ISRN Rheumatology

Efficacy of Anti-TNF Agents as Adjunctive Therapy for Knee Synovitis Refractory to Disease-Modifying Antirheumatic Drugs in Patients with Peripheral Spondyloarthritis

Tue, 11 Jun 2013 13:11:08 +0000

Our aim was to evaluate the effectiveness of tumour necrosis factor (TNF) inhibitors as add-on therapy for knee synovitis that did not respond to disease-modifying antirheumatic drugs (DMARDs) and other standard treatments in patients with peripheral spondyloarthritis (SpA). We retrospectively studied 27 SpA patients, in whom an anti-TNF agent was added for active peripheral arthritis with knee synovitis refractory to DMARDs and treatment with low-dose oral corticosteroids and/or nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular (IA) corticosteroids. As response of knee synovitis, were considered the absence of swelling, tenderness, and decreased range of movement in the clinical examination, after 4 months of anti-TNF therapy. In twenty-four (88.9%) of the patients there was response of knee synovitis. No statistical differences in gender (), age (), disease subtype (), and pattern of arthritis () between knee synovitis responders and nonresponders were found. Fourteen patients managed to stop DMARD therapy and six, all of whom were initially on DMARDs combination, to decrease the number of DMARDs to one, maintaining simultaneously the response of knee synovitis. Our results imply a beneficial effect of adjunctive anti-TNF therapy on knee synovitis not responding to DMARDs and other standard treatments in patients with peripheral SpA.

Investigating the Value of Abatacept in the Treatment of Rheumatoid Arthritis: A Systematic Review of Cost-Effectiveness Studies

Kostas Athanasakis, Ioannis Petrakis, and John Kyriopoulos — Thu, 30 May 2013 12:23:47 +0000

Background. Rheumatoid arthritis is a progressive inflammatory disease that affects greatly patients’ quality of life and demands for aggressive management early on during the course of the disease. The discovery of biologics has equipped rheumatologists with evolutionary treatment tools but has also impacted greatly management costs. Objectives. To conduct a systematic review in order to evaluate the cost effectiveness of abatacept in the treatment of moderate to severe rheumatoid arthritis. Methods. Pubmed, the International Society for Pharmacoeconomics and Outcomes Research Outcomes Research Digest, the National Health System Economic Evaluation Database, and the Database of Abstracts of Reviews of Effects were searched. Results. In total 301 studies were identified and 42 met the inclusion criteria. Half of the selected studies evaluated abatacept in the treatment of rheumatoid arthritis, after failure of or intolerance to tumor necrosis factor alpha inhibitors. Of those, 82% were in favor of abatacept as a cost-effective or dominant strategy versus varying alternatives, whereas 18% favored other treatments. Conclusion. The majority of evidence from the published literature supports that abatacept can be a cost-effective alternative in the treatment of moderate to severe rheumatoid arthritis, especially in patients that have demonstrated inadequate response or intolerance to anti-TNF agents or conventional disease modifying antirheumatic drugs.

Oral Bisphosphonate Related Osteonecrosis of the Jaw: A Challenging Adverse Effect

Ilke Coskun Benlidayi and Rengin Guzel — Thu, 16 May 2013 15:54:09 +0000

Oral bisphosphonates are the most commonly prescribed antiresorptive drugs for the treatment of osteoporosis. However, there are several adverse effects associated with oral bisphosphonates including the bisphosphonate related osteonecrosis of the jaw (BRONJ). With a better understanding of this side effect, reported incidences for BRONJ in oral bisphosphonate users have increased in time. The pathogenesis of BRONJ has not been well determined. Several risk factors such as dentoalveolar surgery, therapy duration, and concomitant steroid usage have been linked to BRONJ. Conservative and surgical methods can be preferred in the treatment. Preventative measures are of great importance for the patients at high risk. In this paper, osteonecrosis of the jaw secondary to oral bisphosphonates was reviewed in order to increase awareness as well as to renew the current knowledge.

Stronger Correlation between Interleukin 18 and Soluble Fas in Lupus Nephritis Compared with Mild Lupus

Thu, 14 Mar 2013 10:41:35 +0000

Lupus nephritis (LN) is a major cause of morbidity in patients with systemic lupus erythematosus (SLE). Several cytokines and apoptotic markers such as IL-18 and soluble Fas (sFas) have been assumed to play a role in the pathogenesis of LN. Previous studies confirmed that serum concentrations of sFas and IL-18 are increased in SLE. However, only a few studies have suggested a possible correlation between IL-18 and sFas. This study was planned to continue our previous study on the correlation between those markers to evaluate this correlation in LN. Thirty-two patients with only LN and 46 patients without any major organ involvement participated in this study. SLEDAI score (except for scores related to nephritis) was the same in these two groups. In both groups, patients with any other major organ involvement were excluded. We found a significant rise in the serum concentrations of sFas () and IL-18 () in patients with proteinuria compared to those without it. This study showed that the correlation between sFas and IL-18 in LN (, ) is significantly stronger than it is in mild SLE (, ) with similar nonrenal SLEDAI score (, ). Between these two serum markers, sFas is the only predictor of proteinuria.

