1,720,965 research outputs found
Inefficacy or Paradoxical Effect? Uveitis in Ankylosing Spondylitis Treated with Etanercept
Full text linkAnkylosing spondylitis (AS) is presented with axial and peripheral articular involvement. Uveitis is a severe and rather specific manifestation of AS. Biologics targeting tumor necrosis factor (TNF) α are effective on both articular and ocular manifestations of disease. The occurrence of uveitis in patients that never had eye involvement or the relapse of uveitis is described during anti-TNFα treatment. The frequency of these events is slightly higher during therapy with etanercept. The available TNFα blockers show different pharmacokinetics and pharmacodynamics yielding different biological effects. There is an ongoing debate whether uveitis during anti-TNFα has to be considered as paradoxical effect or an inadequate response to therapy. Here, we present a case report and review what the evidences for the two hypotheses are
PRESENCE, GRADE AND LOCATION OF POWER DOPPLER PREDICT PROGRESSION OF RADIOGRAPHIC DAMAGE IN TNFα BLOCKER INDUCED CLINICAL REMISSION IN RHEUMATOID ARTHRITIS PATIENTS
No full textIdentification of distinct vascularization pattern in finger joint synovits in rheumatoid arthritis versus other forms of arthritis by contrast enhanced sonography: a preliminary study.
No full textBackground: Rheumatoid arthritis (RA) has among all forms of arthritides the worst outcome. Synovitis in RA is consistent with inflammation, synovial hyperplasia and neovascularization, that correlates with disease activity, aggressiveness and joint destruction. Contrast enhanced ultrasonography (CEUS) has been proven to be a very sensitive method in assessing synovitis in RA, equipollent to magnetic resonance imaging.1,2 The vascularization detected by CEUS in RA synovitis has not yet been compared to other forms of arthritis.
Objectives: To investigate by CEUS the pattern of synovial vascularization in RA and other arthritides and to find parameters able to discriminate between both.
Methods: 40 outclinic patients with arthritis of finger joints were recruited. 23 patients were affected from RA according to ACR criteria. 6 patients had severe, 11 moderate and 2 low disease activity using Das28 score. Of the 17 non RA patients 11 suffered from psoriatic arthritis, 1 from spondiloarthritis, 1 from osteoarthritis, 2 from connectivitis, 1 from septic arthritis, and 1 from arthritis in celiac disease. 5 patients presented severe, 11 moderate and 1 low disease activity. The most active joint was chosen for CEUS investigation. The hands were water-immersed and steady probe was used to increase resolution of superficial interfaces and to avoid artefacts by movement and inhomogenous gel application. Endovenous bolus injection of Sonovue was performed. For image acquisition contrast tune imaging with low mechanical index was used. Software able to recognise different articular structures and to assess pixel properties of contrast enhancement was devised by our bioengineers.
Results: The most active joint of the hands in 23 RA (21 MCF and 2 IFP) and 17 patients affected by other forms of arthritis (12 MCF and 5 IFP) was analysed after contrast administration. The software identified various contrast flow parameters. 8 parameters resulted helpful in discriminating the RA from the non RA group: synovial wash-in and wash-out velocity, synovial peak intensity, fraction of synovial, capsular and peripheral-entheseal pixels, fraction of synovial and peripheral high intensity pixels. The importance for diagnosis of the single parameters was calculated by linear discriminator analysis and summed to an vascularization pattern identifying RA patients. By using this pattern 22 out of 23 RA patients resulted true positive and 1 as false negative compared to clinical diagnosis, whereas true negative results were seen in 16 out of 17 non RA patients and 1 false positive in a patient showing the rheumatoid variant of psoriatic arthritis. The sensibility and specificity was 91% and 94%. The positive predictive value was 95% and the negative predictive value 88%.
Conclusion: We found by CEUS a pattern of vascularization in synovitis of rheumatoid arthritis different from that found in other forms of arthritis. In patients with arthritis CEUS represents available application to detect rheumatoid arthritis with worse prognosis and to lead therapeutic decision
Effects of half dose etanercept (25 mg once a week) on clinical remission and radiographic progression in patients with rheumatoid arthritis in clinical remission achieved with standard dose.
