RS3PE syndrome: an overview

More than ten years ago McCarty et al. described the RS3PE syndrome based on their study of 23 patients. Numerous additional cases have since been reported. In addition to the isolated or "pure" type which probably forms part of the clinical spectrum of polymyalgia rheumatica, inflammatory swelling with pitting edema of the dorsum of the hands and/or feet can be observed in different inflammatory rheumatic diseases as well as in haematological and solid malignancies.

Corticosteroid injections in polymyalgia rheumatica: a double-blind, prospective, randomized, placebo controlled study

OBJECTIVE

To determine the efficacy and safety of shoulder corticosteroid injections in polymyalgia rheumatica (PMR).

METHODS

Twenty consecutive patients with active PMR were randomized into a 7 month, double blind, placebo controlled study. Patients received either bilateral shoulder injections of 40 mg of 6-methylprednisolone acetate or placebo (1 ml saline solution). Responders were treated weekly with the same regimen for a total of 4 bilateral injections and then followed for 6 months. Response was defined as a 70% reduction in visual analog scale (VAS) score for pain and for patient and physician global assessment, and duration of morning stiffness. Bilateral shoulder magnetic resonance imaging (MRI) was performed at different times to evaluate the response of lesions to therapy.

RESULTS

All 10 corticosteroid treated patients responded to the first injection with a significant reduction in duration of morning stiffness, VAS pain scale, patient and physician global assessment, erythrocyte sedimentation rate, and C-reactive protein. Interleukin 6 serum levels were significantly reduced after the 2nd injection. In 5 patients, the response persisted throughout the followup period. The other 5 withdrew within 4 weeks after the 4th injection due to recurrence of symptoms. None of the 10 patients of the placebo group responded to the first injection. The difference between the 2 groups was significant (p = 0.03). No side effects were recorded. MRI showed marked improvement of shoulder lesions one week after first injection and an almost complete resolution one week after last injection in the responders.

CONCLUSION

Shoulder corticosteroid injections seem to be an effective and safe therapy for PMR.

Coexisting Behçet's syndrome and spondyloarthritis

A patient suffering from Behçet's syndrome and undifferentiated spondyloarthritis developed dactylitis and psoriasis over the next three years.

Paraneoplastic remitting seronegative symmetrical synovitis with pitting edema

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a syndrome that may be associated with many conditions, including malignancy. Three further cases of paraneoplastic RS3PE are described and the literature is reviewed. Paraneoplastic RS3PE is more frequently associated with solid tumors, in particular adenocarcinoma. The two clinical characteristics suggestive of paraneoplastic RS3PE are systemic sign/symptoms and the poor response to corticosteroid therapy.

HLA-DRB1, DQA1, and DQB1 alleles associated with giant cell arteritis in northern Italy

OBJECTIVE

To evaluate by molecular typing the possible associations of HLA-DRB1, DQA1, and DQB1 alleles with biopsy proven giant cell arteritis (GCA) in a Mediterranean country, and to examine possible relationships between these alleles and GCA clinical subsets.

METHODS

Thirty-nine patients from the Reggio Emilia area diagnosed over a 12 year period with biopsy proven GCA were studied. The clinical findings at diagnosis and during the followup were evaluated through interviews and by reviewing the medical records. HLA-DRB1, DQA1, and DQB1 alleles were determined in the 39 patients and in 250 healthy controls from the same geographic area by polymerase chain reaction amplification using sequence-specific primers.

RESULTS

No associations were found between GCA and the shared epitope, the DRYF epitope, or the DRB1*04 or DQA1 alleles. The only significant association was with DQB1*0302 allele (p = 0.03, RR = 2.2). However, the association was weak and the significance was lost when corrected for the number of antigens tested. The frequencies of DQB1*0301 and 0302 in DR4 patients were not significantly different from those observed in DR4 positive controls. Significant associations were found between DRB1*04 allele and the presence of systemic signs and/or symptoms (p = 0.04, RR = 1.5) and between DRB1*07 allele and the male patients (p = 0.04, RR = 2.6).

CONCLUSION

Our data showed no associations of biopsy proven GCA with HLA-DRB1*04 and HLA-DRB1*01 alleles, rheumatoid epitope, or DRYF epitope. Discrepancies with other studies may be related to the different ethnic backgrounds of the populations studied and to differences in the referral patterns of patients with GCA.

