Seronegative spondyloarthritis and Darier's disease: more than a casual association?

A 46-year old man, affected by Darier's disease (DD), was seen because of right hand pain, later extended to shoulders and ankles. Physical examination showed swelling and tenderness of the wrist, metacarpophalangeal and metatarsophalangeal joints, of the right Achilles tendon's enthesis and of the left knee, with psoriatic-like lesions of the scalp. A diagnosis of seronegative spondyloarthritis, supported by HLA-B27 positivity and by the magnetic resonance imaging finding of hand synovitis and unilateral sacro-iliitis, was made. The correlation between DD, spondyloarthritis and psoriasis has been already anecdotally reported. Further observations may clarify if this association is more than casual.

Correlations between nailfold microangiopathy severity, finger dermal thickness and fingertip blood perfusion in systemic sclerosis patients

OBJECTIVE

The aim of this study was to identify possible correlations between nailfold microangiopathy severity, finger dermal thickness (DT) and fingertip blood perfusion (FBP) in systemic sclerosis (SSc) patients.

METHODS

Fifty-seven SSc patients and 37 healthy subjects were enrolled. All patients were evaluated by nailfold videocapillaroscopy (NVC) to classify and score the severity of microangiopathy. Both modified Rodnan skin score (mRss) and skin high-frequency ultrasound were used to detect finger DT. Laser Doppler flowmetry (LDF) was employed to detect FBP.

RESULTS

A positive correlation was found between nailfold microvascular damage severity and both ultrasound-DT (p=0.028) and mRss values (p<0.0001). In particular, both ultrasound-DT and mRss were found progressively higher in patients with 'Early', 'Active' or 'Late' NVC pattern of microangiopathy. A negative correlation was observed between nailfold microvascular damage severity and FBP (p<0.0001), showing the lowest FBP of the patients with more advanced NVC patterns. A negative correlation was observed between FBP, and both ultrasound-DT (p=0.007) and mRss values (p=0.0002). SSc patients showed a higher ultrasound-DT at the level of the fingers, as well as a lower FBP than healthy subjects (p<0.0001).

CONCLUSIONS

This study demonstrates a relationship between nailfold microangiopathy severity, DT and FBP in SSc patients.

Italian Society of Rheumatology recommendations for the management of gout

OBJECTIVE

Gout is the most common arthritis in adults. Despite the availability of valid therapeutic options, the management of patients with gout is still suboptimal. The Italian Society of Rheumatology (SIR) aimed to update, adapt to national contest and disseminate the 2006 EULAR recommendations for the management of gout.

METHODS

The multidisciplinary group of experts included rheumatologists, general practitioners, internists, geriatricians, nephrologists, cardiologists and evidence-based medicine experts. To maintain consistency with EULAR recommendations, a similar methodology was utilized by the Italian group. The original propositions were translated in Italian and priority research queries were identified through a Delphi consensus approach. A systematic search was conducted for selected queries. Efficacy and safety data on drugs reported in RCTs were combined in a meta-analysis where feasible. The strength of recommendation was measured by utilising the EULAR ordinal and visual analogue scales.

RESULTS

The original 12 propositions were translated and adapted to Italian context. Further evidences were collected about the role of diet in the non-pharmacological treatment of gout and the efficacy of oral corticosteroids and low-dose colchicine in the management of acute attacks. Statements concerning uricosuric treatments were withdrawn and replaced with a proposition focused on a new urate lowering agent, febuxostat. A research agenda was developed to identify topics still not adequately investigated concerning the management of gout.

CONCLUSIONS

The SIR has developed updated recommendations for the management of gout adapted to the Italian healthcare system. Their implementation in clinical practice is expected to improve the management of patients with gout.

Ultrasound Doppler score correlates with OMERACT RAMRIS bone marrow oedema and synovitis score in the wrist joint of patients with rheumatoid arthritis

PURPOSE

MRI is considered the standard of reference for advanced imaging in rheumatoid arthritis (RA). However, in daily clinical practice ultrasound (US) imaging with Doppler information is more versatile and often used for fast and dynamic assessment of joint inflammation. The aim was to compare low-field MRI scores with the US Doppler measurements in the wrist joint of patients with RA.

