Delphi-Based Consensus on Interstitial Lung Disease Screening in Patients with Connective Tissue Diseases (Croatian National-Based Study)

The aim of this study was to develop a Croatian Delphi-based expert consensus for screening interstitial lung disease (ILD) associated with connective tissue disease (CTD). A systematic literature review was conducted on risk factors for the development of ILD, prevalence and incidence of ILD, diagnostic and screening methods for ILD, and prognosis of ILD in idiopathic inflammatory myopathy (IIM), mixed connective tissue disease (MCTD), primary Sjögren's syndrome (pSS), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSc) were performed. Based on the evidence found, experts developed questionnaires for screening and monitoring ILD in each CTD, which were provided via an online survey. Following the electronic survey, two screening algorithms were developed based on the consensus opinions. The detection strategy for ILD included high-resolution computed tomography (HRCT) in addition to pulmonary function testing for IIM, MCTD, and SSc. and pulmonary function testing for newly diagnosed pSS, RA and SLE. However, in patients with identified risk factors for ILD HRCT, these tests should also be performed. A screening strategy for early identification of patients with various CTD-ILD was first developed by a multidisciplinary team of rheumatologists, pulmonologists, and radiologists to identify early CTD patients at risk of ILD, a severe extra-articular manifestation of CTD.

Very Early Diagnosis of Systemic Sclerosis in Clinical Practice - Case Report and Review of the Literature

Systemic sclerosis (SSc) is a systemic autoimmune disease characterised by generalized microangiopathy and fibrosis of skin and internal organs. The 2013 American College of Rheumatology (ACR) / European League Against Rheumatism (EULAR) criteria have contributed considerably to classifying patients with SSc in earlier stages, but they still lack sensitivity for a very early stage of the disease. Criteria for a very early diagnosis of SSc (VEDOSS) have been proposed by EULAR Scleroderma Trial and Research group (EUSTAR) which include three red flags: Raynaud's phenomenon, puffy fingers and antinuclear antibody positivity, plus SSc specific antibodies positivity and/or abnormal nailfold capillaroscopy. We report a case of a 54-year-old female patient with 6-week history of puffy fingers, Raynaud phenomenon and positive antinuclear antibodies. Further workup revealed early pathologic capillary pattern by nailfold capillaroscopy and positive anticentromere antibodies. Screening for internal organ involvement detected no heart, lung, or upper gastrointestinal tract involvement. The patient was started on pentoxifylline with further follow-up. The aim of the implementation of VEDOSS criteria is to diagnose SSc at the earliest possible stage, so that subclinical internal organ involvement could be detected and appropriate treatment started at a potentially reversible stage.

Treatment Satisfaction, Patient Preferences, and the Impact of Suboptimal Disease Control in a Large International Rheumatoid Arthritis Cohort: SENSE Study

BACKGROUND

Patients' needs and perspectives are important determinants of treatment success in rheumatoid arthritis (RA). Assessing patients' perspectives can help identify unmet needs and enhance the understanding of treatment benefits.

OBJECTIVE

The SENSE study assessed the impact of inadequate response to disease-modifying antirheumatic drugs (DMARDs) on treatment satisfaction, disease outcomes, and patient perspectives related to RA disease management.

METHODS

SENSE was a noninterventional, cross-sectional study conducted in 18 countries across Europe, Asia, and South America. Adult patients with poorly controlled RA of moderate/high disease activity were eligible. Patient satisfaction was assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM v1.4). Treatment adherence, healthcare resource utilization (HRU), quality of life (QoL), work ability, digital health literacy (DHL), patient preference information, and treatment strategy were also assessed.

RESULTS

A total of 1624 patients were included in the study: most were female (84.2%) and middle-aged, and mean disease duration was 10.5 years. Mean TSQM global satisfaction subscore was 60.9, with only 13.5% of patients reporting good treatment satisfaction (TSQM global ≥80). The strongest predictor of good treatment satisfaction was treatment with advanced therapies. Most patients (87.4%) reported good treatment adherence. In general, patients had impaired QoL and work ability, high HRU, and 67.4% had poor DHL. Leading treatment expectations were "general improvement of arthritis" and "less joint pain". Most patients preferred oral RA medications (60.7%) and rapid (≤1 week) onset of action (71.1%). "Increased risk for malignancies" and "increased risk for cardiovascular disease" were the least acceptable side effects. Despite suboptimal control, advanced therapies were only used in a minority of patients, and DMARD switches were planned for only half of the patients.

CONCLUSION

Suboptimal disease control negatively impacts treatment satisfaction, work ability, QoL, and HRU. Data collected on patient perspectives may inform shared decision-making and optimize treat-to-target strategies for improving patient outcomes in RA.

Effects of Yoga in Daily Life program in rheumatoid arthritis: A randomized controlled trial

OBJECTIVES

To explore the feasibility and effectiveness of a yoga program in improving health-related quality of life (HQOL), physical and psychological functioning in rheumatoid arthritis (RA) patients.

DESIGN

Single-centre parallel-arms randomized controlled trial comparing yoga (n = 30) and education control group (n = 27).

SETTING

Tertiary care University hospital.

INTERVENTION

A 12-week yoga program, based on the Yoga in Daily Life system, included 2x weekly/90-minute sessions. The control group had 1xweekly/60-minute educational lectures on arthritis-related topics.

MAIN OUTCOME MEASURES

Assessments were performed at baseline, 12 (post-intervention) and 24 weeks (follow-up). The primary outcome was change in The Short Form-36 (SF-36) HQOL at 12 weeks. Linear regression analysis was adjusted for baseline scores.