Distal extremity swelling with pitting edema in psoriatic arthritis: evidence of 2 pathological mechanisms

Distal extremity swelling with pitting edema due to altered lymphatic drainage has been reported in some patients with psoriatic arthritis (PsA). The edema usually affected the upper limbs in an asymmetric pattern and was resistant to therapy. We describe 2 additional cases. The distal swelling and pitting edema responded promptly and completely to corticosteroids in the first patient but persisted in the second. Lymphoscintigraphy and magnetic resonance imaging (MRI) revealed a predominant tenosynovitis in the hand without lymphedema in the first patient, and impaired lymphatic drainage without tenosynovial sheath involvement in the second. We conclude that 2 different mechanisms, characterized by a different response to therapy, may be associated with the same clinical picture of distal swelling with pitting edema in patients with psoriatic arthritis. Lymphoscintigraphy and MRI are useful in defining the structures involved and in predicting the prognosis.

HLA-DRB1 alleles associated with polymyalgia rheumatica in northern Italy: correlation with disease severity

OBJECTIVE

To examine the association of HLA-DRB1 alleles with polymyalgia rheumatica (PMR) in a Mediterranean country and to explore the role of HLA-DRB1 genes in determining disease severity.

METHODS

A five year prospective follow up study of 92 consecutive PMR patients diagnosed by the secondary referral centre of rheumatology of Reggio Emilia, Italy was conducted. HLA-DRB1 alleles were determined in the 92 patients, in 29 DR4 positive rheumatoid arthritis (RA) patients, and in 148 controls from the same geographical area by polymerase chain reaction amplification and oligonucleotide hybridisation.

RESULTS

No significant differences were observed in the frequencies of HLA-DRB1 types and in the expression of HLA-DRB 70-74 shared motif between PMR and controls. The frequency of the patients with double dose of epitope was low and not significantly different in PMR and in controls. No significant differences in the distribution of HLA-DR4 subtypes were observed between DR4+ PMR, DR+ RA, and DR4+ controls. Results of the univariate analysis indicated that an erythrocyte sedimentation rate (ESR) at diagnosis > 72 mm 1st h, the presence of HLA-DR1, DR10, rheumatoid epitope, and the type of rheumatoid epitope were significant risk factors associated with relapse/recurrence. Cox proportional hazards modelling identified two variables that independently increased the risk of relapse/recurrence: ESR at diagnosis > 72 mm 1st h (RR=1.5) and type 2 (encoded by a non-DR4 allele) rheumatoid epitope (RR=2.7).

CONCLUSION

These data from a Mediterranean country showed no association of rheumatoid epitope with PMR in northern Italian patients. A high ESR at diagnosis and the presence of rheumatoid epitope encoded by a non-DR4 allele are independent valuable markers of disease severity.

Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome: a prospective follow up and magnetic resonance imaging study

OBJECTIVE

To determine the clinical characteristics of patients with "pure" remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome, and to investigate its relation with polymyalgia rheumatica (PMR). Magnetic resonance imaging (MRI) was used to describe the anatomical structures affected by inflammation in pure RS3PE syndrome.

METHODS

A prospective follow up study of 23 consecutive patients with pure RS3PE syndrome and 177 consecutive patients with PMR diagnosed over a five year period in two Italian secondary referral centres of rheumatology. Hands or feet MRI, or both, was performed at diagnosis in 7 of 23 patients.

RESULTS

At inspection evidence of hand and/or foot tenosynovitis was present in all the 23 patients with pure RS3PE syndrome. Twenty one (12%) patients with PMR associated distal extremity swelling with pitting oedema. No significant differences in the sex, age at onset of disease, acute phase reactant values at diagnosis, frequency of peripheral synovitis and carpal tunnel syndrome and frequency of HLA-B7 antigen were present between patients with pure RS3PE and PMR. In both conditions no patient under 50 was observed, the disease frequency increased significantly with age and the highest frequency was present in the age group 70-79 years. Clinical symptoms for both conditions responded promptly to corticosteroids and no patient developed rheumatoid arthritis during the follow up. However, the patients with pure RS3PE syndrome were characterised by shorter duration of treatment, lower cumulative corticosteroid dose and lower frequency of systemic signs/symptoms and relapse/recurrence. Hands and feet MRI showed evidence of tenosynovitis in five patients and joint synovitis in three patients.

CONCLUSION

The similarities of demographic, clinical, and MRI findings between RS3PE syndrome and PMR and the concurrence of the two syndromes suggest that these conditions may be part of the same disease and that the diagnostic labels of PMR and RS3PE syndrome may not indicate a real difference. The presence of distal oedema seems to indicate a better prognosis.

Isolated tenosynovitis associated with psoriasis triggered by physical injury

A 60-year-old man who had been suffering from psoriasis for 20 years developed finger dactylitis and inflammatory swelling with pitting edema over the dorsum of the hand one week after a contusive trauma to the left hand. These were not followed by any other clinical manifestations of PsA.

