capillary abnormalities were seen at the nailfold in more than 90% of patients with SSc. Capillary involvement included several morphologic changes, which are easily distinguished from the pattern of healthy controls. Architectural disruption of the nailfold microvascular network, enlarged loops, neoformation of capillaries, loss of capillaries, and avascular areas are the main abnormalities detected in SSc patients. CONCLUSIONS: Nailfold capillary microscopy is one of the most valuable tools for the early diagnosis of SSc and related disorders. Rheumatologists and internists should be able to recognize these abnormalities because of their diagnostic relevance.

Treatment of rheumatoid arthritis: our experience.

Although an incredible amount of time, work and money has been spent in the evaluation of the relative efficacy of anti-rheumatic drugs, no specific resolutive therapy is currently available for rheumatoid arthritis. In these authors' experience early rheumatoid arthritis should be treated with the most powerful non-steroidal anti-inflammatory drug (indomethacin) and the most tolerated disease modifying anti-rheumatic drug (hydroxychloroquine) available. With respect to hydroxychloroquine, auranofin has a comparable efficacy, but the incidence of side effects is significantly higher than with hydroxychloroquine. Sulphasalazine provides very good results. The enthusiasm for this drug is moderated only by the high frequency of patient drop outs. Corticosteroids should be only used in patients with active disease who do not respond to conventional therapy, and/or those with life-threatening complications (i.e., vasculitis).

The "endothelium/platelet unit" in hypertrophic osteoarthropathy.

Various pathogenetic theories of hypertrophic osteoarthropathy (HOA) have been proposed (neurogenic, hormonal, artero-venous shunts, genetic theory), but none of them is able to satisfactorily explain the genesis of HOA. The hypothesis of a central role of the "endothelium/platelet unit" was recently discussed. Above all, the release of the platelet derived growth-factor (PDGF) contained in platelet granules is particularly interesting. In order to assess the microvascular involvement in HOA we set up a research project whose aims were to evaluate the morphology of the capillary network at the nailfold, the dynamic aspects of microcirculation and in vivo platelet function. Since this study is still in progress, for the time being we present only a few preliminary results.

Intralesional therapy in carpal tunnel syndrome: a sonographic-guided approach.

OBJECTIVE: The aim of this pictorial essay is to show a representative example of sonographic-guided injection in carpal tunnel syndrome associated with tenosynovitis of the finger flexor tendons. METHODS: Images were obtained using a real-time ultrasound system (AU4-idea; Esaote Biomedica, Genoa, Italy) equipped with a 13-MHz linear transducer. The best injection site was detected using a fine metal clip placed between the skin and the transducer. The images here were obtained in a patient with rheumatoid arthritis and carpal tunnel syndrome secondary to tenosynovitis of the finger flexor tendons. RESULTS: Steroid injection within the carpal tunnel under sonographic control was easily performed. All steps of the needle placement within the widened tendon sheath were carefully evaluated on the monitor screen. Marked clinical improvement occurred shortly thereafter (3 days) and increased over the next 6 weeks. CONCLUSION: A detailed assessment of the carpal tunnel and a correct, safe placement of the needle for steroid injection can be quickly performed under sonographic guidance.

A prospective study of the long-term efficacy and toxicity of low-dose methotrexate in rheumatoid arthritis.

OBJECTIVE: To determine the long-term efficacy and safety of weekly low-dose methotrexate (MTX) in rheumatoid arthritis (RA). METHODS: Fifty-one patients receiving MTX for RA were prospectively studied over a mean treatment period of 36 months. Standard clinical and laboratory measures of disease activity were assessed by the same investigator at baseline, and at 3, 6, 12, 24 and 36 months. RESULTS: The overall probability of continuing to take MTX was 80.3% at 12 months, 74.5% at 24 months, and 70.5% at 36 months. Of the 36 patients who completed 36 months of therapy, a significant improvement was noted compared to baseline in all of the clinical disease variables and acute phase reactants, with a steroid-sparing effect. There were no significant differences in these parameters between the 36-month visit and the 24- or 12-month visit. Adverse events occurred frequently (80.3%), but only 15.6% of the patients discontinued MTX permanently. Four patients (7.9%) withdrew due to a lack of efficacy. CONCLUSION: Our findings indicate that MTX remains effective over 36 months of therapy, with an acceptable toxicity profile.

Interactive image analysis in the rectal mucosa of rheumatoid arthritis.