RESULTS

No significant between-group differences were found for SF-36 (all p > 0.05). At 12 weeks the adjusted mean difference between groups favoured yoga for Functional Assessment of Chronic Illness Therapy-fatigue (5.08 CI 1.29 to 8.86; p = 0.009) and Hospital Anxiety and Depression Scale (HADS)-depression (-1.37 CI -2.38 to -0.36); p = 0.008) and at 24 weeks for HADS-anxiety (-1.79 CI -3.34 to - 0.23; p = 0.025), while the impact on fatigue was sustained (5.43 CI 1.33 to 9.54, p = 0.01). The program had no impact on RA disease activity. Feasibility outcomes included recruitment rate 16 %, retention 80.7 %, and adherence to yoga 87.5 vs 82.7 % for control. No serious adverse events were recorded.

CONCLUSIONS

Yoga in Daily Life program was not associated with change in health-related quality of life of RA patients. Significant improvements in fatigue and mood were observed at postintervention and follow-up. This yoga program was found feasible and safe for patients and may complement standard RA treat-to-target strategy.

Influence of Biological Therapeutics on Patient-Reported Quality-Of-Life Outcomes (Whoqol-Bref), Functional Scores and Disease Activity among Croatian Patients with Rheumatoid Arthritis: Our Experience

BACKGROUND

Rheumatoid arthritis (RA) is a chronic and disabling disease with a great impact on the quality of life (QOL). The aim of this study was to assess QOL and health in RA patients treated with biological disease-modifying drugs (bDMARDs) as opposed to those treated with conventional synthetic DMARDs (csDMARDs). We analysed four domains of QOL: physical health (D1), mental health (D2), social relationships (D3) and one's surroundings (D4); as well as general quality of life (W1), general state of health (W2), and disease activity and physical disability.

SUBJECTS AND METHODS

Seventy-seven RA patients (group A=29 on bDMARDs, group B=48 on csDMARDs) were enrolled in the study. QOL was evaluated using WHO questionnaire (WHOQOL-BREF), disease activity using Disease Activity Score 28C-reactive protein (DAS28CRP) and functional status using Health Assessment Questionnaire (HAQ).

RESULTS

There was no statistically significant difference of mean values in the four domains of QOL, nor in the general QOL, between groups A and B. There was also no statistically significant difference regarding RA activity (3.51 vrs 3.54, p=0.56). However, we have found that the variable of the general state of health domain was statistically significantly higher in group B (2.66 vrs 2.89, p=0.001), while HAQ was statistically significantly higher in group A (1.19 vrs 1.07, p=0.018), as well as the duration of RA (6.25vrs 3.75 years, p=0.0006). Statistically significant correlation was found between HAQ and W2, disease duration and D3 in group A and DAS28CRP and D1, D2, W2 and HAQ and D1 and D2 in group B.

CONCLUSION

These findings suggest that the inclusion of bDMARDs in the treatment regimen was overdue, with RA already advancing with developed functional disability, which prevented the achievement of the primary goals of treatment: low disease activity or remission and the improvement of patient's QOL.

The effect of smoking on disease activity in rheumatoid arthritis - our experience

The aim of this study was to investigate the association of smoking with disease activity, seropositivity, age and gender in patients with rheumatoid arthritis. We included 89 rheumatoid arthritis patients. All patients fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism rheumatoid arthritis classification criteria. Activity of the disease was measured by Disease Activity Score 28-joint count C-reactive protein (DAS28CRP). The subjects were stratified into smoking and non-smoking groups and cross-sectionally analyzed. There were 24 (27%) smokers and 65 (73%) nonsmokers. The mean age of patients was 57.1±8.8 years. The mean DAS28CRP was 5.81 in the smoking group and 5.57 in the non-smoking group, without statistically significant difference between the two groups (p=0.148). Similarly, smokers did not differ significantly from non-smokers according to age (p=0.443), gender (p=0.274), rheumatoid factor positivity (p=0.231), anti-citrullinated protein antibody positivity (p=0.754) or seropositivity (p=0.163). In this study, we found no association between smoking status and disease activity, seropositivity, age or gender in rheumatoid arthritis patients. Furthermore, disease activity was not related to age, gender or seropositivity. Additional studies on the effects of smoking on rheumatoid arthritis activity are needed.

Do We Pay Enough Attention to Neuropathic Pain in Knee Osteoarthritis Patients?

SUMMARY – The aim of the study was to determine the prevalence of neuropathic pain in knee osteoarthritis patients using painDETECT questionnaire, and to evaluate correlations between pain intensity, gender, age and types of treatment, and the presence of neuropathic pain. The study included 122 patients. All participants completed a questionnaire on sociodemographic data, duration of symptoms, types of treatment and preventable risk factors (body mass index and waist circumference). The presence of neuropathic pain was assessed by painDETECT, according to which subjects were classified into three groups (neuropathic pain likely, possible, or unlikely). Neuropathic pain was likely in 18 (14.8%), possible in 30 (24.6%) and unlikely in 74 (60.7%) subjects. A significant positive correlation was found between visual analog scale for pain and painDETECT score. There was no statistically significant difference in gender, age, waist circumference and body mass index among three groups of participants according to painDETECT score. In conclusion, knee osteoarthritis patients with neuropathic pain component were experiencing higher levels of pain, implicating poorer pain control with common analgesics. Recognizing these patients as a distinct subgroup would allow clinicians to improve their treatment by using unconventional analgesics with central activity.

Validity of the rheumatoid arthritis impact of disease (RAID) score and definition of cut-off points for disease activity states in a population-based European cohort of patients with rheumatoid arthritis

OBJECTIVES

To assess the validity of the rheumatoid arthritis impact of disease (RAID) for measuring disease activity of rheumatoid arthritis (RA) and to determine cut-off values for defining the disease activity states.

METHODS

A total of 622 RA patients from an European database have been included. Cross-validation was based on assessment of convergent and discriminant validity. Optimal cut-offs were determined against external criteria by calculating the respective 25th and 75th percentiles mean values of RAID. External criteria included definitions for remission (REM), low disease activity (LDA), moderate disease activity (MDA) and high disease activity (HDA), cut-offs of the 28-joint disease activity score-C-reactive protein (DAS28-CRP) score.

