Prevalence and incidence of osteoporotic fractures in patients on long-term glucocorticoid treatment for rheumatic diseases: the Glucocorticoid Induced OsTeoporosis TOol (GIOTTO) study.

Osteoporosis and fractures are common and invalidating consequences of chronic glucorticoid (GC) treatment. Reliable information regarding the epidemiology of GC induced osteoporosis (GIOP) comes exclusively from the placebo group of randomized clinical trials while observational studies are generally lacking data on the real prevalence of vertebral fractures, GC dosage and primary diagnosis. The objective of this study was to evaluate the prevalence and incidence of osteoporotic fractures and to identify their major determinants (primary disease, GC dosage, bone mineral density, risk factors, specific treatment for GIOP) in a large cohort of consecutive patients aged >21 years, on chronic treatment with GC (≥5 mg prednisone - PN - equivalent) and attending rheumatology centers located all over Italy. Glucocorticoid Induced OsTeoporosis TOol (GIOTTO) is a national multicenter cross-sectional and longitudinal observational study. 553 patients suffering from Rheumatoid Arthritis (RA), Polymyalgia Rheumatica (PMR) and Connective Tissue Diseases (CTDs) and in chronic treatment with GCs were enrolled. Osteoporotic BMD values (T score <-2.5) were observed in 28%, 38% and 35% of patients with CTDs, PMR or RA at the lumbar spine, and in 18%, 29% and 26% at the femoral neck, respectively. Before GC treatment, prevalent clinical fractures were reported by 12%, 37% and 17% of patients with CTDs, PMR, or RA, respectively. New clinical fragility fractures during GC treatment were reported by 12%, 10% and 23% of CTDs, PMR and RA patients, respectively. Vertebral fractures were the prevailing type of fragility fracture. More than 30% of patients had recurrence of fracture. An average of 80% of patients were in supplementation with calcium and/or vitamin D during treatment with GCs. Respectively, 64%, 80%, and 72% of the CTDs, PMR and RA patients were on pharmacological treatment for GIOP, almost exclusively with bisphosphonates. The GIOTTO study might provide relevant contributions to clinical practice, in particular by highlighting and quantifying in real life the prevalence of GIOP and relative fractures, the frequency of the main risk factors, and the currently sub-optimal prevention. Moreover, these results emphasize the importance of the underlying rheumatic disease on the risk of GIOP associated fractures.

Impact of hand and face disabilities on global disability and quality of life in systemic sclerosis patients.

OBJECTIVES: In systemic sclerosis (SSc), the frequent involvement of hand and face leads to their disability. We aimed to assess influence of hand and face disability on global disability and Health related Quality of life (HRQoL). METHODS: 119 SSc patients were assessed for global disability by HAQ, HRQoL, by SF36; hand disability by HAMIS, CHFDS, fist closure and hand opening measures; face disability by MHISS and mouth opening measure. RESULTS: Diffuse SSc (dSSc) patients present higher HAQ, lower Summary Physical Index (SPI) of SF36, major hand disability at hand (higher HAMIS, CHFDS, fist closure, lower hand opening) and face (lower mouth opening, higher MHISS) than lSSc patients (p<0.05). SPI of SF36 is negatively correlated with MHISS, CHFDS, HAMIS and positively correlated to mouth and hand opening (p<0.05). Summary Mental Index (SMI) of SF36 is negatively correlated with MHISS (p<0.05). HAQ is negatively correlated with mouth opening and positively correlated to MHISS, HAMIS, CHFDS (p<0.05). By hierarchical multiple linear regression, SPI of SF36 is significantly associated with total MHISS (B=-0.34; t=-3.78; p<0.001) and CHFDS (B=-0.27; t=-3.01; p=0.003), together, explaining 22% of SPI variance. SMI of SF36 is significantly associated only with MHISS total score (B=-0.22; t=-2.41; p=0.017), explaining 4% of its variance. HAQ is significantly associated with CHFDS score (B=0.61; t=7.90; p<0.001), explaining 36% of HAQ variance. CONCLUSIONS: dSSc patients present higher global and local disability, and lower HRQoL in SPI than lSSc patients. Local disabilities, assessed by CHDFS and MHISS, are independently related to global disability and HRQoL.