Interactive measurements of 22 quantitative parameters concerning the status and inflammation of the mucosa were taken in the rectal biopsies of patients suffering from Rheumatoid Arthritis, or with mild nonspecific morphological abnormalities (M.N.M.A.) and inflammation of the lamina propria or with Infective Colitis. The results showed that mean and standard deviation values of the rheumatoid patients are generally intermediate between those of control cases and those of M.N.M.A. and Infective Colitis. The variance analysis revealed that significant differences in some of the features exist between the four groups. Stepwise discriminant analysis helped in identifying three parameters that contributed significantly to discriminating 96.30% of the cases: Mucin area/Mucosal area; Number of inflammatory cells in the lower half/Number of inflammatory cells in the upper half of the mucosal thickness; Number of Granulocytes/mm2 of the lamina propria. Of the 27 cases included in the study, only one belonging to the control group was allocated incorrectly by the computer to the Rheumatoid Arthritis category. High correlation coefficients were observed between some of the morphometric, serological and clinical data in the rheumatoid patients. The highest values were between Number of Mononuclear cells/mm2 of lamina propria and C-Reactive Protein (+0.920) as well as between Mucin area/Mucosal area and serum IgM level (-0.950).

Interferon alpha-2 (IFN alpha 2) increases lacrimal and salivary function in Sjögren's syndrome patients. Preliminary results of an open pilot trial versus OH-chloroquine.

OBJECTIVE: The effect of recombinant interferon alpha-2 (IFN alpha 2) therapy in Sjögren's syndrome (SS) was studied. METHODS: An open study was performed in which 20 SS patients were given IFN alpha 2 3.10(6) MU/3 times/week or OH-chloroquine (OH-C) 6 mg/kg/daily, for a mean period of 11 months. RESULTS: Gland assessment showed that lacrimal and salivary function improved by 67% and 61% versus 15% and 18% respectively (p < 0.01) in the patients treated with IFN alpha 2 compared to those treated with OH-C. Immunological parameters did not change over time in either group. In 3 patients a decrease in the tissue score was observed in the IFN alpha 2 group, while no changes were seen in the control group. Tolerability was acceptable. CONCLUSION: This study shows that IFN can improve tear function and dry mouth in SS, without causing significant side effects.

The clinical features of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by progressive damage of synovial-lined joints and variable extra-articular manifestations. Tendon and bursal involvement are frequent and often clinically dominant in early disease. RA can affect any joint, but it is usually found in metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints, as well as in the wrists and knee. Articular and periarticular manifestations include joint swelling and tenderness to palpation, with morning stiffness and severe motion impairment in the involved joints. The clinical presentation of RA varies, but an insidious onset of pain with symmetric swelling of small joints is the most frequent finding. RA onset is acute or subacute in about 25% of patients, but its patterns of presentation also include palindromic onset, monoarticular presentation (both slow and acute forms), extra-articular synovitis (tenosynovitis, bursitis), polymyalgic-like onset, and general symptoms (malaise, fatigue, weight loss, fever). The palindromic onset is characterized by recurrent episodes of oligoarthritis with no residual radiologic damage, while the polymyalgic-like onset may be clinically indistinguishable from polymyalgia rheumatica in elderly subjects. RA is characteristically a symmetric erosive disease. Although any joint, including the cricoarytenoid joint, can be affected, the distal interphalangeal, the sacroiliac, and the lumbar spine joints are rarely involved. The clinical features of synovitis are particularly apparent in the morning. Morning stiffness in and around the joints, lasting at least 1 h before maximal improvement is a typical sign of RA. It is a subjective sign and the patient needs to be carefully informed as to the difference between pain and stiffness. Morning stiffness duration is related to disease activity. Hand involvement is the typical early manifestation of rheumatoid arthritis. Synovitis involving the metacarpophalangeal, proximal interphalangeal and wrist joints causes a characteristic tender swelling on palpation with early severe motion impairment and no radiologic evidence of bone damage. Fatigue, feveret, weight loss, and malaise are frequent clinical signs which can be associated with variable manifestations of extra-articular involvement such as rheumatoid nodules, vasculitis, hematologic abnormalities, Felty's syndrome, and visceral involvement. Although there is no laboratory test to exclude or prove the diagnosis of rheumatoid arthritis, several laboratory abnormalities can be detected. Abnormal values of the tests for evaluation of systemic inflammation are the most typical humoral features of RA. These include: erythrocyte sedimentation rate, acute phase proteins and plasma viscosity. Erythrocyte sedimentation rate and C-reactive protein provide the best information about the acute phase response. The C-reactive protein is strictly correlated with clinical assessment and radiographic changes. Plain film radiography is the standard investigation to assess the extent of anatomic changes in rheumatoid arthritis patients. The radiographic features of the hand joints in early disease are characterized by soft tissue swelling and mild juxtaarticular osteoporosis. In the the past 10 years, ultrasonography has gained acceptance for studying joint, tendon and bursal involvement in RA. It may improve the early clinical assessment and the follow-up of these patients, showing such details as synovial thickening even within finger joints. Other imaging techniques, such as magnetic resonance, computed tomography and scintigraphy may provide useful information about both the features and the extent for anatomic damage in selected rheumatoid arthritis patients. The natural history of the disease is poorly defined; its clinical course is fluctuating and the prognosis unpredictable. RA is an epidemiologically relevant cause of disability. An adequate early treatment of RA may alter the diseas