RESULTS

The RAID showed a moderate degree of correlation with respect to DAS28-CRP (rho=0.417; P<0.0001). The receiver operating characteristic (ROC) curves to discriminate the ability of RAID to distinguish patients with active and non-active disease was very good with an area under the curve (AUC) of 0.847 (95% confidence interval [CI]: 0.816 to 0.878; P<0.0001). Based on the distributions of RAID in the different disease activity groups, we propose the following cut-off values for REM: RAID ≤3; for LDA: RAID >3 and ≤4; for MDA: RAID >4 and ≤6; for HDA: RAID >6. Mean RAID differed significantly between patients classified as REM, LDA, MDA or HDA (P=0.001).

CONCLUSIONS

The cut-offs revealed good measurement characteristics in cross-validation analysis, had great discriminatory performance in distinguishing patients with different levels of disease activity and are suited for widespread use in everyday practice application and research.

Magnetic resonance imaging in the diagnosis and follow-up of giant cell arteritis: case report and review of literature

A female patient with giant cell vasculitis of the abdominal aorta and its branches and strongly suspected of having extrapulmonary tuberculosis is presented. The diagnoses were based on the clinical picture, laboratory findings, and magnetic resonance imaging (MRI) findings. MRI is highly useful in cases where echosonography and/or vascular biopsy for histopathological analyses are not possible. A combination of giant cell vasculitis and extrapulmonary tuberculosis is extremely rare, and therefore, choosing the right treatment presents a considerable challenge. MRI performed after 6-month antituberculous therapy and 1-year glucocorticoid plus methotrexate therapy showed normal wall of the aorta and its branches, which was consistent with clinical and laboratory remission. Patients with large vessel vasculitis require regular follow-up by MRI.

[ETIOLOGY AND PATHOGENESIS OF PAIN IN RHEUMATIC DISEASES]

Rheumatic diseases are chronic inflammatory disorders with ongoing inflammation that causes tissue damage. Inflammatory and damaged cells synthetize and release many diff erent intracellular substances which can activate highly specialized subsets of primary sensory neurons called nociceptors. Some of these proinflammatory mediators directly activate the nociceptor terminal and produce pain (such as hydrogen ion, adenosine triphosphate, and bradykinin), and others sensitize the terminal so that it becomes hypersensitive to subsequent and non-noxious stimuli (such as prostaglandin E2 and bradykinin). Acute pain has a protective role since it induces behavior that promotes healing and recovery, such as immobilization which limits tissue damage. Chronic pain is unhelpful pain that tends to be out of proportion to the actual tissue damage and persists long after the tissues have healed, so that the pain becomes the problem rather than the tissues of origin. Chronic pain affects the physical and mental status and causes impairment of quality of life as well as work disability. For rheumatologists the assessment and treatment of pain is a very important integral part of patient care, and understanding the etiology and pathogenesis of pain is necessary to fi nd adequate modalities of treatment to prevent suffering.

[GRANULOMATOSIS WITH POLYANGIITIS (GPA) LIMITED TO UPPER RESPIRATORY TRACT--A CASE REPORT]

Granulomatosis with polyangiitis (Wegener's granulomatosis) is one of the anti-neutrophil cytoplasmic anti-body-associated small vessel vasculitides. Upper and lower respiratory system and kidneys are most commonly affected. The disease is characterized by granulomatous inflammation of the respiratory tract and necrotizing vasculitis of small to medium-sized blood vessels. Most patients show involvement of more than one organ systems at the time of diagnosis, and constitutional symptoms may be present. In around a quarter of patients the disease is initially localised, with involvement of upper respiratory tract or lungs. We report a 21-year-old female patient with chronic rhinitis, saddle nose deformity and subglottic stenosis who presented with inspiratory stridor and impending respiratory failure. Initially, urgent tracheotomy was performed. The patient was diagnosed with granulomatosis with polyangiitis limited to upper respiratory tract. Treatment with glucocorticoids and methotrexate was followed by clinical improvement.

Gray-scale and color duplex Doppler ultrasound of hand joints in the evaluation of disease activity and treatment in rheumatoid arthritis

AIM

To evaluate the role of gray-scale and color duplex-Doppler ultrasound (CDUS) in diagnosis of changes of hand joints and assessment of treatment efficacy in patients with rheumatoid arthritis (RA) by comparing qualitative and quantitative US parameters with clinical and laboratory indicators of disease activity.

METHODS

Ulnocarpal (UC), metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints in 30 patients with RA were examined by gray-scale and CDUS before and after six months of treatment. Morphologic and quantitative Doppler findings (synovial thickness, effusion quantity, vascularization degree, resistance index, velocities) were compared with clinical indicators of disease progression: disease activity score (DAS 28), Health Assessment Questionnaire (HAQ), rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), and C reactive protein (CRP).

RESULTS

Clinical indicators changed significantly after treatment: ESR from 38.1±22.4 mm/h to 27.8±20.9 mm/h (P=0.013), DAS 28 from 5.47±1.56 to 3.87±1.65 (P<0.001), and HAQ from 1.26±0.66 to 0.92±0.74 (P=0.030), indicating therapeutic effectiveness. In all MCP and UC joints we observed a significant change in at least one US parameter, in 6 out of 12 joints we observed a significant change in ≥2 parameters, and in 2 UC joints we observed significant changes in ≥3 parameters. The new finding was that the cut-off values of resistance index of 0.40 at baseline and of 0.55 after the treatment indicated the presence of active disease and the efficacy of treatment, respectively; also it was noticed that PIP joints can be omitted from examination protocol.

CONCLUSION

Gray scale and CDUS are useful in diagnosis of changes in UC and MCP joints of patients with RA and in monitoring the treatment efficacy.