Rheumatologic rehabilitation: towards recommendations.

Rheumatic patients are highly complex and often affected by chronic diseases. Rehabilitation is generally needed for proper management of the underlying disease. This article describes the characteristics of an effective rheumatologic rehabilitation, takes into account data published in international literature, suggests recommendations based on scientific evidence to develop a correct rehabilitation plan for rheumatic patients and proposes the basis to draw up guidelines in the field of rheumatologic rehabilitation.

The effect of a combined rehabilitation program on the temporomandibular joint in systemic sclerosis evaluated by ultrasound exam.

PURPOSE: Temporomandibular joint (TMJ) involvement is frequent in Systemic Sclerosis (SSc). Dysfunction and X-ray changes of TMJ were described only in few observational studies. Treatment as well has been seldom considered. Aim of the present study was to evaluate the effects on TMJ of two specifically designed physiotherapy protocols. METHODS: The study group included 26 SSc outpatients (22 females and 4 males with mean age ± SD 59.08 ± 10.31 years). Thirteen patients were randomly assigned to a treatment (protocol 1) including home exercises for TMJ and thirteen to a treatment (protocol 2) including home exercises and a combined procedure. The rehabilitation effects on the TMJ were evaluated by ultrasound examination (UE) in static and dynamic phases. UE was performed in all patients before and at the end of the treatment and after a follow up (8 weeks). RESULTS: Both rehabilitation protocols induced a significant improvement (protocol 1: p < 0.01 and protocol 2: p < 0.005) of mouth opening with a long-lasting effect. Protocol 2 was more effective than protocol 1. A significant increase of bilateral condyle-head temporal bone distance was detected by UE at the end of both treatments. It was maintained at follow-up in patients treated with Protocol 2. CONCLUSIONS: The present investigation shows that a rehabilitation program characterized by home exercises with a combined procedure is useful to recover the function of TMJ. The data also show that UE is helpful in the evaluation of TMJ in SSc and in the assessment of the efficacy of the rehabilitation programs.

The Italian version of the Mouth Handicap in Systemic Sclerosis scale (MHISS) is valid, reliable and useful in assessing oral health-related quality of life (OHRQoL) in systemic sclerosis (SSc) patients.

In systemic sclerosis (SSc), mouth and face involvement leads to problems in oral health-related quality of life (OHRQoL). Mouth Handicap in Systemic Sclerosis scale (MHISS) is a 12-item questionnaire specifically quantifying mouth disability in SSc, organized in 3 subscales. Our aim was to validate Italian version of MHISS, by assessing its test-retest reliability and internal and external consistency in Italian SSc patients. Forty SSc patients (7 dSSc, 33 lSSc; age and disease duration: 57.27 ± 11.41, 9.4 ± 4.4 years; 22 with sicca syndrome) were evaluated with MHISS. MHISS was translated following a forward-backward translation procedure, with independent translations and counter-translation. Test-retest reliability was evaluated, comparing the results of two administrations, with intraclass correlation coefficient (ICC). Internal consistency was assessed by Cronbach's α and external consistency by comparison with mouth opening. MHISS has a good test-retest reliability (ICC: 0.93) and internal consistency (Cronbach's α:0.99). A good external consistency was confirmed by correlation with mouth opening (rho: -0,3869, p: 0.0137). Total MHISS score was 17.65 ± 5.20, with scores of subscale 1 (reduced mouth opening) of 6.60 ± 2.85 and scores of subscales 2 (sicca syndrome) and 3 (aesthetic concerns) of 7.82 ± 2.59 and 3.22 ± 1.14. Total and subscale 2 scores are higher in dSSc than in lSSc. This result may be due to the higher presence of sicca syndrome in dSSc than in lSSc (p = 0.0109). Our results support validity and reliability in Italian SSc patients of MHISS, specifically measuring SSc OHRQoL.

Efficacy of the "body movement and perception" method in the treatment of fibromyalgia syndrome: an open pilot study.