Serum soluble interleukin-2 receptor levels in rheumatoid arthritis: effect of methotrexate, sulphasalazine and hydroxychloroquine therapy.

The aim of this study was to assess the correlations of the serum soluble interleukin 2 receptor (sIL-2R) concentrations with disease activity parameters and response to treatment with second line drugs in patients with rheumatoid arthritis (RA). Sixty-seven patients with active disease completed a 24-week, open, randomized study of methotrexate (MTX) versus sulphasalazine (SSZ) or hydroxychloroquine (HCQ). Serum sIL-2R levels were evaluated before entry and after 24 weeks by ELISA. Serum sIL-2R were significantly higher in RA patients than in controls (P = 0.0001) and correlated significantly only with erythrocyte sedimentation rate (P = 0.03) and with Chronic Arthritis Systemic Index (P = 0.01) at study entry. No correlation was found between serum sIL-2R and other laboratory and clinical indices of disease activity. After 24 weeks of treatment no differences in serum sIL-2R in comparison with basal levels were found in either responding or in non-responding patients, although the mean reduction of sIL-2R was more marked in the MTX-treated cohort than in the HCQ and SSZ-treated groups. These data suggest that in RA the measurement of sIL-2R should be used with caution as an isolated index of disease activity and that it is not a useful marker of response to treatment with second line drugs.

Corticosteroid prescribing in rheumatoid arthritis and psoriatic arthritis.

Corticosteroid usage was assessed in rheumatoid arthritis (RA) and psoriatic arthritis (PA) patients in Italy. A multicentre, observational study was undertaken in 10 Italian rheumatological centres from 1990 to 1992 using a computerised clinical data bank. Nine hundred and seven RA patients and 180 PA patients were studied; 510 (56.2%) RA patients and 44 (24.4%) PA patients were using corticosteroids. The percentage of patients taking corticosteroids ranged from 20.5 to 85.4% for RA patients and from 0 to 55% for PA patients for the different centres. Methylprednisolone was the most prescribed corticosteroid, both in RA patients (63.2%) and in PA patients (65.9%). The average methylprednisolone daily dose was 5.7+/-3.6 mg in RA patients and 4.5+/-1.4 mg in PA patients. The data provide evidence that corticosteroids are taken in an unexpectedly high percentage of patients with RA and PA in Italy.

HLA-B27 negative ankylosing spondylitis and hidradenitis suppurativa: report of a case.

The association between hidradenitis suppurativa and joint involvement is well recognized. We describe a 63-year-old man with a severe HLA-B27 negative ankylosing spondylitis associated with hidradenitis suppurativa. We are not aware of any reports of such an association in the literature.

Methotrexate-induced pneumonitis in patients with rheumatoid arthritis and psoriatic arthritis: report of five cases and review of the literature.