No full textOBJECTIVES:
This prospective long-term follow-up study evaluated the effects of half-dose etanercept (25 mg weekly) on clinical remission and radiographic progression in a large cohort of patients with rheumatoid arthritis (RA) in clinical remission after etanercept 25 mg bi-weekly.
METHODS:
524 biologic-naïve RA patients were treated with etanercept 25 mg bi-weekly after failure of conventional drugs. Patients achieving remission (DAS28 <2.6) for ≥12 months were randomised to receive etanercept 25 mg weekly or 25 mg bi-weekly. Patients were assessed at baseline and every 12 weeks. Remission rates, radiographic progression, incidence of infections and costs of the regimens were compared.
RESULTS:
After a mean follow-up of 18±11 months, 347 patients (66.2%) achieved DAS28 remission; 323 were randomised to one of two dose regimens: etanercept 25 weekly (group A, 159 patients) and etanercept 25 mg bi-weekly (group B, 164 patients). At the end of follow-up, 81.8% patients of group A maintained remission for a mean of 3.6±1.5 years. Radiographic progression occurred in a small number of patients of group A and the rate of radiographic progression (TSS >0) was not significantly different in the two groups (18.85% vs. 19.0% after the first year and 16.9% vs. 21.6% after the second year, respectively). The incidence ratio of severe infections was 2.3/1.000 patient-years in group A. Etanercept half-dose regimen resulted in a saving of €3.190.545 with a cost saving up to €827.318 per year.
CONCLUSIONS:
Clinical remission and arrest of radiographic progression persisted in a substantial percentage of patients with RA even after reduction of standard-dose etanercept
Anakinra, a recombinant human IL-1 receptor antagonist, in clinical practice. Outcome in 60 patients with severe rheumatoid arthritis
No full textAbstract
OBJECTIVE:
We evaluated both the efficacy and safety of anakinra in daily routine rheumatoid arthritis clinical practice.
METHODS:
We studied 60 cases, including patients with previous anti-TNFalpha exposure, treated with anakinra (100 mg/daily s.c.) in combination with methotrexate (7.5-10 mg/week i.m.) or leflunomide (20 mg/die) in a two year observational study. Efficacy measures were assessed using the American College of Rheumatology (ACR) response criteria. Safety was evaluated according to a modified World Health Organization adverse reaction term dictionary.
RESULTS:
At week 14, ACR 20% response criteria have been fulfilled by 53 (91.3%) out of 58 patients, 51 (87.9%) of them achieving also an ACR 50%and 15 (25.8%) an ACR 70%response. Thirteen patients touched 102 weeks of treatment: ACR 20% response was achieved in 92.3%, while ACR 50% and ACR 70% were respectively found in 84.6% and 38.4% of the cases. The mean decrease in HAQ score was 0.38, p<0.001. Of the 16 patients who were previously treated with anti-TNFalpha blockers, 81.2% responded to anakinra. There was no significant difference in the ACR response between groups with and without previous anti-TNFalpha exposure. Seventeen patients (28.3%) stopped anakinra because of side-effects (5%) or failure to respond (23.3%). Only 4 cases of pulmonitis, of which 2 have been hospitalised, and 1 case with tuberculosis (previously treated with infliximab) were observed.
CONCLUSIONS:
Our clinical experience confirms that anakinra is effective and safe in the treatment of rheumatoid arthritis. Anakinra seems also useful in patients with previous anti-TNFalpha blockers failures. Even though major adverse events were rare, clinicians should be aware of such a possibility
Economia articolare e artrite reumatoide: risultati di uno studio randomizzato controllato
No full textL’economia articolare (EA) è un insieme di interventi riabilitativi che possono essere utilizzate nei pazienti con artrite reumatoide (AR), con l’obiettivo di diminuire o rallentare i deterioramenti articolari e di superare gli ostacoli che si presentano nelle normali attività della vita quotidiana. Essa comprende l’educazione gestuale, l’addestramento all’uso di tutori, l’adattamento dell’ambiente circostante e la formazione-informazione del malato cronico. In Italia, da quanto ci risulta, questo approccio appare ancora poco diffuso nella pratica riabilitativa; lo scopo di questo studio era, pertanto, quello di verificare la validità di un corso di EA in un gruppo di pazienti affetti da AR medio-grave residenti in Veneto.