OBJECTIVES: Group exercises may be useful in fibromyalgia syndrome (FMS). The 'Body movement and perception' (BMP) method is based on low impact exercises, awareness of body perception and relaxation, aimed at treating small groups of patients following the Resseguier method (RM) and integrating RM with exercises derived from soft gymnastics. We assessed the effects of BMP method on FMS. METHODS: 40 women with FMS (age and disease duration: 51.7±7.2 and 4.9±3.8 years) participated in an open pilot study. BMP sessions were performer twice a week (50 minutes each) for 8 weeks. Patients were assessed at enrolment (T0) and at the end of the study (T1) by a self-administered questionnaire (temporal characteristics of pain, pain interference in working and recreational activities and in night-time rest, awareness of pain, fatigue, irritability, well-being, quality of movement, ability to focus on perception and to perceive whole body, postural selfcontrol, ability to relax) and a clinical evaluation (tender points, assumption of analgesics/NSAIDs, distribution of pain, pain in sitting and standing position, pain during postural passages and gait, postural body alignment, muscular contractures). RESULTS: At T1, FMS patients significantly improved with respect to T0 in pain, fatigue, irritability, well-being, quality of movement, postural self-control, ability to relax mind and body, movement perception, tender point scores, assumption of analgesic/NSAIDs, body alignment and muscle contractures (p<0.05 for all the comparisons T1 versus T0). CONCLUSIONS: In FMS patients, rehabilitation with BMP improves pain and well being, reduces the number of tender points and muscle contractures, thus it is useful in FMS management.

The rehabilitation of facial involvement in systemic sclerosis: efficacy of the combination of connective tissue massage, Kabat's technique and kinesitherapy: a randomized controlled trial.

In Systemic Sclerosis (SSc), face involvement causes functional loss as well as aesthetic changes and loss of the self-image. The aim of the work is to evaluate the efficacy of a rehabilitation program based on the combination of Kabat's technique, connective massage and kinesitherapy specifically conceived for the face of SSc patients. Forty SSc patients were enrolled: 20 patients (interventional group) were treated for 9 weeks (twice a week, 1 h per session) with a combined connective tissue massage, Kabat's technique, kinesitherapy and home exercise program, and 20 patients (control group) were assigned only home exercise program. All patients were assessed at baseline (T0), at the end of the treatment (T1) and after 9 weeks of follow-up (T2). They were evaluated with SF-36, HAQ, modified Rodnan skin score, mouth opening in centimeters and Mouth Handicap in Systemic Sclerosis (MHISS) scale. At T1, both groups improved in mouth opening (P < 0.05), but the improvement was maintained at T2 only in interventional group. In interventional group, facial skin score ameliorated at T1 and maintained at T2 (P < 0.05 vs. T0), while no change was observed in controls. In both groups, SF-36 and HAQ were not affected by the treatment. MHISS scale improved significantly in interventional group at T1 (P < 0.001), while no change was found in controls. The combination of connective tissue massage, Kabat's technique, kinesitherapy and home-based exercises is more effective than a home exercise program alone in the rehabilitative treatment of SSc facial involvement.

The Italian version of the Hand Mobility in Scleroderma (HAMIS) test: evidence for its validity and reliability.

OBJECTIVES: In systemic sclerosis (SSc), hand involvement is frequent and leads to prominent disability. The Hand Mobility in Scleroderma (HAMIS) test is a hand function test for SSc patients assessing the movements included in an ordinary range of motion examination. Our aim is to validate the Italian version of HAMIS, by assessing its test-retest reliability, internal consistency and external consistency in Italian SSc patients. METHODS: The Italian version of HAMIS was administered to 40 SSc patients. HAMIS was translated according to international procedures. Test-retest reliability was assessed by intra-class correlation coefficient (ICC), internal consistency by Cronbach's alpha and external consistency by comparison with Cochin Hand Function Scale (CHFS), fist closure, hand opening, HAQ. RESULTS: HAMIS showed a good testretest reliability (ICCs=0.99 for right and left hand) and internal consistency (Cronbach's α=0.94 for right and 0.93 for left hand) for both hands. A good external consistency was confirmed by the correlation of right and left hand HAMIS with CHFS (p<0.0001, in both cases); fist closure of homolateral hand (p<0.0001 in both cases), opening of homolateral hand (p<0.05 and <0.005, respectively), HAQ (p<0.001 in both cases). HAMIS scores for right and left hands were 7.95±6 .68 and 7.5±6.60 (p=NS), respectively. HAMIS scores for both hands were higher in dSSc and in patients with hand arthritis and flexion contractures. CONCLUSIONS: HAMIS is a hand function test measuring hand disability in SSc. Our results support its validity and reliability in Italian SSc patients.