Clinical Features of Inflammatory Myopathies and Their Association with Malignancy: A Systematic Review in Asian Population

Mon, 25 Feb 2013 11:19:50 +0000

Introduction. Idiopathic inflammatory myopathies (IIMs) are a group of chronic systemic autoimmune diseases that mainly affect the skeletal muscle. The common subtypes include adult dermatomyositis (DM), polymyositis (PM), and inclusion body myositis (IBM). Most of the earlier studies that described the clinical characteristics of IIM as well as their association with cancer were conducted in Western population. Our study is the first systematic review that summarizes the clinical data of DM/PM in Asian population. Methods. We identified 14 case series of DM/PM that met our eligibility criteria. We then compared this data with that from previous reports from Europe and North America. Results. Our systematic review included 2518 patients. Dermatomyositis is more common, with the ratio of dermatomyositis to polymyositis being 1.36 : 1. 69% of them were females with mean age of 45.5 years. Extramuscular manifestations, including arthritis/arthralgia, dysphagia, and interstitial lung disease, are found in one-third of the patients. Malignancy was found in 10% of patients, with lung and nasopharyngeal carcinomas being the most common malignancies associated with these myopathies. Conclusion. Clinical presentation of PM/DM appears to be similar in both Western and Asian populations. However, the type of associated malignancies in Asians differs from that in Caucasians. Ethnic background should be one of the factors that clinicians should consider while screening for malignancy.

Wound Healing with Medications for Rheumatoid Arthritis in Hand Surgery

A. R. Barnard, M. Regan, F. D. Burke, K. C. Chung, and E. F. S. Wilgis — Mon, 03 Dec 2012 16:59:17 +0000

Introduction. Medications used to treat rheumatoid arthritis, such as corticosteroids, disease-modifying agents (DMARDs), and injectable biological agents (anti-TNFα), may have widespread effects on wound healing. In hand surgery, it is important to balance the risks of poor wound healing from continuing a medication against the risks of a flare of rheumatoid arthritis if a drug is temporarily discontinued. Materials and Methods. A United Kingdom (UK) group of 28 patients had metacarpophalangeal joint replacement surgery in 35 hands (140 wounds). All medication for rheumatoid arthritis was continued perioperatively, except for the injectable biological agents. Results. There were no instances of wound dehiscence or deep infection and only one episode of minor superficial infection. Conclusions. We conclude that provided care is taken to identify and treat any problems promptly, it is appropriate to continue most antirheumatoid medications in the perioperative period during hand surgery to reduce the risk of destabilising the patients' overall rheumatoid disease control.

Neuropsychiatric Features of a Cohort of Patients with Systemic Lupus Erythematosus

Tue, 20 Nov 2012 10:28:23 +0000

In order to establish if neuropsychiatric systemic lupus erythematosus (NPSLE) can be identified by any characteristic other than those used to diagnose the neuropsychiatric (NP) disease itself, we retrospectively reviewed 98 systemic lupus erythematosus (SLE) patients followed over a mean period of 10 years. NPSLE was identified in 22 patients. Stroke and generalized seizures were the most frequent NP manifestations. The NPSLE and non-NPSLE groups were similar with regard to demographic characteristics, ACR criteria, serum autoantibodies, and frequency of hypertension and hypercholesterolemia. Of note, compared to the non-NPSLE group, NPSLE was associated with a higher frequency of smoking (78 versus 26%), organ damage (73 versus 34%), and cumulative mortality rate (14 versus 7%). The series of patients was further analysed according to the presence of antiphospholipid syndrome (APS). Significantly, the interval between the onset of NP disease and SLE diagnosis was shorter in the APS− ( years) than in the APS+ ( years) groups. Recurrence and/or persistence of NP events were only documented in the APS− group. Overall cumulative mortality was highest in NPSLE and in APS+ patients with inadequate anticoagulation control, identifying an aspect that requires improved vigilance and the development of novel therapeutic modalities.