Behçet's disease with unusual cutaneous lesions

A variety of cutaneous lesions may occur in Behçet's disease (BD) both at presentation and over the course of the disease. Skin involvement of the hands and feet has been infrequently observed. We describe a patient with BD with recurrent, multiple, papulonodular cutaneous lesions affecting the palm and fingers of both hands, occurring simultaneously with aphthous stomatitis. The lesions consisted of roundish, erythematous, painful, bluish-red nodules, 0.5-1 cm in diameter, with a "pernio-like" aspect. Histologic examination revealed perivascular neutrophilic infiltrates. We suggest that cutaneous lesions with a pernio-like aspect as observed in our patient may be included in the spectrum of the cutaneous manifestations of Behçet's disease.

Distal musculoskeletal manifestations in polymyalgia rheumatica: a prospective followup study

OBJECTIVE

To determine the frequency and the characteristics of distal musculoskeletal manifestations in polymyalgia rheumatica (PMR).

METHODS

Prospective followup study of 177 consecutive patients meeting clinical criteria for PMR, diagnosed over a 5-year period in 2 rheumatology secondary referral centers in Italy.

RESULTS

Seventy-nine of the 177 patients (45%) had distal musculoskeletal manifestations. Peripheral arthritis occurred in 45 patients (25%), carpal tunnel syndrome in 24 (14%), distal extremity swelling with pitting edema in 21 (12%), and distal tenosynovitis in 5 (3%). These manifestations were usually associated with PMR proximal symptoms (69%); however, 31% of the episodes represented isolated relapse/recurrence at distal sites. Distal symptoms responded promptly to corticosteroids. No evidence of joint deformities, erosions, or development of rheumatoid arthritis was observed during the followup. The group of patients with peripheral arthritis included a higher proportion of females, had a longer duration of therapy, and had more relapses/ recurrences. Patients who had distal extremity swelling with pitting edema had a higher age at disease onset, a shorter duration of therapy, and lower initial and cumulative prednisone doses.

CONCLUSION

Inflammatory involvement of distal articular and/or tenosynovial structures occurs in approximately half of the cases of PMR. Peripheral arthritis is associated with more severe disease, while distal extremity swelling with pitting edema appears to identify a more benign disease subset.

Psoriatic arthritis

Recent population-based studies have examined the incidence, prevalence, and survival rates of patients with psoriatic arthritis (PsA). Although there are still no completely satisfactory diagnostic criteria for PsA, Moll and Wright's criteria--although not a true classification/diagnostic scheme--are the most used. The sensitivity of these criteria is low (61%), as are the sensitivities of the European Spondyloarthropathy Study Group and Amor classification criteria for the whole spectrum of spondyloarthropathy. In some patients, PsA can occur only with peripheral enthesitis, particularly Achilles tendinitis or dactylitis. These patients may represent a subset of PsA that is not defined by the Moll and Wright or European. Spondyloarthropathy Study Group criteria and is, therefore, poorly recognized as such. Recent studies have analyzed the expression of adhesion molecules, cytokines, and chemokines in the synovial fluid and synovial membrane of patients with PsA. The therapeutic approach to PsA must be multidisciplinary, involving dermatologists and rheumatologists. Currently the most widely used second-line drugs are methotrexate, sulfasalazine, and cyclosporine. Used in combination, these drugs will probably become a well-established therapy for PsA.

Retrocalcaneal bursitis in spondyloarthropathy: assessment by ultrasonography and magnetic resonance imaging

OBJECTIVE

To establish by magnetic resonance imaging (MRI) and ultrasonography (US) the frequency of retrocalcaneal bursa involvement in Achilles enthesitis of spondyloarthropathy (SpA) and to compare the results of the 2 examinations.

METHODS

Nineteen Achilles tendons with severe enthesitis and 9 normal tendons of 14 patients meeting the Amor criteria for SpA were examined by MRI and US.

RESULTS

Both MRI and US showed a significant increase in the mean Achilles tendon thickness in the pathologic legs compared to the normal legs both at the superior calcaneal surface and 3 cm above. MRI showed retrocalcaneal bursitis in 14 (73.7%) of 19 pathologic legs and superficial bursitis in 2 (10.5%). US showed fluid collection only in 7 of 14 retrocalcaneal bursae positive on MRI, and failed to show fluid in the 2 superficial bursae involved. Using MRI as the gold standard, US showed 50% sensitivity and 100% specificity for retrocalcaneal bursa involvement and lacked sensitivity for superficial bursitis.

CONCLUSION

Achilles tendon involvement in SpA is not only a disease of the enthesis but also of the adjacent bursae.