[RETROSPECTIVE DATA ANALYSIS OF THE PATIENTS WITH INFLAMMATORY JOINT DISEASES TREATED WITH GOLIMUMAB IN CROATIA]

Golimumab is a human monoclonal antibody which inhibits tumor necrosis factor-alpha (TNF-α) and is approved for the treatment of inflammatory arthritides (rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis) when the conventional non-pharmacological and pharmacological therapies fail to cause remission or low disease activity. In this retrospective study there were included patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis who were treated in Croatia with golimumab, from June 2011 to June 2013. included and these retrospective data are compared with similar data from clinical trials and other available databases. Standard variables of disease activity and functional ability were observed. Results demonstrated significant efficacy of golimumab regarding lowring the disease activity and imrpving functional ability in pateints with these inflammatory rherumatic disease. In conclusion, in this retrospective study during two years treatment golimumab showed efficacy in decreasing disease activity and imrpove functional ability in patiemts with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.

[BONE MINERAL DENSITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS--OUR RESULTS]

INTRODUCTION

Patients with systemic lupus erythematosus (SLE) are at an increased risk of developing low bone mass (LBM) or osteoporosis, either because of the disease itself or due to its treatment. Osteoporosis and osteoporotic fractures significantly contribute to morbidity and mortality. We aimed to determine the associations of bone mineral density (BMD) changes with the duration of SLE, age, gender, and glucocorticoid treatment in SLE patients treated at our Department.

PATIENTS AND METHODS

BMD measurements of the lumbar spine and total hip were performed by dual-energy X-ray absorptiometry (DXA). Osteoporosis and LBM were determined according to the 1994 World Health Organization definition. In the statistical analysis, the independent Mann-Whitney U test and Tukey post-hoc testing were used.

RESULTS

The study included 48 SLE patients (44 female and 4 male), with a mean age of 45.8 years and an average SLE duration of 9.8 years. Osteoporosis was diagnosed in 21%, and LBM in 15% of the patients. The mean ages of the subgroups with normal BMD, LBM, and osteoporosis were 41.1, 47.6, and 59.0 years, respectively. Variant analysis showed a statistically significant correlation between age and BMD (p < 0.05). The duration of SLE was significantly shorter in patients with normal BMD (7.3 years), compared to patients with LBM (16.1 years) and osteoporosis (12.9 years) (p < 0.05). Nearly all patients (47 of 48) were on long-term treatment with glucocorticoids. One third (33.3 %) of patients did not take vitamin D3, and 56.3 % did not take calcium supplements.

CONCLUSION

The etiopathogenesis of decreased BMD in SLE patients is multifactorial and includes both traditional and SLE-related risk factors. In our group of SLE patients age and glucocorticoid treatment were the major risk factors for LBM. Timely prevention and treatment of LBM and osteoporosis in SLE patients, according to current knowledge, are essential for reducing morbidity and mortality.

Scabies in a Patient with Rheumatoid Arthritis Treated with Adalimumab - A Case Report

Rheumatoid arthritis is a chronic systemic inflammatory disease characterized by synovitis, erosions, and destruction of affected joints. If untreated, it leads to severe disability and premature mortality. Tumor necrosis factor alpha (TNF-α) inhibitors are biological drugs used in treatment of rheumatoid arthritis. Possible side effects include skin allergic reactions, which, if generalized, are the reason for discontinuation of the drug. We report the case of a 46-year-old female patient with rheumatoid arthritis who presented with pruritus and erythematous papular exanthema after administration of the second dose of adalimumab. At first, we suspected a drug hypersensitivity reaction. As the signs and symptoms persisted for 2 months after discontinuation of adalimumab and despite continuous administration of antihistamines and glucocorticoids, further work-up was performed, and scabies was diagnosed. The patient was treated with topical 10% crotamiton. The symptoms were persistent and additional applications of the preparation were needed. After clinical remission of scabies, treatment of active rheumatoid arthritis with adalimumab was restarted without any complications.

[Clinical manifestations of antineutrophil cytoplasmic antibodies associated vasculitis]

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides are rare diseases, with the average of 30 new cases per million inhabitants per year. Their main characteristic is systemic involvement with necrosis of the vessel walls (histological changes showing necrosis of the media and inflammation of adventitia and intima). In some forms granulomas may be found surrounding the vessels. ANCA-associated vasculitides include granulomatosis with polyangiitis (GPA, previously called Wegener's), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA, previously called Churg-Straus). Honorific eponyms are now changing to a disease-descriptive or etiology-based nomenclature. ANCA-associated vasculitides are a distinctive group of vasculitides because they dominantly involve small sized vessels, sometimes even medium sized vessels, are associated with antineutrophil cytoplasmic antibodies with high risk of developing glomerulonephritis and respond well to immunosuppresion with cyclophosphamide.

[Raynaud's phenomenon - first sign of malignancy: case report]

Raynaud's phenomenon is a common phenomenon in the general population. It most commonly occurs in healthy individuals, in whom there is no associated illness or any other cause of Raynaud's phenomenon (primary or idiopathic Raynaud's phenomenon). Secondary Raynaud's phenomenon is common with rheumatic diseases (systemic sclerosis, systemic lupus erythematosus, primary Sjögren's syndrome, mixed connective tissue disease, etc.), occlusive vascular diseases, hematologic disorders, use of vibrating tools and use of some medications, and rarely with malignancy. We report on a patient who presented with a three-week history of painful Raynaud's attacks, which was the reason for seeking assistance of internists in emergency clinic. Upon admission to the hospital and diagnostic work-up, adenocarcinoma of the lung was found. Antinuclear antibodies (ANA), anti-dsDNA antibodies, anticardiolipin IgM and IgG antibodies were present in a lower titer. It is known that rheumatoid factor or ANA characteristic of rheumatic disease are often present in patients with paraneoplastic rheumatic syndromes, which can lead to wrong conclusions about the possible systemic connective tissue diseases and ultimately delay the correct diagnosis. The first appearance of Raynaud's phenomenon as an isolated symptom in people older than 50, with painful signs of ischemia, as in our patient, or the occurrence of asymmetric grasping fingers, especially in men, regardless of the presence of RF, ANA, anti-dsDNA or other autoantibodies, requires broader diagnostic evaluation for malignancy.