Rheumatological Findings in Candidates for Valvular Heart Surgery

Wed, 24 Oct 2012 09:55:29 +0000

Background and Objectives. Valvular heart diseases are among the frequent causes of cardiac surgery. Some patients have a well-known rheumatic condition. Heart valves are fragile connective tissues which are vulnerable to any systemic autoimmune diseases. This study was designed to evaluate the frequency of rheumatological background in patients candidate for valvular heart surgery in Afshar Cardiovascular Center, Yazd, Iran. Methods. One hundred and twenty (120) patients candidate for valvular heart surgery were selected for this study. Careful history and physical examination were undertaken from rheumatological stand points. The most sensitive screening serologic tests were also assayed. Results. The result of this study showed that 53.3% were male and 46.6% were female with mean age of years old. 45.8% of the patients had history of nonmechanical joint disease, 14.2% had history of rheumatological conditions in their family, and 30% had history of constitutional symptoms. 29.8% had positive joint dysfunction findings in their physical examination while 25.8% had anemia of chronic disease. Positive Rheumatoid factor (RF), anticyclic citrullinated peptide (CCP, ACPA), C-reactive protein (CRP), antinuclear antibody (ANA), abnormal urine and elevated erythrocyte sedimentation rate (ESR) were 34, 2.5, 26.7, 4.2, 5, and 36.7%, respectively. Antineutrophil cytoplasmic antibody (ANCA) and antiphospholipid (APL) were positive in a few cases. Conclusion. The findings of this study show immunologic bases for most patients with valvular heart diseases candidate for surgery. Undifferentiated connective tissue diseases may play an important role in the pathophysiology of valvular damage.

Cardiac Manifestations of Rheumatological Conditions: A Narrative Review

Wed, 17 Oct 2012 14:22:34 +0000

Cardiovascular diseases are common in systemic rheumatologic diseases. They can be presented at the time of diagnosis or after diagnosis. The cardiac involvements can be the first presentation of rheumatologic conditions. It means that a patient with rheumatologic disease may go to a cardiologist when attacked by this disease at first. These manifestations are very different and involve different structures of the heart, and they can cause mortality and morbidity of patients with rheumatologic diseases. Cardiac involvements in these patients vary from subclinical to severe manifestations. They may need aggressive immunosuppressive therapy. The diagnosis of these conditions is very important for choosing the best treatment. Premature atherosclerosis and ischemic heart disease are increased in rheumatoid arthritis and systemic lupus erythematosus, and may be causes of mortality among them. The aggressive control of systemic inflammation in these diseases can reduce the risk of cardiovascular disease especially ischemic heart disease. Although aggressive treatment of primary rheumatologic diseases can decrease mortality rate and improve them, at this time, there are no specific guidelines and recommendations, to include aggressive control and prevention of traditional risk factors, for them.

The Swindon Foot and Ankle Questionnaire: Is a Picture Worth a Thousand Words?

Rosemary Waller, Peter Manuel, and Lyn Williamson — Wed, 26 Sep 2012 09:29:39 +0000

Objectives. Despite increased awareness of the high prevalence and significance of foot and ankle problems in rheumatoid arthritis (RA), feet remain neglected. Reasons may include the perception that feet are difficult to assess, they are not included in the DAS28, and lack of freely available foot screening tools specific for RA. Methods. The Swindon Foot and Ankle Questionnaire (SFAQ) is a simply worded 10-point foot and ankle screening questionnaire with diagrams of feet and ankles for use in general rheumatology outpatients. All RA patients on our electronic database were invited to complete the questionnaire and attend clinic for assessment. Patients assessed clinically were scored out of 10 using the parameters from the questionnaire. The SFAQ was compared to the Manchester Foot Pain and Disability Index (MFPDI), DAS28, HAQ, HAD, and OSRA scores. Results. 597 questionnaires were sent, 301 (50%) returned, and 137 seen in clinic. There was good correlation between the postal SFAQ score, clinic score (), and the MFPDI (). Neither of the foot scores correlated with other RA disease outcome measures. 75% patients completed the picture. 73% corresponded to clinical findings. 45% of patients required an intervention following clinical review and trended towards higher scores. Conclusions. The SFAQ was quick to complete and correlated with the MFPDI. Lack of association with standard RA outcome measures suggests that relying on these scores alone may miss foot pathology. The diagrams were a useful complement. This simple screening tool could aid identification of RA foot and ankle problems.