The efficacy of the Rességuier method in the treatment of fibromyalgia syndrome: a randomized controlled trial.

OBJECTIVES: In fibromyalgia syndrome (FMS) defined rehabilitation guidelines are yet to be validated. Our aim is to evaluate the efficacy of the Rességuier method (RM) in FMS. METHODS: Forty-one patients were randomly assigned to Interventional (22 pts) and Observational (19 pts) Group (IG and OG). The study lasted 8 months. Patients were assessed at baseline (T0) after a 2-month rehabilitation (T1) and at a 6-month follow-up (T2) (only IG) with SF-36 Physical (PSI) and Mental Synthetic Index (MSI), Regional Pain Scale (RPS), Fibromyalgia Impact Questionnaire (FIQ), Number Rating Scales 0-10 to measure pain, movement quality, sleep, relax ability, analgesics number/per week. OG patients maintained their lifestyle for the duration of the study. RM aims to obtain patient awareness and control of bodily perceptions, thus reaching a modulation of responses to pain. Therapist controls patient attention and perception by verbal and manual contacts and leads them to perform bodily and respiratory active and conscious movements. RESULTS: In IG, at T1 all items were improved: PSI and MSI (p<0.001 and =0.001), FIQ (p<0.0001), RPS (p<0.001), pain (p<0.0001), movement quality (p=0.001), relax ability (p<0.0001), sleep (p<0.001); analgesics number/per week was reduced (p<0.001). All results obtained at T1, except FIQ, were maintained at T2. In OG at T1 versus T0, no difference in any of the assessed parameters was observed. CONCLUSION: In FMS patients, the rehabilitation with RM improves HRQoL, FMS-related disability and perceived pain, thus reducing the assumption of analgesics.

[How to prescribe physical exercise in rheumatology]. / Come si prescrive l'esercizio fisico in reumatologia.

Physical exercise, aiming to improve range of movement, muscle strength and physical well being, lately substituted the immobilization previously prescribed in rheumatic diseases. International guidelines, recommendations of Scientific Societies, and structured reviews regard physical exercise as of pivotal importance in treating rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, fibromyalgia syndrome, osteoporosis, and to be considered in connective tissue diseases. Therapeutic exercise should: aim to improve firstly local symptoms and then general health; respect the pain threshold; be a part of a treatment including pharmacological therapies and other rehabilitation techniques, be administered by skilled physiotherapist under the guide of a rheumatologist, be different according to different diseases, disease phases and patient expectations.

Efficacy of a tailored rehabilitation program for systemic sclerosis.

INTRODUCTION: Rehabilitation may contribute to the management of Systemic Sclerosis (SSc) dealing with disabilities due to skin and joint involvement. AIM: to evaluate the efficacy of a district specific and global rehabilitation program tailored for SSc patients. MATERIALS AND METHODS: 20 SSc patients were enrolled and randomly assigned to 2 groups. Interventional group (10 pts) was treated that included hand and face specific rehabilitation and at least a global rehabilitation technique such as hydrokinesytherapy or land-based program, also comprising respiratory exercises. Hand lymphatic drainage was added when necessary. Observational group (10 patients) was only provided with educational advices and medical information about SSc. Patients were evaluated at baseline (T0) and after the 9 weeks treatment period (T1). Interventional group was also assessed after a 9 weeks follow-up (T2). Patients were evaluated by SF-36, HAQ and a purpose-built-questionnaire for global health condition and with Hamis test, Duruöz scale, range of motion, water volumetric test, mouth opening and a purpose-built-questionnaire for hand and face involvement. RESULTS: At the end of the treatment, patients of interventional group improved in all the parameters evaluated. At follow-up, mouth mobility and functionality such as global health status was partially lost, only hand mobility and functionality parameters were maintained. No changes were observed in controls. CONCLUSION: The association and of district-specific and global rehabilitative techniques conceived and tailored for SSc patients improves disability, HRQoL, hand and face disability and functionality, with its effects partially maintained at the follow-up.