Sono stati reclutati 85 pazienti dell’età media di 53.7 anni (DS 11.6, range 34-78 anni), randomizzati in due gruppi: gruppo di trattamento (GT), composto da 36 pazienti dell’età media di 54.2 anni (DS 9.8, range 33-68 anni) che partecipavano ad un corso di EA, e gruppo di controllo (GC) composto da 33 pazienti dell’età media 46.2 anni (DS 11.9, range 29-64 anni) che seguivano soltanto il trattamento medico. Il corso di EA prevedeva 3 incontri in cui i pazienti con AR erano informati sugli aspetti fisiopatologici ed evolutivi della malattia, addestrati all’esecuzione di esercizi e gestualità corrette da praticare nella vita quotidiana insieme a suggerimenti sull’effettuazione di piccole modifiche ambientali e, infine, istruiti sulle normative vigenti a tutela del malato reumatico.
La valutazione dei risultati veniva effettuata somministrando, all’inizio e alla fine dello studio, la scala visuo-analogica (VAS) per la valutazione del dolore, l’Health Assessment Questionnaire (HAQ), l’Arthritis Impact Measurement Scale (AIMS) e lo Short Form-36 Health Survey (SF-36) per la valutazione, rispettivamente, dello stato di salute e della disabilità nei sui vari aspetti, e l’Health Service Interview (HSI) per la valutazione del grado di conoscenza della propria malattia.
Risultava, dopo un tempo medio di 7 mesi, che i pazienti che hanno partecipato al corso di EA presentavano miglioramenti significativamente superiori ai controlli sul sintomo dolore, la disabilità motoria e funzionale e lo stato di salute generale; conseguentemente, anche la qualità di vita ne risultava migliorata. Infine, dall’analisi dell’HSI risultava che i pazienti presentavano uno scarso grado di conoscenza della patologia reumatica e delle sue conseguenze. In base ai risultati del presente studio, si poteva ritenere che l’EA è utilmente inseribile tra gli interventi terapeutici nei pazienti con AR
Dynamic Automated Synovial Imaging (DASI) For Differentiating Between Rheumatoid Arthritis And Other Forms Of Arthritis: Automated Versus Manual Interpretation In Contrast-Enhanced Ultrasound
No full textBackground: Rheumatoid arthritis (RA) is the most aggressive chronic arthritis and affects about 1% of population, impacting severely both the individual wellbeing and the health care system. Early diagnosis and effective treatment can avoid the devastating outcome of RA1, but the differential diagnosis is especially difficult at its onset. The diagnosis relies on conventional methods (clinical parameters, autoantibodies), even if distinct vascularization patterns have been identified in biopsy specimens2. Contrast-enhanced ultrasound (CEUS) allows a non-invasive dynamic study of synovial vascularisation and perfusion, although its capacity in differentiating among different arthritis forms has not yet been evaluated3,4.
Objectives: to investigate the performance of quantitative analysis of CEUS data versus manual semiquantitative assessment in differentiating RA from other arthritis (non-RA).
Methods: 78 outclinic patients with finger joints arthritis were recruited, 33 with RA and 45 with other arthritis. The most active joint was chosen for CEUS examination as previously described3, using a US device (MyLab25, Esaote) equipped with Contrast tuned Imaging (CnTI, Esaote), and as contrast agent sulfur hexafluoride microbubbles (SonoVue; Bracco International). Both the anatomical B-mode image and the CnTI cineloop video were digitally stored for subsequent quantiative analysis or manual review. Two in arthritis experienced radiologists manually assessed the examinations as consistent with RA or not. Quantitative image analysis was performed firstly applying a semi-automatic detection of synovial boundaries5. Then, the contrast time-activity curve of all pixels belonging to the synovial and perisynovial region was analysed fitting a gamma curve f(t)=A(t-t0)a×e(t-t0)/b on the data. The statistics summarizing the distribution of the estimated kinetics parameters in the synovial and in the perisynovial tissue were computed and their difference between the two groups (RA and non-RA) analyzed, so to study the existance of different vascularization or flow patterns. Finally, a supervised classifier (random forest) was trained to classify each patient through its CEUS-derived parameters, validating the classifier diagnostic power using a leave-one-out strategy.