Tuberculous spondylitis as a cause of inflammatory spinal pain: a report of 4 cases

Patients are said to have inflammatory spinal pain if they fulfill at presentation 4 of the following 5 criteria: duration of spinal discomfort for at least 3 months, spinal morning stiffness, age less than 40, insidious onset of symptoms, and no relief from pain with rest, but improvement with exercise. Inflammatory spinal pain is typical of the spondylarthropathies. Only in a minority of the cases it is found in other rheumatic disorders such as rheumatoid arthritis, fibromyalgia or infectious spondyilitis. Tuberculous spondylitis is rarely mentioned as a possible cause of inflammatory spinal pain. We describe 4 patients with tuberculous spondylitis seen over a 3-year period who met the clinical criteria for inflammatory spinal pain at presentation. We conclude that inflammatory spinal pain may be a presenting feature, albeit rare, of tuberculous spondylitis. Awareness of this finding should help facilitate the proper diagnosis and the institution of appropriate therapy.

Possible association between eosinophilic fasciitis and subcutaneous heparin use

The association between the onset of eosinophilic fasciitis and exposure to a drug or a toxin has occasionally been reported. We describe 3 patients who developed eosinophilic fasciitis a few months after they received subcutaneous calcium heparin. In 2 patients, clinical manifestations and eosinophilia improved after interruption of the therapy. Although spontaneous occurrence of eosinophilic fasciitis cannot be excluded in our patients, the temporal relationship with the beginning of subcutaneous heparin therapy raises the possibility that the syndrome might be precipitated by the drug.

[Pharmacological cardioversion of isolated atrial fibrillation: recovery of atrial mechanical function and correlation with duration of arrhythmia]

To evaluate how the duration of atrial fibrillation before cardioversion affects the recovery of atrial systolic function, serial transthoracic pulsed Doppler echocardiographic studies were performed within 2 hours and at 2 days, 7 days, 1 month and 2 months after chemical cardioversion to sinus rhythm. Peak A wave velocity (A), velocity time integral of A wave (A-VTI) and percent A-wave filling (A/VTI-tot) were assessed in 60 patients with lone atrial fibrillation of brief (> or = 12 to < or = 72 hours, 20 patients), moderate (> 72 hours to < or = 4 weeks, 20 patients) or prolonged (> 4 to < or = 24 weeks, 20 patients) duration. The three groups were well matched for age and left atrial size and none of the patients underwent antiarrhythmic therapy during follow-up. Atrial mechanical function is greater immediately and at 2 and 7 days after cardioversion in patients with brief atrial fibrillation, as compared moderate and prolonged atrial fibrillation (A and A/VTI-tot values: p < 0.05, p < 0.005 and p < 0.05, respectively). In addition, at 7 days after cardioversion, atrial systolic function is greater in patients with moderate atrial fibrillation as compared to prolonged atrial fibrillation (A value, p < 0.005 and A/VTI-tot value, p < 0.05). In all groups, atrial mechanical function increases over time and ultimately achieves similar levels. Full recovery of atrial mechanical function is achieved within 2 days in patients with brief atrial fibrillation, within 7 days in patients with atrial fibrillation of moderate duration and within 1 month in patients with prolonged atrial fibrillation. Recovery of the mechanical function of the left atrium is related to the duration of atrial fibrillation before cardioversion. These findings have important implications for assessing the early hemodynamic benefits of successful cardioversion.

Therapy with cyclosporine in psoriatic arthritis

OBJECTIVE

To evaluate the efficacy and toxicity of cyclosporin A (CsA) in the treatment of patients with psoriatic arthritis (PsA).

METHODS

We reviewed the literature dealing with CsA treatment of PsA.

RESULTS

In the 1980s, some studies evaluating CsA in severe cases of psoriasis documented an improvement in the associated arthritis. Subsequently, open prospective studies included patients with active peripheral arthritis. Using initial CsA dose of 3 to 6 mg/kg/day, improvement in the clinical parameters was noted. A controlled trial showed that CsA and methotrexate (MTX) are equally effective treatment for PsA. CsA and MTX combination was effective in PsA patients resistant to previous second-line therapy. No studies have evaluated the efficacy of CsA on axial disease and on the progression of radiological damage. The most important side effect was nephrotoxicity. However, of 170 CsA-treated patients in 16 studies, only 10 (6%) discontinued the drug because of renal side effects.

CONCLUSIONS

CsA seems to be an effective and safe therapy for PsA. However, controlled studies on large number of patients are necessary.