MATERIAL AND METHODS

Fifty consecutive patients with RA (46 women & 4 men) completed both low-field dedicated extremity MRI (E-scan®, Esaote) and a high-end US (Sequioa®, Siemens) imaging of the wrist before initiating either biological treatment (n = 26) or intraarticular injection of Depomedrole® (n = 24). Mean age was 56 years (range 21 - 83 years); mean disease duration 87.2 months (range 4 - 349 months), mean DAS 28 4,8 (range 2 - 7). MRI was scored according to the OMERACT RAMRIS recommendations and US Doppler colour-fractions were determined.

RESULTS

Using Spearman's rho, we found a relatively good to moderate correlation between the US colour-fraction and the total OMERACT bone marrow oedema and synovitis scores on MRI (r = 0.6; p < 0.001 and r = 0.4; p < 0.006 respectively). There was a trend but no significant correlation with the total OMERACT erosion score (r = 0.3; p = 0.06).

CONCLUSION

Within limits, the OMERACT RAMRIS scores of inflammation in RA patients (bone marrow oedema and synovial enhancement) are comparable to the US colour-fraction measurements using a high-end US scanner. Both imaging modalities detect inflammation although showing different aspects of the inflammatory process in the wrist joint. The higher correlation between US colour-fractions and MRI bone marrow oedema indicates a potential importance of US Doppler in monitoring inflammatory disease changes in RA.

Crohn's disease: prevalence of intestinal and extraintestinal manifestations detected by computed tomography enterography with water enema

BACKGROUND

Computed tomography enterography (CTE) may detect the presence, severity, and extent of bowel inflammation in patients with Crohn's disease (CD). The aim of our study was to assess, among a cohort of 22 histologically proven CD patients, the prevalence of disease distribution, behavior, anastomotic recurrence and extraintestinal manifestations detected by an original CTE technique.

METHODS

Two radiologists reviewed 221 CTEs performed providing both small and large bowel distension by oral administration of neutral contrast material and trans-rectal introduction of a water enema (CTE-WE).

RESULTS

Ileal CD was detected in 116 CTE-WEs (52.4%), including 71/116 (61.2%) non-stricturing/non-penetrating, 17/116 (14.6%) stricturing, and 28/116 (24.1%) penetrating forms. Colonic CD was appreciable in 35 (15.8%) patients, including 18/35 (51.4%) non-stricturing/non-penetrating, 6/35 (17.1%) stricturing, and 11/35 (31.4%) penetrating forms. Ileocolic CD was present in 52 (23.5%) CTE-WEs, including 30/52 (57.7%) non-stricturing/ non-penetrating; 3/52 (5.7%) stricturing, and 19/52 (36.5%) penetrating forms. In 10/221 patients (4.5%), upper gastrointestinal involvement (UGI) was present. Perianal disease was observed in 17/221 patients (7.7%). Fistulas were present in 52 (23.5%) and abscesses in 24 (10.8%) CTE-WEs, respectively. Among 57/221 (25.8%) patients who had undergone a disease-related intestinal resection, in 30/57 cases (52.6%) CD recurrence at the anastomosis was present. 4/221 patients (1.8%) with a histologically confirmed intestinal neoplastic stenosis were observed. Sacroiliitis (24%) was found to be prevalent over hepatic steatosis (10.8%), cholelithiasis (8.6%), and nephrolithiasis (4%).

CONCLUSIONS

CTE-WE represents a comprehensive imaging technique which may demonstrate bowel inflammation and CD extraintestinal manifestations. A peculiar prevalence of UGI involvement and neoplastic strictures were observed. In our study the prevalence of sacroiliitis resulted higher than previously reported.

Has the clinical spectrum of gout changed over the last decades?

OBJECTIVES

To evaluate if the clinical spectrum of gout has changed over the last decades, a cohort of 107 patients was studied in relation to the date of disease onset and of presentation to our Institution.

METHODS

The structured questionnaires of 107 consecutive patients with gout seen between 1989 and 2009 were retrospectively reviewed. Patients were divided into two subgroups according to the year of the first acute arthritis attack: (a) patients with gout onset dating back to 1967-2001, and (b) patients with gout of later (2002-2009) onset. The patients were also subdivided according to the date of their first admission to our Institution: 1989-2006 and 2007-2009 admissions.

RESULTS

The male to female ratio changed from 11.3 in the patients who had the first attack before 2002 to 2.4 in the second onset group (p=0.02). A family history of gout was slightly more frequent in the second subgroup (22.7% vs. 6.4%, p=0.05). The mean number of acute attacks was higher in patients seen before 2002 (p=0.01). Synovial fluid was examined more frequently in the subgroup visited for the first time after 2006 (p=0.001).