[Comorbidities in patients with rheumatoid arthritis]

Comorbidity in rheumatoid arthritis (RA) patients significantly impairs and limits management of primary disease, decreases general quality of life, and worsens outcomes. Cardiovascular comorbidity is the leading cause of excess mortality in RA patients, which is up to two times higher compared to the general population. Infections, pulmonary disease and malignant diseases also contribute to excess mortality, while fatigue, depression and osteoporosis are related to decreased quality of life. Adequate management of RA patients should therefore, besides tight control of disease activity, also include comorbidity screening and management. This approach should improve both RA and comorbidity related outcomes.

[Henoch-Schönlein purpura with late-onset necrotising glomerulonephritis--a case report]

Henoch-Schönlein purpura (HSP) is the most common systemic vasculitis in children, while it is rare in adults. Typical clinical manifestations include palpable purpura without thrombocytopenia and/or coagulopathy, arthritis/arthralgia, abdominal pain, and/or renal involvement. In adulthood the disease tends to be more serious than in children, with renal manifestations developing over a period of several days to one month after initial symptoms. In this article we present a 22-year-old female patient with cutaneous vasculitis and arthralgia, in whom renal disease developed 8 weeks after disease onset with microscopic hematuria and proteinuria in urinalysis. Renal biopsy subsequently performed revealed focal necrotising glomerulonephritis with IgA deposits. The patient was treated with high dose methylprednisolone followed by gradual tapering, which induced complete remission of the disease. In conclusion, patients with HSP should be carefully monitored for systemic involvement, since serious renal disease can develop even as late as two months after disease onset.

[From unexplained fever to visceral leishmaniasis--a case report]

Visceral leishmaniasis or kala-azar is a systemic infectious vector-borne disease caused by protozoa Leishmania donovani and Leishmania infantum that are transmitted to mammalian hosts by sand flies. It occurrs sporadically in endemic areas, including Mediterranean basin. Southern coastal territories of Croatia have been recognized as the foci of the disease. Dogs are the main reservoir of human infection. Clinical features include prolonged fever, malaise, hepatosplenomegaly, pancytopenia and inversion of albumin-globulin ratio. If left untreated, the disease causes death in majority of cases. We report a 47-year-old Croatian patient who was admitted to hospital with 2-month history of fever of unknown origin. Based on bone marrow aspirate findings and positive serological tests, the diagnosis of visceral leishmaniasis was established. We also considered secondary hemophagocytic lymphohystiocytosis in the differential diagnosis. After a 4-week treatment with sodium-stibogluconate clinical remission was achieved as well as complete recovery of hematopoesis. The aim of our case-report is to stress the importance of considering visceral leishmaniasis in patients with longstanding fever in endemic areas.

[The proposal of Croatian Society for Rheumatology for anti-TNF-alpha therapy in adult patients with spondyloarthritides, 2013]

Croatian Society for Rheumatology of Croatian Medical Association updated the proposal for the application of TNF-alpha inhibitors in adult patients with spondyloartritides (SpA) in accordance with the new classification of SpA and european recommendations for the treatment of SpA with biologic agents. In this way a standardized method of diagnosis, targeted treatment, monitoring and evaluating outcomes are proposed.

[Gluten-sensitive enteropathy: a disease to take into consideration - a case report]

Gluten-sensitive enteropathy or celiac disease is a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals. Although the disease may manifest itself at any age, it occurs mostly in either early childhood or in the third or fourth decade of life. Malabsorption syndrome as a typical clinical feature is commonly absent. Patients may exhibit minor gastrointestinal complaints, as well as numerous extraintestinal manifestations. We report a 43-year-old female patient with mi gratory arthralgias as the leading symptom, fatigue, sideropenic anemia and mild intermittent diarrhoea, who was diagnosed with gluten-sensitive enteropathy. Four months after introduction of gluten-free diet the patient reported no arthralgias, and complete clinical response was achieved. The aim of our case-report was to show that migratory arthralgias can be an extraintestinal manifestation of gluten-sensitive enteropathy. Unexplained articular complaints should raise clinical suspicion of celiac disease.

[The proposal of the Croatian Society for Rheumatology for the treatment of adult rheumatoid arthritis patients with biologics, 2013]

Standardized approach to the patients with rheumatoid arthritis (RA) is one of the requirements of good clinical practice. Croatian Society for Rheumatology (HRD) of Croatian Medical Association (HLZ) updated the Proposed treatment of rheumatoid arthritis (RA) with biologic agents in line with recent findings in rheumatology for the last 3 years. By complying with the agreed standards of treatment we can avoid malpractice and irrational consumption, and to the most patients provide a greater chance for a favorable outcome.

[Large vessel vasculitides]

Large vessel vasculitis includes Giant cell arteritis and Takayasu arteritis. Giant cell arteritis is the most common form of vasculitis affect patients aged 50 years or over. The diagnosis should be considered in older patients who present with new onset of headache, visual disturbance, polymyalgia rheumatica and/or fever unknown cause. Glucocorticoides remain the cornerstone of therapy. Takayasu arteritis is a chronic panarteritis of the aorta ant its major branches presenting commonly in young ages. Although all large arteries can be affected, the aorta, subclavian and carotid arteries are most commonly involved. The most common symptoms included upper extremity claudication, hypertension, pain over the carotid arteries (carotidynia), dizziness and visual disturbances. Early diagnosis and treatment has improved the outcome in patients with TA.

Erectile dysfunction is frequent in systemic sclerosis and associated with severe disease: a study of the EULAR Scleroderma Trial and Research group

Introduction

Erectile dysfunction (ED) is common in men with systemic sclerosis (SSc) but the demographics, risk factors and treatment coverage for ED are not well known.

Method

This study was carried out prospectively in the multinational EULAR Scleroderma Trial and Research database by amending the electronic data-entry system with the International Index of Erectile Function-5 and items related to ED risk factors and treatment. Centres participating in this EULAR Scleroderma Trial and Research substudy were asked to recruit patients consecutively.