Thrombosis in Systemic Lupus Erythematosus: A Review Article

Ibrahim A. Al-Homood — Mon, 30 Jul 2012 09:10:55 +0000

Thrombosis is a well-known clinical entity in systemic lupus erythematosus (SLE), and it is multifactorial. The most important risk factor is the presence of antiphospholipid antibodies (APLAs). However, approximately 40% of adults with SLE who are negative for APL A are diagnosed with thrombosis, indicating the importance of other risk factors. Thus, the thrombosis risk factors should be evaluated extensively and regularly and treated aggressively in every patient with systemic lupus erythematosus.

Orbital IgG4-Related Disease: Clinical Features and Diagnosis

Toshinobu Kubota and Suzuko Moritani — Thu, 21 Jun 2012 09:30:12 +0000

Orbital IgG4-related disease, which can occur in adults of any age, is characterized by IgG4-positive lymphoplasmacytic infiltrations in ocular adnexal tissues. The signs and symptoms include chronic noninflammatory lid swelling and proptosis. Patients often have a history of allergic disease and elevated serum levels of IgG4 and IgE as well as hypergammaglobulinemia. Orbital IgG4-related disease must be differentiated from idiopathic orbital inflammation and ocular adnexal marginal zone B-cell lymphoma to ensure appropriate and effective treatment. Systemic steroid therapy decreases the size of the lesions, but relapse often occurs when systemic steroid therapy is discontinued.

Prevalence and Risk Factors of Discordance between Left- and Right-Hip Bone Mineral Density Using DXA

Sun, 17 Jun 2012 07:58:57 +0000

To determine the prevalence of significant left-right differences in hip bone mineral density (BMD), and the impact of this difference on osteoporosis diagnosis, we measured bilateral proximal femora using dual energy X-ray absorptiometry (DXA) in 3481 subjects (608 males, 2873 females). The difference between left and right hip was considered significant if it exceeded the smallest detectable difference (SDD) for any of the three hip subregions. Contralateral femoral BMD was highly correlated at all measuring sites (𝑟=0.92–0.95). However, significant left-right differences in BMD were common: the difference exceeded the SDD for 54% of patients at total hip, 52.1% at femoral neck, and 57.7% at trochanter. The prevalence of left-right differences was greater in participants >65 years. For 1169 participants with normal spines, 22 (1.9%) had discordant left-right hips in which one hip was osteoporotic; for 1349 patients with osteopenic spines, 94 (7%) had osteoporosis in one hip. Participants with BMI < 20 kg/m2 were more likely to show major T-score discordance (osteoporosis in one hip and normal BMD in the other). Multiple regression analysis showed that the only significant statically parameter that persists after adjusting for all potential confounding parameters were age over 65 years.

Clinical and Immunopathologic Profile of Mexican Patients with IgG4 Autoimmune Pancreatitis

Mon, 14 May 2012 08:55:33 +0000

Autoimmune pancreatitis is part of the spectrum of IgG4-associated diseases. Its diagnostic criteria and histological subtypes have been formally proposed recently and although based on current data it has been suggested that there are differences in clinical presentation among populations, more research is needed to properly establish if this heterogeneity exists. In this paper, we describe 15 cases of autoimmune pancreatitis diagnosed at a Mexican centre of reference, all of them associated to the lymphoplasmocytic sclerosing pancreatitis variant. The mean age at the onset of symptoms was 47.5 ± 14.4 years, and 53% of patients were male. The main manifestations were weight loss (87%), obstructive jaundice (53%), and acute (27%) and chronic (27%) pancreatitis. Only 20% of patients had high IgG4 serum levels at the time of diagnosis. All patients receiving prednisone responded favourably, both in their pancreatic and extrapancreatic manifestations. Clinical manifestations of Mexican patients showed certain differences with respect to those usually reported.

Anti-Ro52 Antibodies and Interstitial Lung Disease in Connective Tissue Diseases Excluding Scleroderma

Tue, 27 Mar 2012 07:52:38 +0000

Introduction. The presence of anti-Ro52 antibodies has been reported in a wide variety of autoimmune diseases, particularly in myositis, scleroderma, and autoimmune liver diseases. Clinical significance of anti-Ro52 antibodies remains controversial, and studies are lacking for clarifying the association of anti-Ro52 with interstitial lung disease (ILD) in connective tissue diseases (CTD). Objectives. To determine if anti-Ro52 antibodies are associated with ILD in CTD other than scleroderma. Methods. Single-center, retrospective study based on immunoblotting panel analysis and patients clinical records. Results. In our connective tissue disease cohort, 162 patients had immunoblotting panels with anti-Ro52 reactivity analysis, 41 (25,3%) had inclusion criteria. Among the 41 selected sera, 85.4% (𝑛=35) had anti-Ro52 reactivity. The prevalence of ILD in the positive anti-Ro52 antibodies was 71.4% (𝑛=25), and 16.7% (𝑛=1) in the negative anti-Ro52 group (𝑃=0.018). Overall sensitivity (96.2%), specificity (83.3%), positive (71.4%) and negative (83.3%) predictive values of anti-Ro52 antibodies to determine ILD in CTD is detailed in this study. Conclusion. Ro52 autoantibodies are associated with ILD in CTD excluding scleroderma. We suggest that the presence of anti-Ro52 reactivity in CTD should increase the clinician curiosity for the search of ILD.