Diagnostic and classification criteria, clinical and functional assessment, and therapeutic advances for spondyloarthropathies

Two sets of criteria have been proposed and widely accepted in the last few years for the classification of the whole spectrum of spondyloarthropathy, including the undifferentiated forms. These classification criteria--the Amor criteria and the European Spondyloarthropathy Study Group criteria--are not, however, particularly helpful for diagnosis because they do not include the milder and monosymptomatic forms. Outcomes research in spondyloarthritis is growing, and new instruments have been suggested. An international study group of experts is working to propose a core set of measures to be included in future clinical trials on ankylosing spondylitis. Intrasynovial corticosteroid injections in the sacroiliac joints may represent a valid alternative for patients with inflammatory low back pain that is unresponsive to nonsteroidal anti-inflammatory drugs. Sulfasalazine is an effective therapy for the psoriatic arthritis and peripheral arthritis of ankylosing spondylitis. A recent study has suggested its efficacy in reactive arthritis as well. In reactive arthritis, the use of long-term antibiotic therapy has been proposed and is under study.

Proximal bursitis in active polymyalgia rheumatica

BACKGROUND

The cause of musculoskeletal symptoms in the proximal extremities of patients who have polymyalgia rheumatica is not completely understood. The diffuse and severe discomfort can only be partially explained by the mild joint synovitis that is observed in these patients.

OBJECTIVE

To determine the involvement of the synovial structures of the shoulder girdle of patients who have active symptoms of polymyalgia rheumatica.

DESIGN

Case-control study.

SETTING

2 secondary referral centers of rheumatology.

PATIENTS

13 case-patients who had active symptoms of polymyalgia rheumatica seen during a 6-month period, 9 control-patients who had early symptoms of elderly-onset rheumatoid arthritis, and 10 age-matched healthy controls.

MEASUREMENTS

Magnetic resonance imaging of the shoulder was done on the 13 case-patients, 9 control-patients, and 10 healthy controls.

RESULTS

The frequency of subacromial and subdeltoid bursitis was significantly higher in the case-patients (who had polymyalgia rheumatica) than in the control-patients (who had elderly-onset rheumatoid arthritis). The frequencies of synovitis of the joints and tenosynovitis of the biceps did not significantly differ between the 13 case-patients and the 9 control-patients. None of the healthy controls showed evidence of fluid accumulation in the joints, bursae, or sheaths of the long head of the biceps.

CONCLUSIONS

Inflammation of subacromial and subdeltoid bursae in association with synovitis of the glenohumeral joints and tenosynovitis of the biceps may contribute to the diffuse discomfort in the shoulder girdle observed in patients with polymyalgia rheumatica.

Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis

OBJECTIVE

To identify isolated peripheral enthesitis and/or dactylitis as a subset of psoriatic arthritis (PsA) and to define the clinical characteristics of these patients.

METHODS

We examined 401 unselected patients with PsA seen in 3 Italian rheumatological centers over a 6 month period. The diagnosis of PsA was based upon the clinical experience of a rheumatologist. The clinical features of patients with PsA were assessed by clinical examination and review of the patients' charts, evaluating the presence of peripheral arthritis, spinal involvement, dactylitis, and enthesitis. A series of 483 rheumatological patients without psoriasis and spondyloarthropathy (European Spondylarthropathy Study Group criteria) seen consecutively in a one month period constituted the control group.

RESULTS

14 patients (3.5%) presented isolated episodes of peripheral enthesitis and/or dactylitis. No patient developed peripheral arthritis and/or axial involvement during the followup period (median 30 mo; range 3-72 mo). 10/14 patients (71%) presented at least one episode of finger and/or toe dactylitis. 5 of these 10 patients (50%) had additional episodes of peripheral enthesitis (Achilles tendinitis, plantar fasciitis, and posterior tibial tendinitis). Episodes of Achilles tendinitis and/or plantar fasciitis were present in 8/14 patients (57%). 3 of these 8 patients (37%) had associated peripheral enthesitis in other sites as well: lateral epicondyle, insertion of the patella tendon into the inferior pole of the patella, femoral quadriceps, and posterior tibial tendons. An additional case had posterior tibial tendinitis and 2 episodes of toe dactylitis. None of these 14 cases presented radiological evidence of sacroiliitis and only one of the 13 typed was HLA-B27 positive. 12 patients (2.4%) of the control group had episodes of peripheral enthesitis (11 plantar fasciitis and one Achilles tendinitis). No patient had episodes of dactylitis. The frequency of isolated Achilles tendinitis and/or dactylitis was significantly higher in patients with PsA compared to controls (3.5 vs 0.2%; p = 0.001).

CONCLUSION

In some patients PsA can occur only with peripheral enthesitis, particularly Achilles tendinitis, and/or dactylitis. These patients may represent a subset of PsA, not defined by Moll and Wright and spondyloarthritis classification criteria, and poorly recognized in the studies on PsA.