Results

Of the 130 men studied, only 23 (17.7%) had a normal International Index of Erectile Function-5 score. Thirty-eight per cent of all participants had severe ED (International Index of Erectile Function-5 score ≤ 7). Men with ED were significantly older than subjects without ED (54.8 years vs. 43.3 years, P < 0.001) and more frequently had simultaneous non-SSc-related risk factors such as alcohol consumption. In 82% of SSc patients, the onset of ED was after the manifestation of the first non-Raynaud's symptom (median delay 4.1 years). ED was associated with severe cutaneous, muscular or renal involvement of SSc, elevated pulmonary pressures and restrictive lung disease. ED was treated in only 27.8% of men. The most common treatment was sildenafil, whose efficacy is not established in ED of SSc patients.

Conclusions

Severe ED is a common and early problem in men with SSc. Physicians should address modifiable risk factors actively. More research into the pathophysiology, longitudinal development, treatment and psychosocial impact of ED is needed.

[Pathogenesis of polymyositis and dermatomyositis]

The idiopathic inflammatory myopathies, collectively called myositis, are a heterogeneous group of diseases of which polymyositis and dermatomyositis are the best known. These heterogeneous group of chronic disordes sharing the clinical symptom of muscle weakness and, in typical cases, inflammatory cell infiltrates in muscle tissue. There are four major types of idiopathic inflammatory myopathies: dermatomyositis, polymyositis, inclusion body myositis and immune-mediated necrotizing myopathies (autoimmune necrotizing myopathies). Clinical and histopatological distinctions between these conditions suggest that different pathogenic processes underline each of the inflammatory myopathies.

[Extra-articular manifestations of seronegative spondyloarthritides]

The term seronegative spondyloarthritides (SpA) is used to refer to a family of inflammatory rheumatic diseases characterised by inflammation of axial joints, asymmetric oligoarthritis and enthesitis, sometimes involving nonarticular structures, such as skin, heart, aortic valve, eye and kidney. The SpA consist of the following entities: ankylosing spondylitis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with IBD and undifferentiated spondyloarthritis. The prevalence of SpA in the population is 0,5-2%.

[Relapsing polychondritis--case report]

Relapsing polychondritis (RP) is a rare systemic inflammatory disease in which recurrent episodes of cartilage inflammation result in destruction of ears, nose and tracheobronchal tract. The joints, eyes, audiovestibular system and cardiovascular system can also be involved. About 30% of patients with RP have coexisting autoimmune disease, or malignant disease like colon, breast, and lung carcinoma, or malignant lymphoma. Pathogenesis is still unknown, and there is no consistent laboratory parameter specific for RP, which makes the diagnosis mainly clinical. Glucocorticoids are a mainstay of medical treatment of RP, whereas newer studies show positive effects of biological therapy. The course of RP is characterized by recurrent episodes of cartilage inflammation, and the prognosis has been recently improved because of improved medical and surgical treatment. We present a case of a patient with RP who was diagnosed 1 month after the development of first symptoms and responded well to glucocorticoid therapy.

The importance of urgent cytological examination of synovial fluids in differentiation inflammatory and non-inflammatory joint diseases

The aim of this study was to imply the possibilities of the urgent cytological examination of synovial fluids in differential diagnosis of arthropathies and to motivate the clinicians to use this method. It gave valuable information particularly with respect to differentiate the inflammatory and non-inflammatory joint diseases. This study included 115 synovial fluids obtained by fine needle aspiration (FNA) of the swollen knee from the patients in the period between 2003 and 2008. At our department the urgent cytological examination of the synovial fluids consisted of macroscopic analysis that includes volume, colour, clarity, viscosity and mucin clot test, native microscopic analysis for crystals and tissue fragments, counting the total nucleated cell count and semiquantitative microscopic analysis for neutrophil granulocyte percentage on the slides stained with Hemacolor rapid staining. All cytological analyses were done within one hour since FNA. According to our results the clarity, viscosity, mucin clot test, the total nucleated cell count and the neutrophil granulocyte percentage enabled distinction between inflammatory and non-inflammatory diseases with statistically significant difference at the 0.01 level but we could not differentiate these two groups of illnesses according to volume and colour. In inflammation the total nucleated cell count and the neutrophil granulocyte percentage was greater than in non-inflammation, the clarity was only translucent and opaque, the viscosity was low and the mucin clot test was negative. In non-inflammatory diseases the clarity varied from transparent to opaque, the total nucleated cell count and the neutrophil granulocyte percentage was smaller than in inflammatory diseases, the viscosity was high and consequently the mucin test was highly positive in all samples. Crystals were detected in only 12 samples of synovial fluids, mostly in inflammation and they were all monosodium urate (MUS) so we could diagnose gout. We could conclude that the urgent cytological analysis of the synovial fluid is a very useful, simple and reliable basic diagnostic screening test in differentiation inflammatory and non-inflammatory joint diseases and we recommended using it as the initial test in the diagnostic procedure of these illnesses using our protocol.

[Proposal for biologic drugs therapy in rheumatoid arthritis]

Rheumatoid arthritis is a chronic, inflammatory disease with the prevalence about 1%. Rheumatoid arthritis is characterized with synovitis, often evolve erosions of the joints, pain and functional deficit. Etiology is unknown, but the development of such autoimmune disease is due to genetic and environmental factors. Most of the patients with diagnosis of rheumatoid arthritis use nonbiologic disease modifying antirheumatic drugs. Advances in the undersstanding of the disease process have led to the development of biological agents to treat rheumatoid arthritis. With the use of biologic agents we wish to evolve the goal of therapy from that of symptomatiic relief to clinical remission. Biologic drugs have documented, fast and continuous efficacy with generaly well accepted safety profile. On behalf of Croatian Society for Rheumatology we propose recommendations for the biologic therapy in rheumatoid arthritis.