CONCLUSIONS

Our data indicating that the patients' sex ratio has changed over time, with women more frequently affected, could be of importance to clinicians who often believe that gout is a disease affecting males only. The increased utilisation of synovial fluid analysis suggests a closer attention to the disease in recent years. Clinicians should be aware that gout is increasingly affecting women.

Imaging studies of crystalline arthritides

Gout, calcium pyrophosphate dihydrate (CPPD) deposition disease, and calcium hydroxyapatite deposition disease (HADD) are the three most common crystal-induced arthropathies. Multimodality imaging may help in their diagnosis, and is useful for a precise and comprehensive assessment and grading of the related osteoarticular damage. Plain film radiography, due to its low cost and wide availability, is the first imaging technique to be used in crystal deposition diseases, providing well-known and specific findings for CPPD deposition disease and HADD, while it may undergrade the early osteoarticular lesions in gouty patients. Ultrasonography (US) is a radiation-free approach that accurately depicts crystal deposits in cartilage, peri- and intra-articular soft tissues, but it does not give a panoramic view of the affected joints. Cross-sectional imaging techniques can examine crystal deposits in the spine and axial joints. CT has the potential to distinguish monosodium urate (MSU) crystals from calcium containing crystals, due to their different attenuation values. MRI may demonstrate synovitis, erosions and bone marrow edema in gouty patients and it may differentiate tophi from other soft tissue nodules due to its high contrast resolution and power of tissue characterization.

Imaging in arthritis: quantifying effects of therapeutic intervention using MRI and molecular imaging

Modern imaging techniques are becoming increasingly important in assessing the course of arthritis and in permitting measurement of response to treatment as part of the follow-up of patients. They include ultrasonography (US), MRI, PET/CT, and biofluorescence. In patients with rheumatoid arthritis, clinical evaluation is significantly less sensitive than either US or MRI in detecting synovitis. As a result, imaging is a useful alternative to achieving proper assessment of disease activity. The different areas in which the new imaging techniques could help practicing rheumatologists and internal physicians include the following: early and differential diagnosis of arthritis, evaluation of disease activity, prognosis, assessment of treatment efficacy, assessment of remission, and evaluation of subclinical disease. MRI is probably the best imaging method to study disease activity in RA, because it can study all the joints with similar efficacy, has been sufficiently standardised, and yields data on inflammation that can be quantified. Different methods, developed to score synovitis activity, are increasingly used in clinical trials. The main application of PET/CT in rheumatology is the diagnosis and follow-up of large vessel vasculitis. More recently, also RA disease activity has been evaluated, allowing a panoramic view of the patient. Molecular imaging studies molecular and cellular processes in intact living organisms in a non-invasive fashion. In fluorescence, dyes, that emit light upon excitation by a light source and are read by a camera, can be used to show inflamed areas where neoangiogenesis, vasodilatation, and increased vessel permeability are present. These dyes can be coupled with different compounds including antibodies and drugs.

[Multimodal imaging in the differential diagnosis of soft tissue calcinosis]

Soft tissue calcinosis is a common radiographic finding, which may be related to different types of pathological processes. Multimodality imaging, combined with analysis of clinical and laboratory data, plays an important role for the differential diagnosis of these conditions. Conventional radiography is considered the first line approach to soft tissue calcinosis; CT and MRI may provide further information to better characterize calcified deposits. Imaging may help to distinguish metabolic calcification, such as primary tumoral calcinosis and the secondary one (associated with acquired disorders of calcium or phosphate regulation), from dystrophic calcification, which is associated to normal blood values of phosphate. The sedimentation sign typical of tumoral calcinosis has been demonstrated by plain film radiography, CT, MRI, and, more recently, by ultrasonography. Other types of soft tissue calcinosis may have a degenerative, metaplastic or neoplastic origin, and their characterization strongly relies on multimodality imaging.

Italian consensus on EULAR recommendations 2005 for the management of hip osteoarthritis

The recommendations for the management of osteoarthritis (OA) of the hip were proposed by EULAR in 2005. Among the most important objectives of the expert charged to provide these recommendations were their wide dissemination and implementation. Thus, the information generated can be used by each individual country to produce their own set of management guidelines and algorithms for treatment in primary care. According with that previously executed for the EU-LAR recommendation 2003 for the knee, the Italian Society of Rheumatology (SIR) has organised a Consensus on the EULAR recommendations 2005 for the management of hip OA. To obtain an acceptability as large as possible, the group of experts was composed by many physicians interested in the management of hip OA, including Orthopaedics, Rheumatologists, Physiatrists, and General Practitioners. Main aim of the Consensus was to analyse the acceptability and applicability of the recommendations according to own experience and local situations in the Italy. The results of this Consensus have demonstrated that a large majority of the EULAR recommendations are endorsed by the Italian experts. Furthermore, the final document of the Italian Consensus clearly indicated the need that the specialists involved in the management of hip OA strongly encourage the dissemination of the EULAR 2005 recommendations also in Italy.