Pyoderma gangrenosum in association with undifferentiated seronegative spondylarthropathy

The cases of 2 women with pyoderma gangrenosum (PG) and undifferentiated seronegative spondylarthropathy (SpA) are described. These 2 cases, together with the recently reported case of PG and B27-positive psoriatic spondylarthropathy, suggest that PG may also occur in association with forms of seronegative SpA that are different from primary ankylosing spondylitis (AS) and AS associated with inflammatory bowel disease.

Intravenous propafenone: efficacy and safety in the conversion to sinus rhythm of recent onset atrial fibrillation--a single-blind placebo-controlled study

The effectiveness of intravenous propafenone for conversion to sinus rhythm (SR) of paroxysmal atrial fibrillation (AF), lasting less than 7 days, was evaluated with a single-blind, randomized, placebo-controlled study, given the possible spontaneous conversion of this arrhythmia. Group 1 (98 patients) received intravenous propafenone (2 mg/kg iv over 10 minutes followed by 0.007 mg/kg/min); and group 2 (84 patients) received intravenous placebo (0.9% saline solution). The infusion was continued until restoration of SR but no longer than 24 hours. Eight-nine patients (90.8%) received propafenone and 27 patients (32%) receiving placebo were converted to SR (p < 0.005). The mean conversion time was 2.46 +/- 2.59 hours in group 1 and 17.15 +/- 5.78 hours in group 2 (p < 0.005). In patients treated with propafenone, conversion of SR mostly occurred in the first 4 hours (86.5%), considered to be the optimal infusion time in our experience. In both groups, the left atrial size was significantly larger in nonconverted than in converted patients. Similarly, the duration of the arrhythmia was significantly longer in nonconverted patients. In nonconverted patients, the mean ventricular rate decreased from 143 +/- 16 beats/min to 101 +/- 18 beats/ min after propafenone and from 135 +/- 19 beats/min to 119 +/- 16 beats/min after placebo (group 1 vs. group 2: p < 0.005). Two episodes of sinus standstill (3.4 and 3.8, seconds, respectively) occurred at SR restoration obtained with propafenone. Intravenous propafenone is an effective, safe, and usually rapid drug for AF treatment. Moreover, it produces a real and significant reduction in the mean ventricular rate in nonconverted patients.

[Propafenone and sotalol: long-term efficacy and tolerability in the prevention of paroxysmal atrial fibrillation. A placebo-controlled double-blind study]

BACKGROUND

Atrial fibrillation is a relatively frequent atrial arrhythmias activated with increased morbidity and mortality.

METHODS

To assess the propafenone and sotalol efficacy in the prevention of paroxysmal atrial fibrillation (FA) we enrolled, in a double blind placebo controlled study over 1 year, 300 patients (168 males); mean age 52.3 +/- 17.2 years, randomized to receive orally, three times daily, either propafenone (mean daily dose of 13 +/- 1.5 mg/Kg; Group A: 102 patients) or sotalol (mean daily dose of 3 +/- 0.4 mg/Kg; Group B: 106 patients) or placebo (Group C: 92 patients). All subjects experienced in previous 12 months at least 4 FA episodes. During follow-up we considered atrial tachyarrhythmia (TAA) onset: FA recurrences and/or the onset of atrial flutter (FIA). Three patients (3%) of Group A and 5 (5%) of Group B interrupted therapy for side effects; 5 patients (5.5%) of Group C with supraventricular tachycardia interrupted the double blind therapy; 11 were lost to follow-up.

RESULTS

Of the remaining 276 patients, TAA were observed in 43 (44.8%) of 96 patients in Group A, 28 (29.5%) of 95 patients in Group B and 62 (72.9%) of 85 patients in Group C. TAA were significantly less in A and B groups than in Group C (p < 0.005); a significant TAA reduction was also observed in patients treated with sotalol compared with those treated with propafenone (p < 0.05). TAA were: FA-118 (88.7%) and FIA-15 (11.3%). The arrhythmia free time was significantly shorter in Group C.

CONCLUSIONS

Sotalol seems to be more effective than propafenone and therefore represents a valid alternative for FA prevention.

Effects of short-term, high dose, heparin therapy on biochemical markers of bone metabolism

To evaluate the effects of the short-term, high-dose sodium heparin therapy on biochemical markers of bone metabolism, we studied 20 patients (11 males and 9 females) with pulmonary embolism, treated with sodium heparin (daily dose range: 40,000-45,000 I.U. by continuous i.v. infusion). Heparin therapy lasted 5-7 days, after which patients received warfarin over 12 months. Eleven patients (6 males and 5 females) with ischaemic stroke, treated with i.v. glycerol and pentoxifilline, were used as controls. Before and after therapy serum and urinary markers of bone metabolism were evaluated; in 12 heparin-treated pts., the parameters were also evaluated 4 months after discontinuation of warfarin therapy. After heparin therapy a significant reduction vs. basal value was observed in levels of serum osteocalcin (ng/ml;mean + SEM): 3.32 & 0.19 vs. 2.05 + 0.21; p < 0.001. In the 12 patients evaluated 4 months after discontinuation of warfarin therapy, serum osteocalcin levels returned to basal value: 3.41 + 0.12 ng/ml (p:n.s.). No significant changes of the examined parameters were observed in controls. In conclusion, our data seem to indicate an effect of i.v. short-term heparin therapy on bone metabolism. This effect seems to be characterized by an inhibition of osteoblast function as suggested by the reduction of serum osteocalcin levels.