[Scleroderma renal crisis]

Systemic sclerosis (SSc) is a multisystem disease whose clinical manifestations result from inflammation, vascular injury and obliteration, and cutaneous and visceral fibrosis. Scleroderma renal crisis (SRC) occurs in 5% of patients with particullary diffuse form of SSc. It is characterized by malignant hypertension and oligo/ anuric acute renal failure. SRC was once a uniformly fatal complication of SSc. The prognosis of SRC has significantly improved with the introduction of angiotensin-converting enzyme inhibitors (ACEi) as treatment. The treatment of SRC relies on tight control of blood pressure and aggressive treatment with ACEi, if needed in combination with other types of antihypertensive drugs.

[Safety of rituximab in patients with rheumatoid arthritis]

RA is a chronic disease and long-term use of treatments that target TNF or B cells will be required for continued disease control. One approach to targeting B cells in RA is the use ofrituximab. It is a genetically engineered chimeric monoclonal antibody that selectively depletes peripheral B lymphocytes by binding CD20 on the cell surface. Long-term safety data show that rituximab treatment is associated with rates of infections and serious infections that remain stable over multiple treatment courses. Also, is associated with rates of malignancy consistent with data from the general RA population and is not associated with an increase in the rate of serious infections in patients who receive subsequent biologic treatment. In conclusion, rituximab is generally safe and well tolerated.

[Why do we need registries of patients on biologics drugs?]

Significant data on applied biologic drugs can be found in national registries of treated patients. The main reason of establishing registries is monitoring the efficacy and safety of biologic drugs in long-term treatment. Registries provide information on outcome of the disease, life quality, and risk-benefit ratio including society costs.

[Guidelines of the Croatian Society for Rheumatology for the treatment of knee and hip osteoarthritis]

Osteoarthritis of the hip and the knee belongs to one of the most disabiliting conditions. Treatment goals for these patients include a reduction in pain, an improvement in joint mobility and to limit functional impairment. To properly manage osteoarthritis, both nonpharmacologic (non-interventional) and pharmacologic modalities may be employed, while minority of patients will require surgery. According to the available evidence for available therapies and experts' opinion here we present guidelines for the treatment of hip and the knee osteoarthritis in Croatia.

Initial presentation of hereditary angioedema as abdominal pain and ascites in puerperium: case report

Hereditary angioedema is a rare genetic disorder resulting from an inherited deficiency or dysfunction of the C1 inhibitor. It is characterized by recurrent, circumscribed, and self-limiting episodes of cutaneous and mucous membrane swelling involving different organs. Hereditary angioedema may present with diverse clinical pictures, even within families with the same mutation. We present a first reported case of type 1 hereditary angioedema in a young woman presenting as recurrent abdominal pain associated with ascites without any other clinical features of hereditary angioedema, with initial presentation in puerperium. The recognition or awareness of hereditary angioedema as a cause of acute and/or recurrent abdominal pain associated with ascites is important, and may avoid unnecessary invasive procedures and facilitate appropriate treatment.

[Cardiovascular diseases and rheumatoid arthritis]

Morbidity and mortality rates are higher in rheumatoid arthritis (RA) patients than in the general population. RA is associated with an increased risk of cardiovascular disease. All of the cardiac structures can be affected during the course of RA. Rheumatoid arthritis, per se, is a cardiovascular (CV) risk factor as arterial hypertension, dyslipidemia and diabetes etc. Although the increased CV risk is acknowledged, limited attention is paid to detecting and managing CV comorbid conditions. Early identification, adequate CV risk management and ongoing monitoring of risk factors are mandatory to reduce the CV risk. Also, adequate control of arthritis disease activity is necessary to lower CV risk.

[Renal changes in vasculitis: case report]

Fifteen patients with vasculitis and renal manifestations have been analyzed. All patients had renal manifestation of vasculitis. Renal biopsy was performed in 13 patients: 6 patients had microscopic polyangiitis, 4 Wegener's granulomatosis, 2 microscopic polyangiitis limited to the kidneys and 3 polyarteritis nodosa. Renal biopsy was not performed in 2 patients. One patient had renal insufficiency and small kidneys and one patient had polyarteritis nodosa. The diagnosis of the polyarteritis nodosa in this last patient was made because of other clinical and laboratory data. Pauci-immune type of glomerulonephritis was found in 11 patients. The crescents, usually cellular, fibrocellular and rarely fibrotic, were present in 20-100% glomeruli. Renal insufficiency at baseline was present in 14 patients (creatinine 215-1224 micromol/L). Only one patient had borderline renal function when the diagnosis of vasculitis was made (creatinine 115 micromol/L). All patients with glomerulonephritis were treated with glucocorticosteroids and cyclophosphamide. Five patients with pulmonary manifestations of disease or advanced renal failure also were treated with plasmapheresis. Eight patients were treated by hemodyalisis. The complete or partial remission in the first year of the follow-up was reached in 9 patients, and 5 patients were treated by chronic dialysis due to chronic renal failure. One patient with Wegener's granulomatosis died after he developed toxic megacolon and postoperative sepsis.

[Lupus nephritis]

Systemic lupus erythematosus, an autoimmune disorder which predominantly affects young women, is frequently complicated by renal involvement. Lupus nephritis (LN) is characterized by immune-complex mediated glomerular and tubulointerstitial inflammation Ieading to chronic renal insufficiency in up to 30% affected patients. In patients with suspected lupus nephritis, renal biopsy may be used to confirm the diagnosis and determine appropriate therapy. The ISN/RPS classification of LN represents a significant advance over the 1982 WHO scheme. The treatment of lupus nephritis often consists of a period of intensive immunosuppressive therapy (induction therapy) followed by a period of less intensive maintenance therapy. The established treatment of lupus nephritis with cyclophosphamide and steroids has improved the outcome of LN but is burdened with significant adverse effects. Results of clinical studies showed that mycophenolate mofetil is equally effective with fewer toxic complications than standard therapy, but its long-term efficacy is not yet known. New therapeutic agents (biologic drugs) targeted to the pathogenetic mechanism of the disease are promissing improved efficacy with less toxicity. Despite recent advances, treatment of lupus nephritis remains a challenging clinical problem.