Pneumonitis is emerging as one of the most unpredictable and potentially serious, adverse effects of treatment with MTX. Its prevalence in rheumatoid arthritis (RA) has been estimated from several retrospective and prospective studies to range from 0.3% to 18%. On the other hand, MTX-induced pneumonitis seems to be very rare in psoriatic arthritis (PsA). Our review of 194 RA patients and 38 PsA patients receiving MTX has identified four RA patients and one PsA patient with MTX-induced pneumonitis, giving a prevalence of 2.1% and 0.03%, respectively. Diagnosis was suggested by clinical history and radiographic findings, but the bronchoalveolar lavage plays an important role both in excluding infectious agents and in providing information for understanding the pathogenesis of lung injury. The presence of a lymphocyte alveolitis with a predominance of CD4+ T cells in 3 RA patients and CD8+ T cells with a concomitant increase in neutrophils in another case suggests that immunologically mediated reactions may be one damage mechanism in MTX-induced pneumonitis. Although risk factors for MTX-induced pulmonary toxicity are poorly understood, the presence in 3 out of 5 of our patients of pre-existing lung disease, represented by diffuse interstitial changes on chest X-ray, and mild bronchial asthma in two RA patients and by pulmonary silicosis in the patient with PsA may account for a predisposition to the development of MTX pneumonitis.

Hypertrophic osteoarthropathy: endothelium and platelet function.

Hypertrophic osteoarthropathy (HOA) is characterized by finger clubbing, periostosis and arthritis. The pathogenesis of hypertrophic osteoarthropathy is still uncertain. Earlier studies have been focused on the potential role of platelet and endothelium in the pathogenesis of HOA. The aim of this study was to evaluate the circulating levels of endothelin-1 (ET-1), beta-thromboglobulin (beta-TG) and platelet-derived growth factor (PDGF) in 21 HOA patients. The circulating levels of ET-1, beta-TG were significantly higher in HOA patients vs healthy controls, but not vs controls with lung diseases. On the contrary, PDGF was significantly higher in HOA patients vs healthy controls and vs subjects with lung diseases. These findings suggest that "endothelium/platelet unit" may play a role in the pathogenesis of HOA, and PDGF could induce the changes observed in HOA.

Monitoring of nonsteroidal antiinflammatory drugs.

Until now, little or no attention has been paid to the monitoring of therapy with nonsteroidal antiinflammatory drugs (NSAIDs). The authors discuss reasons for that situation. They emphasize that lack of monitoring of unwanted side-effects of the widely used NSAIDs is no doubt due to the overuse of these drugs. The expedience and a protocol concerning the efficacy and toxicity monitoring of such drugs are critically discussed. The authors stress that toxicity monitoring should be performed in selected patient groups that to only in those patients at risk.

Intra-articular injection of somatostatin in knee osteoarthritis: clinical results and IGF-1 serum levels.

Recently somatostatin (SST) intra-articular administration has been used in the treatment of some rheumatoid diseases such as rheumatoid arthritis, psoriatic arthritis and osteoarthritis with encouraging results. The aim of this study was to evaluate the efficacy and tolerability of SST intra-articularly injected, involving 20 patients with knee osteoarthritis. Treatment consisted of 4 injections, administered weekly, each of 750 mcg SST. Additionally, in six of them we evaluated the circulating levels of the insulin-like growth factor (IGF)-1 at the base-line time and then every 7 days (immediately before each dose of SST). The results revealed an improvement in pain and in joint function after intra-articular SST, confirmed by statistical analysis. The circulating levels of IGF-1 did not show significant variations following intra-articular administration of SST. The excellent tolerability and the absence of unwanted side-effects with SST allow us to foresee that intra-articular SST could be used in cases of painful knee osteoarthritis, especially in those patients in which other drugs are not appropriate. Moreover, in the absence of modifications of serum levels of IGF-1, SST could be used in athletes.

[Juvenile chronic arthritis and imaging: comparison of different techniques] / Artrite cronica giovanile e imaging: tecniche a confronto.

OBJECTIVE: The aim of this study was to compare imaging findings obtained with different techniques in a patient with juvenile chronic arthritis. METHODS: The patient was a 12 years-old child with a 7-months history of arthritis of the first metatarsophalangeal joint of the right foot. The involved area was explored with the following imaging techniques: X-ray, technetium bone scintigraphy, magnetic resonance, gray-scale and power-Doppler ultrasonography. RESULTS: No abnormalities were detected with conventional X-ray. Scintigraphy showed an abnormal uptake of the radionuclide in the first metatarsophalangeal joint of the right foot. Magnetic resonance without contrast revealed clearly evident features of an active process of synovitis. Ultrasonography was able to detect the presence of joint effusion, synovial proliferation, bone erosion of the first metatarsal head. Power-Doppler examination revealed evident signs of soft tissue hyperaemia. CONCLUSIONS: Comparative assessment of different imaging techniques in this patient with recent-onset juvenile chronic arthritis indicates that high resolution ultrasonography provides the most detailed evaluation of the joint involvement with respect to the other imaging techniques.