The Risk Factors for Nosocomial Infection in Chinese Patients with Active Rheumatoid Arthritis in Shanghai

Mon, 19 Mar 2012 13:07:46 +0000

Objective. To analyse the potential risk factors of nosocomial infections in patients with active rheumatoid arthritis (RA). Methods. A total of 2452 active RA patients at Hospitals in Shanghai between January 2009 and February 2011 were analyzed. Their demographic and clinical characteristics were compared with those without infection, and the potential risk factors were determined by logistic regression analysis. Results. Multivariate analysis indicated the gender (OR=0.70, 95% CI 0.53–0.92), duration in hospital (OR=1.03 , 95%CI 1.01–1.05), number of organs involved (OR=0.82, 95%CI 0.72–0.92), number of disease-modifying antirheumatic drugs ((DMARDs) (OR=1.22, 95%CI 1.061–1.40)), corticosteroid therapy (OR=1.02, 95%CI 1.01–1.03), peripheral white blood cell counts ((WBC) (OR=1.04, 95%CI 1.00–1.08)), levels of serum albumin (OR=0.98, 95%CI 0.97–0.99), and C-reactive protein ((CRP) (OR=1.03 , 95%CI 1.01–1.04)) that were significantly associated with the risk of infections. Conclusion. The female patients, longer hospital stay, more organs involved, more DMARDs, corticosteroid usage, high counts of WBC, lower serum albumin, and higher serum CRP were independent risk factors of infections in active RA patients.

Computerized Morphometric Analysis of Human Femoral Articular Cartilage

Neeru Goyal and Madhur Gupta — Wed, 15 Feb 2012 11:08:45 +0000

Objective. Articular cartilage shows changes with age that are considered to be the most important factors in the development and progression of osteoarthritis. The studies on age changes in articular cartilage have been traditionally based on individual observations but this approach is limited by its subjectivity and bias, yielding considerable variability. So the present study was conducted to observe various age related changes in morphology of femoral articular cartilage using computerized morphometric analysis. Design. The articular cartilage specimens were divided into two groups according to age: group 1 (𝑛=16) below 40 years (16–40 years) and group 2 (𝑛=12) above 40 years (41–86 years) of age. 5 μm thick paraffin sections were stained with H&E and analyzed using Image Pro Express image analysis software for quantitative analysis of articular cartilage. Various parameters, that is, total thickness of the cartilage, area of lacunae in each zone, area of subchondral cavities, and number of chondrocytes per 10,000 μm2 area in each zone were measured. Results. Significant difference with age was found in the total thickness and area of lacunae in zone 3. Conclusions. Not much difference is observed in articular cartilage morphology with age. So ageing is not the only risk factor in development of osteoarthritis.

High Dose Infliximab in the Treatment of Refractory Uveitis: Does Dose Matter?

Sukesh Sukumaran, Katherine Marzan, Bracha Shaham, and Andreas Reiff — Thu, 05 Jan 2012 17:35:31 +0000

Background. Infliximab (INF) has been shown to be beneficial in treating refractory uveitis, however, no data exist on optimal dosing and the efficacy of higher dosing. Objectives. To compare the efficacy of low-dose (LD) (<10 mg/kg), moderate-dose (MD) (≥10–15 mg/kg), and high-dose (HD) INF (≥15–20 mg/kg) in the treatment of uveitis. Methods. Retrospective chart review children with uveitis diagnosed at Childrens Hospital Los Angeles and Millers Children’s Hospital, CA, USA. Results. Of the 34 INF-treated children, 6 patients received LD, 19 received MD, and 9 received HD. Average disease duration prior to therapy was 10.6, 24.6, and 37.1 months each group, respectively. Topical steroids were discontinued after an average of 3 months, 9.5 months, and 10.2 months in the LD, MD, and HD groups, respectively. We found that 66% of patients receiving LD, 42% of MD, and 66% receiving HD INF failed therapy and required either dose escalation or alternate medication for disease control. Conclusions. INF is beneficial in the treatment of uveitis, and dose escalation up to 4 times above the approved dose is often necessary to achieve disease control in patients with uveitis. Doses < 10 mg/kg every 4 weeks may not be sufficient to control disease.