Correlation between radiographic, echographic and MRI changes and rheumatoid arthritis progression

OBJECTIVES

To review the imaging methods used for the evaluation of disease progression in rheumatoid arthritis (RA) and to evaluate the results of their application in pharmacological trials.

METHODS

Literature articles dealing with radiology, echography, and magnetic resonance imaging (MRI) of patients with RA were evaluated in a non-systematic fashion.

RESULTS

Conventional radiology is the gold standard for the evaluation of disease progression in RA because of its diffusion, economy, and standardization. Different techniques have been proposed to evaluate radiological damage of the joints, with the Larsen's and Sharp's methods being most widely used. These methods are commonly used for the evaluation of the ability of DMARDs to slow RA progression. Among traditional DMARDs, gold salts, sulphasalazine, methotrexate, cyclosporin, and leflunomide have shown efficacy in slowing the appearance of new erosions. The same effect has been recently demonstrated for infliximab plus methotrexate, anakinra and etanercept. However, conventional radiology has several disadvantages, because it is monoplanar and has a low sensitivity to change. Newer imaging techniques, such as echography and MRI are extensively studied and have been used occasionally in the mediumterm evaluation of DMARDs, with promising results.

CONCLUSIONS

Although conventional radiology is still the gold standard for the evaluation of disease progression in RA, newer techniques are increasingly studied. In particular, standardization of echographic and MRI imaging of the joints is in progress.

Glucocorticoid treatment of polymyalgia rheumatica

Glucocorticoids are the mainstay of treatment in patients with polymyalgia rheumatica (PMR). Moreover, lower serum cortisol levels have been reported in patients with PMR, suggesting an important role of impaired hypothalamus-pituitary-adrenal (HPA) axis in the pathogenesis of the disease. Therefore, a good response to glucocorticoids has been recognised as a feature of PMR, even if disagreement remains concerning an exact starting dose, duration of treatment and schedule of administration. The role of glucocorticoids in the pathogenesis of PMR, as well as the available evidence concerning different schedules of glucocorticoid treatment, including administration according to circadian rhythms, are discussed.

Epidemiology of psoriasis and psoriatic arthritis

Psoriasis is widely diffused in the World, with the exception of a few populations, such as the natives from Alaska and Australia, where it is unknown. Its average prevalence is about 3-4%. This is probably an underestimate, for it is mostly based on self-reports. In fact, on the one hand minimal psoriasis, e.g. nail disease, could remain undiagnosed; on the other, precise classification criteria for psoriatic arthritis (PsA) are lacking and the skin disease is often of elusive nature. The frequency of PsA may be higher than commonly believed, as suggested by recent studies reporting a prevalence of up to 0.42%. There are no major differences in the frequency of psoriasis between sexes, nor specific time trends. Indirect data suggest that PsA may be more frequent in the old than in the new World, a point that could be clarified only by standardized international studies. In practice, both psoriasis and PsA are relatively common conditions, with major impact on the patients'quality of life, and requiring appropriate intervention strategies. An important advance should be the adoption of univocal definitions of psoriasis and PsA, including guidelines for patterns of skin and joint involvement.

Assessing the cost-effectiveness of biologic agents for the management of moderate-to-severe rheumatoid arthritis in anti-TNF inadequate responders in Italy: a modelling approach

OBJECTIVES

The objective of this study is to assess cost-effectiveness of different biologic strategies in patients with moderate-to-severe active RA after an insufficient response to anti-TNF agents within the context of the Italian healthcare system.

METHODS

Simulation models were developed allowing for potential biologic therapy switch at each 6-month time point in case of an insufficient response to the previous biologic agent. Biologic treatments included etanercept, abatacept, adalimumab, rituximab or infliximab. Effectiveness criteria for these models were defined as achieving a state of low disease activity (LDAS) [DAS28 ≤3.2] or remission (RS) [DAS28<2.6]. Monte-Carlo simulations were performed for each sequence to manage data variability.