[The rehabilitative approach in rheumatoid arthritis]. / L'approccio riabilitativo nell'artrite reumatoide.

The rehabilitative approach for the patient with rheumatoid arthritis should be early, global and complementary to an early pharmacological therapy, in the context of a multidisciplinary approach, that should include physicians with different specialties and other health professionals. Evaluation scales assessing disability and quality of life are necessary for the rehabilitative approach. These can be classified in 2 groups: specific tools and generic tools, each evaluating different components of the health status. After the evaluation and the definition of the aims of the rehabilitation, a rehabilitative project, potentially including physical therapies, therapeutic exercises, occupational therapy and orthosis should be defined.

The fibrinolytic system components are increased in systemic sclerosis and modulated by Alprostadil (alpha1 ciclodestryn).

OBJECTIVES: To evaluate urokinase plasminogen activator (u-PA), urokinase plasminogen activator soluble receptor (su-PAR), plasminogen activator inhibitor 1 (PAI-1) and tissue plasminogen activator (t-PA) plasma levels in SSc patients (pts) versus healthy controls and their modulation by intravenous alphacyclodestrine (Alprostadil). METHODS: Plasma levels of u-PA, su-PAR, PAI-1 and t-PA were measured in 40 SSc (34 lSSc and 6 dSSc) pts and in 30 healthy controls. In SSc, blood was drawn before and after 3 consecutive daily of Alprostadil infusion (60 mg in 250 cc NaCl 0.9%). RESULTS: In SSc su-PAR basal levels were higher than controls (7.48 +/- 2.5 vs 4.69 +/- 0.4 ng/ml; p = 0.001) and were significantly reduced by Alprostadil (5.93 +/- 1.7; p = 0.002), but remain higher than controls (p = 0.03). u-PA basal levels were higher than controls (3.78 +/- 1.5 vs 1.29 +/- 0.3 ng/ml; p < 0.001) and were reduced by Alprostadil (2.39 +/- 1.7; p < 0.001) to control levels. SSc PAI-1 basal levels were lower than controls (31.60 +/- 7.7 vs 48.30 +/- 6.8 ng/ml; p < 0.001) and increased by Alprostadil (34.66 +/- 5.4; p = 0.04), but lower than controls (p < 0.001). SSc t-PA basal levels were higher in respect to controls (1645.81 +/- 792.7 vs 571.95 +/- 75.5 pg/ml; p < 0.0001) and reduced by Alprostadil (1318.06 +/- 603.5; p = 0.04), but still higher than controls (p = 0.001). CONCLUSION: Fibrinolysis were increased in SSc. Infusions of Alprostadil modulate u-PA, su-PAR, PAI-1 and t-PA, restoring near normal levels. In SSc, fibrinolysis system may become a potential target for new therapies.

Superoxide anion production by circulating polymorphonuclear leucocytes in rheumatoid arthritis.

In twelve rheumatoid arthritis (RA) patients, receiving only nonsteroid anti-inflammatory therapy, superoxide anion (02-) generation by polymorphonuclear leucocytes (PMNs) was assessed by Cytochrome C reduction. The 02- production by non-activated PMNs in RA patients was significantly higher than in healthy controls. The 02- production by PMNs activated by zymosan and phorbol myristate acetate was significantly lower than in controls. PMNs from controls preincubated with rheumatoid sera generated higher 02- levels than the same PMNs incubated in normal sera.

The diagnosis value of beta 2-microglobulin and immunoglobulins in primary Sjögren's syndrome.