Effectiveness of intravenous propafenone for conversion of recent-onset atrial fibrillation: a placebo-controlled study

To evaluate the efficacy of propafenone in converting recent-onset atrial fibrillation (AF) lasting < 7 days, 182 patients were treated intravenously with propafenone (Group 1, n = 98) and with placebo 0.9% saline solution (Group 2, n = 84) in a double blind study. The treatment was continued until sinus rhythm (SR) was restored, but for no more than 24 h. Eighty-nine patients treated with propafenone (90.8%) and 27 patients treated with placebo (32.1%) responded to the treatment and SR was restored (p < 0.0005). The mean time for SR restoration was 2.51 +/- 2.77 h in Group 1, and 17.15 +/- 7.8 h in Group 2 (p < 0.0005). In both groups the patients in whom SR was not restored (nonresponders) had larger left atrial size and longer duration of AF than responders at the onset of the arrhythmia. Nonresponders in Group 1 showed a decrease in mean ventricular rate (MVR) from 143 +/- 16 to 101 +/- 18 (p < 0.0005), while in the nonresponders in Group 2 no reduction of MVR was observed. Two patients whose SR was restored with propafenone had sinus standstill lasting 3.4 and 3.8 s, respectively. Propafenone used intravenously is an effective, quick, and safe drug for treating AF. Moreover, it significantly reduces MVR in nonresponders.

L-carnitine adjuvant therapy in essential hypertension

This study was undertaken to demonstrate L-carnitine therapeutical effect in patients with essential hypertension. Two groups were tested, A and B. First group (A) was split in two subgroups, A1 and A2. Subgroup A1 included 14 patients with essential hypertension, they were treated with antihypertensive drugs and L-carnitine. Subgroup A2 included 14 patients with essential hypertension, that were treated with antihypertensive drugs only. Group B included 9 patients with essential hypertension and they were treated with L-carnitine only. Subgroup A1 patients were treated with oral L-carnitine 2 gm per day for 22 weeks; group B patients were treated with the same dose for 10 weeks. The asthenia symptom was evaluated, a resting and dynamic E.C.G. was carried out, serum triglycerides, serum total and high-density lipoprotein (HDL) cholesterol, serum sodium and potassium, serum creatinine, serum glucose and blood pressure were determined before and at the end of test in group A patients. Test procedure of group B patients included also serum evaluation of apolipoproteins A1 and B and radionuclide angiocardiography. In subgroup A1 patients extrasystoles as well as some electrocardiographic signs of minor changes of ventricular repolarization reversed or diminished, the asthenia symptom was improved significantly and triglyceride values decreased from 148 +/- 15.8 mg/dl to 121 +/- 14.3 mg/dl (p < 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)

[Fluoxetin combined with cyclobenzaprine in the treatment of fibromyalgia]

The aim of this study is to evaluate the effectiveness of fluoxetin associated with cyclobenzaprine vs cyclobenzaprine in the treatment of fibromyalgia. Twenty-one females with fibromyalgia were randomly assigned to 2 groups: group A (11 patients) was treated over 12 weeks with fluoxetin (20 mg/die) and cyclobenzaprine (10 mg/die), group B with cyclobenzaprine (10 mg/die). Basally and after 12 weeks patient self-assessment of pain, number of painful tender points, tender points index and morning stiffness were evaluated. The study has shown a significant improvement of the examined parameters in both treatment groups; however the comparison between the two groups showed a greater effectiveness, statistically significant, of the treatment with Fluoxetin associated with cyclobenzaprine.