RESULTS

The biologic treatment sequence using abatacept after an insufficient response to a first anti-TNF agent appeared significantly more efficacious over 2 years (102 days in LDAS) compared to rituximab (82 days in LDAS). The sequence using abatacept after 2 anti-TNF agents appeared significantly more efficacious (63 days in LDAS) compared to using a third anti-TNF agent (32 days in LDAS). Mean cost-effectiveness ratios showed significantly lower costs per day in LDAS with abatacept used after one anti-TNF agent (€376) compared to rituximab (€456). The sequence using abatacept after 2 anti-TNF agents was also more cost-effective (€642 per day in LDAS) versus a sequential use of anti-TNF therapies (€1164 per day in LDAS). All comparisons were confirmed when using the remission effectiveness criteria.

CONCLUSIONS

The results of this health economics modelling study suggest that the biologic treatment sequence using abatacept after an insufficient response to a first anti-TNF agent appears significantly more effective and cost-effective versus a similar sequence using rituximab for achieving remission or LDAS. The results also indicate that in the case of an insufficient reponse to 2 anti-TNF agents, abatacept appears more effective and cost-effective than using a 3rd anti-TNF agent.

Imaging of tophi with an extremity-dedicated MRI system

OBJECTIVES

To describe the MRI features of gout tophi in the soft-tissues or joints of the limbs by low-field extremity-dedicated MRI.

METHODS

Nine consecutive patients, 8M/1W, affected by chronic tophaceous gout were studied. Mean patients' age was 71.3±11.5 years, mean disease duration 98.1±44.9 months, and mean serum uric acid concentration 9.2±2.8 mg/L. Diagnosis was based on the ACR classification criteria for gout, and by identification of MSU crystals in the tophi and synovial fluid. Conventional radiograms and MRI with an extremity-dedicated system were obtained of the joint areas involved by tophi.

RESULTS

At T1 weighted MRI images, all tophi showed a homogeneous intermediate signal intensity, similar to that of muscle. Conversely, in T2 weighted images, a wide spectrum of signal intensity patterns was observed. The pattern of contrast enhancement was variable from intense homogeneous to peripheral and heterogeneous. Capsulo-ligamentous structures were often thickened and degenerated and, on occasion, could be recognised as inhomogeneous, hypointense ribbon-shaped elements in the context of the tophus. In only two cases, tendons were infiltrated by tophaceous matter. Bone marrow oedema (BME) and erosions were seen in 8 out of 10 bones adjacent to tophi.

CONCLUSIONS

The MRI appearance of gout tophi using an extremity-dedicated machine is similar to that described in the literature using whole body machines. BME adjacent to the tophus was a frequent finding. This technique may occasionally help in the differential diagnosis of nodules and in the follow-up of the disease. It also represents a useful tool to investigate the pathogenesis of gout and to better understand its clinical progression.

Study on the possible role of the -174G>C IL-6 promoter polymorphism in predicting response to rituximab in rheumatoid arthritis

OBJECTIVE

Identification of genetic biomarkers of response to biologics in rheumatoid arthritis (RA) is a relevant issue. The -174G>C interleukin-6 (IL-6) promoter polymorphism was investigated in RA patients treated with rituximab (RTX), being IL-6 a key cytokine for B cell survival and proliferation, thus possibly implicated in rituximab efficacy.

METHODS

The study was conducted in a real-life retrospective cohort of 142 unselected RA patients (120F/22M) treated with RTX and referred to 7 rheumatologic centres in the north of Italy. One hundred and thirteen (79.6%) patients were rheumatoid factor (RF)-positive and 112 (78.9%) were anti-CCP antibodies positive. The response to therapy was evaluated at the end of the sixth month after the first RTX infusion, by using both the EULAR criteria (DAS28) and the ACR criteria. The IL-6 -174G>C promoter polymorphism was analyzed by RFLP following previously reported methods.

RESULTS

Lack of response to RTX at month +6 by EULAR criteria was more prevalent in RA patients with the IL-6 -174 CC genotypes (9/21, 42.8%), than in the GC/GG patients (23/121, 19.0%) (OR 3.196, 95% CI=1.204-8.485; p=0.0234). Similar results were found when evaluating the response by ACR criteria. No differences were found in RA duration, baseline DAS28, baseline HAQ, RF status, anti-CCP status according to the different IL-6 -174 genotypes.

CONCLUSION

IL-6 promoter genotyping may be useful to better plan treatment with RTX in RA. Larger replication studies are in course to confirm these preliminary results.