Postambulatory Hand Swelling (Big Hand Syndrome): Prevalence, Demographics, and Association with Dog Walking

Tue, 06 Dec 2011 15:09:45 +0000

Introduction. Postambulatory hand swelling (PAHS) seems to be common in the general population. There are few mention in the medical literature. The objective were (1) to identify prevalence; (2) to compare gender and age groups; (3) to determine if dog owners and walkers are more or less prone. Materials and Methods. 1009 semirandomly surveys were completed from walkers. Age, gender, and dog ownership were assessed. We discussed, among dog owners, whether or not they walk their dog regularly, whether or not they notice swollen hands after walking, and, if so, if the swelling resolves over 24 hours or persists. Results. 699 females and 410 males, among whom, 28.9% of females but only 16.3% of males reported PAHS (𝑃<0.001). Surprisingly, those with swelling were statistically younger than those without (49.2 versus 52.8 years, 𝑃=0.003), and dog owners were more likely than nonowners to report swelling (28.1% versus 21.7%; 𝑃=0.015). In terms of persistent swelling, this was observed in twice the percentage of females as males (13.3 versus 6.5%) and tended to involve older subjects (54.0 versus 48.8 years), but with no statistical difference significance. Conclusions. PAHS is a relatively common phenomenon, seemingly more common in females.

Esophageal Involvement in Scleroderma: Clinical, Endoscopic, and Manometric Features

M. Lahcene, N. Oumnia, N. Matougui, M. Boudjella, A. Tebaibia, and B. Touchene — Mon, 03 Oct 2011 10:00:04 +0000

Aim. To evaluate characteristics of esophageal involvement in scleroderma. Methods. The study was prospective and concerned 194 patients with a definite systemic sclerosis. Gastroesophageal endoscopy and esophageal manometry were performed in all the cases. Results. Symptoms were present in 118 cases (60.8%); they were signs of GERD or dysphagia, respectively, in 94 (48.4%) and 91 patients (46.9%). Reflux esophagitis was found in 73 cases (37.6%); it was mild or moderate in 47 cases (24.2%) and severe or complicated in the remaining cases. Manometry revealed a lower esophageal sphincter incompetence and esophageal motor disorders, respectively, in 118 (60.8%) and 157 cases (80.9%). Presence of these late was not related to age, duration, or skin extension of the disease, but with clinical complaint and/or mucosal damage. Conclusion. Esophageal involvement is frequent during scleroderma. Manometry is the most sensible examination and could be a screening procedure.

Assessment of Panoramic Radiomorphometric Indices of the Mandible in a Brazilian Population

Wed, 14 Sep 2011 19:18:21 +0000

The aim of this study was to evaluate radiomorphometric indices in dental panoramic radiographs in order to identify possible interrelationships between these indices and the sex and age of the patients analyzed. The study included 1287 digital panoramic radiographic images of patients that were grouped into five age groups (1 = age 17–20; 2 = age 21–35; 3 = age 36–55; 4 = age 56–69; 5 = over age 70). Two indices—cortical width at the gonion (GI) and below the mental foramen (MI)—were measured bilaterally in all panoramic radiographs. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney tests (alpha = 0.05). Results for the indices measurements showed significant differences among patient age groups of both sexes, considering that groups 4 and 5 presented lower values for the cortical width of both indices. The present paper supports the role of sex- and age-related changes in mandibular radiomorphometric indices in identifying skeletal osteopenia.

Results of a Pilot Randomized Placebo-Controlled Trial in Primary and Secondary Raynaud's Phenomenon with St. John's Wort: Detecting Changes in Angiogenic Cytokines When RP Improves

Mon, 12 Sep 2011 15:59:13 +0000

Objectives.To perform a 6-week double-blind RCT in Raynaud's phenomenon (RP) comparing the plant extract St. John's Wort (SJW) to placebo. Methods. RP patients having at least 7 attacks per week were stratified by primary and secondary RP and within secondary by systemic sclerosis or other connective tissue disease. Subjects completed a daily standardized diary recording all RP attacks (frequency, duration and severity). Serum levels of 18 inflammatory and angiogenic cytokines were measured pre- and post-treatment. Results. Eighteen patients completed the study; 8 received SJW and 10 placebo. The decrease in mean number of attacks per day was 0.75 with SJW and 1.01 with placebo, 𝑃=0.06. Attack duration and severity were not different between groups. Cytokine analyses demonstrated no between-groups differences. Combining treatment groups, those with >50% improvement in frequency of attacks yielded a significant increase in E-selectin (𝑃=0.049), MMP-9 (𝑃=0.011), G-CSF (𝑃=0.02), and VEGF (𝑃=0.012) pre- versus post-treatment. A ≥50% improvement in severity of attacks corresponded to a significant increase in levels of sVCAM-1 (𝑃=0.003), sICAM-1 (𝑃=0.007), and MCP-1 (𝑃=0.004). Conclusions. There were no clinical or biomarker benefit of SJW versus placebo in RP. However, combining all patients, there were changes in some cytokines that may be further investigated.