Coenzyme Q10 in essential hypertension

This study was undertaken to clarify the mechanism of the antihypertensive effect of coenzyme Q10 (CoQ10). Twenty-six patients with essential arterial hypertension were treated with oral CoQ10, 50 mg twice daily for 10 weeks. Plasma CoQ10, serum total and high-density lipoprotein (HDL) cholesterol, and blood pressure were determined in all patients before and at the end of the 10-week period. At the end of the treatment, systolic blood pressure (SBP) decreased from 164.5 +/- 3.1 to 146.7 +/- 4.1 mmHg and diastolic blood pressure (DBP) decreased from 98.1 +/- 1.7 to 86.1 +/- 1.3 mmHg (P < 0.001). Plasma CoQ10 values increased from 0.64 +/- 0.1 microgram/ml to 1.61 +/- 0.3 micrograms/ml (P < 0.02). Serum total cholesterol decreased from 222.9 +/- 13 mg/dl to 213.3 +/- 12 mg/dl (P < 0.005) and serum HDL cholesterol increased from 41.1 +/- 1.5 mg/dl to 43.1 +/- 1.5 mg/dl (P < 0.01). In a first group of 10 patients serum sodium and potassium, plasma clinostatic and orthostatic renin activity, urinary aldosterone, 24-hour sodium and potassium were determined before and at the end of the 10-week period. In five of these patients peripheral resistances were evaluated with radionuclide angiocardiography. Total peripheral resistances were 2,283 +/- 88 dyne.s.cm-5 before treatment and 1,627 +/- 158 dyn.s.cm-5 after treatment (P < 0.02). Plasma renin activity, serum and urinary sodium and potassium, and urinary aldosterone did not change. In a second group of 11 patients, plasma endothelin, electrocardiogram, two-dimensional echocardiogram and 24-hour automatic blood pressure monitoring were determined.(ABSTRACT TRUNCATED AT 250 WORDS)

Seronegative spondylarthropathy without spine involvement in Behçet's syndrome

The case of a 49-year-old man affected by Behçet's syndrome (BS) without any clinical or radiological evidence of ankylosing spondylitis, exhibiting a peripheral enthesitis typical of seronegative spondyloarthropathy (SpA) is reported. The diagnosis of SpA is supported by computed tomographic evidence of sacroiliitis. This case confirms our hypothesis that patients with BS may have other forms of SpA than AS.

[Cholesterol and vascular disease. Study of pravastatin ]

Variations in lipid profile and incidence of vascular events were evaluated. Group 1 had a 29.3% reduction of total and a 38.3% reduction of LDL cholesterol as against reductions of 9% and 9.6% respectively in group 2. No significant difference was observed between the two groups as far as the vascular events considered were concerned. Pravastatin is an effective and safe drug. The lack of influence on the evolution of vascular disease would appear to be correlated to the small number of subjects studied and the short follow-up.

[The efficacy of intravenous propafenone and amiodarone in the conversion of recent-onset atrial fibrillation. A 1-year follow-up with oral treatment]

One hundred and ninety-six patients with stable atrial fibrillation of recent onset received propafenone (98 patients) or Amiodarone (98 patients) intravenously. Eighty-nine subjects (90.8%) who received propafenone, and 79 patients (80.6%) who received amiodarone were converted to sinus rhythm (p > 0.05). The mean conversion time was 2.51 +/- 2.77 hours after propafenone and 11.21 +/- 4.32 hours after amiodarone (p < 0.0005). The same drug was continued per os in converted patients, and efficacy in maintaining sinus rhythm was evaluated in a one-year follow-up. Symptomatic atrial tachydysrhythmias were observed in 20 (22.4%) of the 89 patients treated with oral propafenone and in 12 (15.18%) of the 79 patients receiving oral amiodarone (p > 0.05). Conversion to sinus rhythm was affected by the duration of arrhythmia and by left atrial size, the latter determining sinus rhythm stability. Both drugs used intravenously are efficacious and safe. Propafenone showed a more rapid action. Oral treatment with low doses for long periods of time with both drugs showed neither important side effects nor proarrhythmic consequences, with satisfactory results.

[Serum osteocalcin and diabetes mellitus. A study of 98 patients]

The goal of this study was to evaluate in 98 diabetic patients the serum levels of osteocalcin (OC) and their relationship with glycosylated hemoglobin levels and with the duration, calculated in years, of the disease. Patients were divided in 3 groups: 17 IDDM patients, 62 NIDDM patients treated with oral hypoglycaemic agents, and 19 NIDDM patients treated with insulin. Results were compared to 2 different control groups. In IDDM patients OC serum levels were significantly lower if compared either to control group and to NIDDM patients. The 2 groups of NIDDM patients showed significantly higher OC values than controls. No significant relationship resulted between OC levels, the duration of diabetes and the glycosylated hemoglobin values. The results of the study indicate a direct correlation between pancreatic function and osteoblastic activity: insulin lack is associated with reduced OC serum levels.

[Dysplasia of the right ventricle]

The end of this work is to talk about a relatively new disease: right ventricular dysplasia (RVD). The Authors consider clinical and instrumental features of the illness with particular reference to recent data for histopathological and instrumental diagnosis. Most interesting are the electron microscopy observations and, above all, nuclear resonance magnetic (NMR) findings.