Salivary and serum concentrations of beta 2-microglobulin, salivary levels of the immunoglobulins, and salivary flow (as measured by a gravimetric method) were assessed in 34 patients and 11 controls. Of the 34 study patients, 16 had a primary form of Sjögren's syndrome (pSS) and 18 had sicca syndrome. The salivary and serum concentrations of beta 2-microglobulin and salivary levels of IgA and IgG were much higher in the patients with pSS than in controls or those with sicca syndrome (p < 0.001). Similarly, the salivary IgM levels of patients with pSS were higher (although at a lower degree of statistical significance) as compared to those of patients with sicca syndrome (p < 0.01) or controls (p < 0.05). No correlation was observed among the salivary flow and the salivary IgG and IgM levels, while there was a negative relationship (p < 0.01 with salivary IgA levels in all 45 patients considered as a whole. In 12 patients with pSS, the coefficient of correlation between the salivary gland biopsy focus score and the salivary (but not serum) concentration of beta 2-microglobulin was highly significant (p < 0.001). A similar relationship was observed with the IgG (p < 0.001) and IgM (p < 0.05) levels, but not IgA. In the diagnosis of pSS, the salivary IgA level demonstrates high sensitivity and low specificity. In contrast, serum and salivary concentrations of beta 2-microglobulin, salivary IgG, and to a lesser degree, salivary IgM have high specificity and positive predictive value.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serum ferritin in rheumatoid arthritis: an acute phase protein or indication of iron deposits?]. / La ferritina sierica nell'artrite reumatoide: proteina della fase acuta o indice dei depositi marziali?

Serum ferritin was determined in 24 menopausal women who did not have any iron metabolic disorders but were suffering from RA. We furthermore investigated its correlation to various clinical and laboratory indexes of activity. The regression analysis revealed significant coefficients of direct correlation between serum ferritin, ESR, and Ritchie's index as well as an indirect correlation to the hematic haemoglobin and to serum iron. These data would apparently be in agreement with the hypothesis that, during the course of RA, serum ferritin assumes the significance of an acute phase protein; nonetheless, in spite of this, these data would induce one to believe that the serum ferritin levels closely reflect that RES iron deposits, the extent of which is influenced by chronic phlogosis.

[Salivary immunoglobulins in the diagnosis of primary Sjögren's syndrome]. / Le immunoglobuline salivari nella diagnostica della sindrome di Sjögren primitiva.

The salivary concentrations of immunoglobulins and total proteins and the salivary flow rate (measured by the method of Deniker et al.) were determined in 29 patients with keratoconjunctivitis sicca and xerostomia and in 11 healthy subjects. According to Fox criteria the group pf 29 patients was divided into two groups: 14 patients with primary Sjögren's syndrome (pSS) and 15 patients with sicca syndrome (SS). The IgA salivary levels were significantly higher in the patients with pSS than in the patients with SS (p < 0.05) and in the healthy subjects (p < 0.001). Moreover the IgG and IgM salivary levels in the first group of patients were higher than in the group of patients suffering from sicca syndrome (p < 0.05) and in the control group (p < 0.02). The salivary flow rate of the patients with pSS and sicca syndrome was lower when compared with the control group (p < 0.005). No significant correlation was found between the salivary flow rate and the immunoglobulins in the three groups of patients. The salivary flow was inversely correlated (p < 0.01) only with the IgA levels in all 40 subjects. The salivary total proteins were significantly elevated in pSS patients when compared with the SS patients (p < 0.04) and with the control group (p < 0.01). The immunoglobulins/total proteins ratios in saliva were significantly higher in the first group than in the other groups (p < 0.005) for the IgG and in the first group than in the SS patients (p < 0.05) for the IgM; no significant differences were noted for the IgA. The bioptic focus scores, graded according Greenspan's criteria, of minor salivary glands of 20 patients with pSS or sicca syndrome were directly correlated with a high significance (p < 0.001) to IgG salivary levels and with a lower significance (p < 0.05) with IgM salivary levels. No significant correlation was found between the bioptic focus scores and the IgA levels. The present results demonstrated a high specificity (100%) and a good sensitivity (86%) of the assessment of salivary IgG for the diagnosis of pSS. The sensitivity of the salivary levels of IgA was higher than that of IgG (93%) but the specificity was low (50%); on the contrary the specificity of the assessment of salivary IgM was good (92%) but the sensitivity was low (60%). This study therefore indicated that the assessment of salivary IgG has a great value for the diagnosis of pSS because IgG levels are related to the amount of lymphoplasmocytic infiltration.(ABSTRACT TRUNCATED AT 400 WORDS)

[The use of low doses of sodium aurothiomalate in the treatment of rheumatoid arthritis. Current trends in basic therapy]. / L'uso di basse dosi di aurotiomalato di sodio nel trattamento dell'artrite reumatoide. Attuali orientamenti nella terapia di fondo.

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.