Results: Manual assessment of CEUS examination consistent with RA or non-RA performed by radiologists showed high sensitivity (0,9), but indeed low specificity and accuracy (0,46 and 0,69, respectively). On the contrary, the classifier using CEUS quantitative parameters showed both good sensitivity (0,88) and specificitity (0,94), resulting in a diagnostic accuracy of 0,92.
Conclusions: The Dynamic Automated Synovial Imaging (DASI) proposed provided a high accuracy in discriminating RA from non-RA arthritis. DASI promises to be a powerful tool for the diagnosis and follow-up of arthritis, attributing to CEUS a new role in the field
Update Of Disease Activity Assessment In Rheumatoid Arthritis: Comparison Between Clinical, Ultrasound And Mri Scores And Introduction Of Volumetric Inflammation Measure Concept
No full textBackground: Therapeutic decisions in rheumatoid arthritis (RA) are driven by the estimated grade of disease activity. It is clinically evaluated by composite scores such as DAS28, SDAI and CDAI (1). Ultrasound (US) and MRI imaging of the joints provide further characterization of disease activity. US assessments search for the presence of synovitis, joint effusion and Power Doppler (PD) scored semi-quantitatively from 0-3 on joints of DAS28 or proposed reduced score systems (2). MRI joint imaging is evaluated through RAMRIS (RA MRI Scoring) grading separately with a semi-quantitative score (0-3) synovitis after contrast enhancement (CE-MRI), extension of bone marrow edema and erosions on 7 joints of each hand. In 2010 SAMIS (Simplified RA MRI Score) was proposed for reducing examination time by analyzing the most tender or dominant hand only (3). Despite all efforts for objectively quantifying disease activity, all evaluations depend on the subjective feeling of patient or examiner and on the interpretation of imaging data.
Objectives: Comparison of clinical, US and MRI scores and volumetric measure of synovial inflammation by dedicated MRI software.
Methods: Methods: Clinical data (CRP, ESR, DAS28, CDAI, SDAI and HAQ) were collected from 32 RA patients. Rheumatologists assessed further the number of joints positive for presence of synovitis, effusion and PD (DAS28 and 12-joint US score). Three radiologists independently performed RAMRIS and SAMIS validation on CE-MRI. Moreover, an software was developed in house to estimate total volume of contrast perfusion in joint spaces of both hands. Correlations were analyzed by Spearmen test.
Results: SAMIS and RAMRIS correlated significantly for synovitis, edema and erosions (p<0,0001). Interoperator agreement was nearly perfect (Kendall coefficient=0,99). SAMIS and RAMRIS synovitis correlated significantly with DAS28, SDAI, CDAI, HAQ, PCR and ESR (p<0,05), whereas US scores did neither correlate with MRI nor clinical scores. The measure of “inflammation volume” estimated with the software was assumed to be a proxy of synovitis, but did not correlate with clinical, US and MRI scores.
Conclusions: MRI remains the gold standard for estimating disease activity in RA, since it correlates with clinical scores more than US-derived scores. Software evaluation of total contrast perfusion or “synovitis volume” is an objective measurement that might provide an independent variable, but its role has yet to be fully tested
AB0953 A Comparison of Region-Based and Pixel-Based CEUS Kinetics Parameters in the Differentiation of Rheumatoid Arthritis and Simil-Rheumatoid Psoriatic Arthritis
No full textElderly onset of primary Sjogren's syndrome: Clinical manifestations, serological features and oral/ocular diagnostic tests. Comparison with adult and young onset of the disease in a cohort of 336 Italian patients.
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