The Performance of Quantiferon TB Gold In-Tube as a Screening Tool in Paediatric Rheumatology prior to Initiation of Infliximab: A Single Centre's Experience

Mon, 15 Aug 2011 10:08:20 +0000

Background. Patients with autoimmune diseases and latent tuberculosis infection (LTBI) are at risk of developing catastrophic tuberculosis disease following infliximab treatment. Quantiferon-TB gold in-Tube (QTB) has proven a more accurate screening tool than tuberculin skin test (TST) in adult populations. Objectives. To assess the utility and validity of QTB in children, prior to treatment with infliximab. Methods. Retrospective cohort of patients started on infliximab following endorsement of QTB as a screening tool by the NICE guidelines in 2006. Results. Twenty three patients (12 females and 11 males) were included in the study. A chest radiograph (CXR) and QTB was performed prior to starting infliximab. Fourteen patients had a recorded negative TST result. One patient had a positive QTB while two had indeterminate results. Their CXRs were not suggestive of TB and TSTs were negative. The patients with indeterminate results were started on infliximab and had regular clinical assessment for TB disease. Repeat QTB was negative in one while remained indeterminate in the other. None of our 23 patients developed TB. Conclusion. QTB is a useful screen tool for LTBI. Indeterminate results warrant careful assessment and re-evaluation, but should not preclude from initiation of anti TNF treatment.

Recommendations for Diagnosis and Management of Osteoporosis in COPD Men

Elias E. Mazokopakis and Ioannis K. Starakis — Wed, 10 Aug 2011 11:04:01 +0000

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for osteoporosis and fractures because of lifestyle factors, systemic effects of the disease, side effects of treatment, and comorbidities. The initial evaluation of COPD men for osteoporosis must include a detailed medical history and physical examination, assessment of COPD severity, and additional tests, as suggested by results of clinical evaluation. Osteoporosis is diagnosed on the basis of bone mineral density (BMD) measurement with DEXA of the lumbar spine and hip, but fracture risk assessments tools, as FRAX, could be used as useful supplements to BMD assessments for therapeutics interventions. The prevention and treatment of osteoporosis in COPD involves nonpharmacologic and pharmacologic measures, as lifestyle measures and nutritional recommendations, management of COPD treatment (based on the use of limited corticosteroids doses), and drug therapy (bisphosphonates, teriparatide). In this paper, the current recommendations for diagnosis and management of osteoporosis in COPD men, based on recent medical bibliography, are presented and discussed.

The Contribution of Four Immunogenetic Markers for Predicting Persistent Activity in Patients with Recent-Onset Rheumatoid Arthritis or Undifferentiated Arthritis

Mon, 08 Aug 2011 08:05:21 +0000

We assessed the contribution of four baseline markers—HLA-DRB1 shared epitope (SE), −308 tumor necrosis factor α gene promoter polymorphism, rheumatoid factor, and anticitrullinated peptide antibodies—for predicting persistent activity (DAS28 score ≥2.6) after one year of followup in a cohort of 201 patients with recent-onset rheumatoid arthritis (RA) or undifferentiated arthritis (UA) aged 16 years or older who had a 4-week to 12-month history of swelling of at least two joints. Patients had not been previously treated with corticosteroids or disease-modifying antirheumatic drugs (DMARD). In the best logistic regression model, only two variables were retained: SE positivity and number of DMARD administered (area under the curve = 76.4%; 95% CI: 69.2%, 84.4%; 𝑃<0.001). The best linear regression model also included these two variables, explaining only 22.5% of the variability of DAS28 score. In this study, given an equal number of DMARD administered, the probability of persistent activity in patients with recent-onset RA or UA was significantly influenced by SE presence.