The role of endothelin-1 and nitric oxide in the pathogenesis of hypertension in diabetic patients

The pathogenesis of renal hypertension has not yet been fully clarified. As the potential role of endothelin-1 (ET-1) and nitric oxide (NO) has been postulated, their concentrations were determined in plasma and urine of diabetic patients. The study included 30 diabetic patients (both IDDM and NIDDM) with initial or advanced diabetic nephropathy (decreased endogenous creatinine clearance, proteinuria) and 20 healthy control subjects. The correlation with blood pressure and other renal function parameters was monitored and compared with the control group. Also, the effect of ACE inhibitors (ACEI) on ET-1 and NO patterns was monitored in correlation with arterial hypertension. In diabetic patients that did not receive ACEI therapy, the increase in plasma ET-1 was associated with both systolic and diastolic blood pressure elevation, whereas in those administered ACEI the increase in plasma ET-1 was associated with a systolic blood pressure decline. In addition, the increase in plasma NO was accompanied by a statistically significant decline of both systolic and diastolic blood pressure in diabetic patients receiving ACEI.

[Meloxicam--the balance of efficacy and safety]

NSAIDs remain the principal pharmacological agents used for symptom relief in patients with rheumatic disease. They represent the largest single group of drugs used worldwide. Given the large number of available NSAIDs, it is unsurprising that some differences exist among them with regard to mechanism of action, pharmacokinetics, and tolerability. How these differences affect the overall risks and benefits of treatment continues to be examined in clinical trials. Meloxicam is COX-2 selective NSAID with favourable gastrointestinal and thromboembolic safety profile.

Fatal toxic epidermal necrolysis and severe granulocytopenia following therapy with cefuroxime

Toxic epidermal necrolysis (TEN) is one of the most threatening adverse reactions to various drugs. No case of concomitant occurrence TEN and severe granulocytopenia following the treatment with cefuroxime has been reported to date. Herein we present a case of TEN that developed eighteen days of the initiation of cefuroxime axetil therapy for urinary tract infection in a 73-year-old woman with chronic renal failure and no previous history of allergic diathesis. The condition was associated with severe granulocytopenia and followed by gastrointestinal hemorrhage, severe sepsis and multiple organ failure syndrome development. Despite intensive medical treatment the patient died. The present report underlines the potential of cefuroxime to simultaneously induce life threatening adverse effects such as TEN and severe granulocytopenia. Further on, because the patient was also taking furosemide for chronic renal failure, the possible unfavorable interactions between the two drugs could be hypothesized. Therefore, awareness of the possible drug interaction is necessary, especially when given in conditions of their altered pharmacokinetics as in case of chronic renal failure.

[Rituximab (Mabthera)--treatment of rheumatoid arthritis patients with inadequate response to TNF inhibitors--when to change therapy?]

B cells play a critical role in the pathogenesis of rheumatoid arthritis. Recently, a number of biological agents that target B cells have been tested as therapies for these conditions. Of this group of agents, the first in clinical use has been rituximab, a chimeric monoclonal antibody that depletes B cells by binding to the CD20 cell-surface antigen. 25-40% of patients treated with a TNF inhibitor fail to achieve adequate response. A treatment response is inadequate if low disease activity or remission is not achieved. Treatment of patients with inadequate response to TNF inhibitors represents a challenge. What are the options? Switch to another anti-TNFalpha agent or initiate treatment with a biological agent with a different mechanism of action? In patients with persistent active disease despite anti-TNFalpha therapy, treatment with rituximab may be more effective than switching to another anti-TNFalpha.

[Cardiovascular disorders in rheumatoid arthritis]

Rheumatoid arthritis (RA) is associated with an increased risk of cardiovascular disease. Traditional cardiovascular risk factors (including male sex, family history for cardiovascular disease, age, dyslipidaemia, arterial hypertension, diabetes mellitus, smoking and obesity) do not adequately account for the extent of cardiovascular disease in RA. The pathogenesis of accelerated atherosclerosis in RA is not clear. Increasing evidence suggests a key role of inflammation in the onset and progression of atherosclerosis. Endothelial dysfunction represents the earliest manifestation of atherosclerosis. Hypertension prevalence in patients with RA is higher than that in the general population, It is attributable risk to the development of future cardiovascular events. Despite its serious complications, control of hypertension is far from adequate in the general population and even more so in rheumatoid arthritis patients.

[Alendronate and vitamin D (Fosavance): persistence, adherence and importance of vitamin D]

Persistence and adherence are major determinants of optimal results in the treatment of osteoporosis. In order to improve the efficacy of antiresorptive drugs, fewer demands on patients and better adherence were obtained with less frequent dosing schedule. Once-weekly and once-monthly oral bisphophonates showed equivalency with once daily medications. Comparison of persistence and adherence between weekly and monthly bisphosphonate regimens revealed conflicting results. In Croatia, persistence and adherence of weekly alendronate seem to be better than in other countries. In the light of compliance problems there is a need to assure adequate intake of vitamin D, because it is essential for prevention and treatment of osteoporosis and osteoporotic fractures. Vitamin D has other beneficial effects, particularly on neuromuscular performances. A high prevalence of vitamin D inadequacy was seen across all geographic regions. Weekly alendronate and vitamin D in one tablet provides proven fracture prevention at the spine and hip, and assure that patients receive a weekly dose of vitamin D.

[Rational pharmacotherapeutic pain treatment in seronegative spondyloarthropathies]

The aims of management in seronegative spondiloarthritides are to control pain and inflammation, maintain optimal mobility of spine and peripheral joints, restoration and preservation of functional ability, prevent contractures and deformities. Non-steroidal anti-inflammatory drugs are the basis of drug treatment. Numerous non-steroidal anti-inflammatory drugs have been shown to reduce pain and inflammation. Apart from non-steroidal anti-inflammatory drugs, in order to control the pain pure analgesics and weak opioids are the most often used drugs. In this paper is discussed use of these drugs in patients with seronegative spondyloarthritides.