Management of Acute Spinal Fractures in Ankylosing Spondylitis

Saad B. Chaudhary, Heidi Hullinger, and Michael J. Vives — Thu, 30 Jun 2011 17:18:16 +0000

Ankylosing Spondylitis (AS) is a multifactorial and polygenic rheumatic condition without a well-understood pathophysiology (Braun and Sieper (2007)). It results in chronic pain, deformity, and fracture of the axial skeleton. AS alters the biomechanical properties of the spine through a chronic inflammatory process, yielding a brittle, minimally compliant spinal column. Consequently, this patient population is highly susceptible to unstable spine fractures and associated neurologic devastation even with minimal trauma. Delay in diagnosis is not uncommon, resulting in inappropriate immobilization and treatment. Clinicians must maintain a high index of suspicion for fracture when evaluating this group to avoid morbidity and mortality. Advanced imaging studies in the form of multidetector CT and/or MRI should be employed to confirm the diagnosis. Initial immobilization in the patient's preinjury alignment is mandatory to prevent iatrogenic neurologic injury. Both nonoperative and operative treatments can be employed depending on the patient's age, comorbidities, and fracture stability. Operative techniques must be individually tailored for this patient population. A multidisciplinary team approach is best with preoperative nutritional assessment and pulmonary evaluation.

Osteoporosis and Bisphosphonate-Related Osteonecrosis of the Jaw Bone

Thu, 30 Jun 2011 14:07:17 +0000

The aim of this longitudinal study is to present data from 76 female patients treated with bisphosphonates (BPs) for postmenopausal osteoporosis and referred to the Unit of Oral Diagnosis and Day Surgery of the University of Milano for diagnosis and treatment. All patients received a thorough oral examination. The diagnosis of osteonecrosis of the jaw bone (ONJ) was made from radiographic and clinical findings. 9% of individuals had BRONJ at first visit. Patients with dental or periodontal abscess were significantly more likely to develop BRONJ (OR: 2.9, 95% CI 0.5–15.9). Patients with osteoporosis receiving BPs may develop BRONJ, especially in the presence of an active infectious process in the mouth. Clinicians should carefully follow up on individuals receiving bisphosphonates therapy to avoid the occurrence of osteonecrotic lesions.

Pericarditis Revealing Large Vessel Vasculitis

Bruno Couturier, Valerie Huyge, and Muhammad S. Soyfoo — Wed, 22 Jun 2011 10:01:54 +0000

Large vessels vasculitis and more specifically, Giant cell arteritis, is characterized by increased inflammatory markers, headaches and altered clinical status. Diagnosis is confirmed by biopsy of temporal arteries showing the presence of granuloma and vasculitis. We hereby report the case of a patient presenting initially as pericarditis and revealing large vessel vasculitis using FDG-PET.

Wegener's Granulomatosis Presenting with Pachymeningitis: Clinical and Imaging Remission by Rituximab

Wed, 08 Jun 2011 18:55:48 +0000

A 27-year-old woman was admitted for intractable right-sided neck, ear, and jaw pain with gradual development of tinnitus and hearing loss. A cerebral MRI showed meningo-dural enhancement, and additional diagnostic workup revealed a right pulmonary infiltrate and positive PR-3 ANCA. Biopsies from nasal mucosa and lung showed chronic inflammation with granuloma formation. Based on these findings the patient was diagnosed with Wegener's granulomatosis with pachymeningitis. There was no clinical response to oral Prednisolone and Cyclophosphamide, but complete clinical and imaging remission was achieved by adding Rituximab.

Clinical and Ultrasound Examination of the Leeds Enthesitis Index in Psoriatic Arthritis and Rheumatoid Arthritis

Wed, 04 May 2011 10:12:15 +0000

Objective. To compare scores for the Leeds enthesitis index in psoriatic arthritis and rheumatoid arthritis using clinical assessment and ultrasonography (US). Design. Swelling and tenderness of the enthesis was assessed at six sites: lateral epicondyles of humerus (LE), medial condyles of femur (MC), and the insertion of the Achilles tendon (AT). US assessed “inflammatory activity” (power Doppler signal, oedema, tendon thickening, and bursal swelling) and “damage” (erosions and enthesophytes). Results. 94 patients were included, 71 with PsA and 23 with RA. The patients with RA were significantly older (PsA 47.6 years; RA 62.6 years; (mean difference in ages =15.0 years, 95% CI 9.3–20.7 years)). US scores were higher in RA at the LE, significantly so for the “damage” scores. No differences between RA and PsA were seen at the other sites. As a result, the odds ratio for PsA, given an US score above the median, was 0.41 (0.13–1.03). However, using the clinical score, the odds ratio for PsA was 2.16 (0.81–5.70). Conclusions. Although clinical scores of enthesitis are greater in PsA compared to RA, US enthesitis scores did not distinguish between RA and PsA. This may in part be due to more frequent juxta-articular involvement in RA and in part due to the older age of the subjects with RA.