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Adult-onset Still's disease: still a long way to go. Comment on the article 'Adult-onset Still's disease: review of 41 cases' by Riera et al.
No full textSirs,
We have read with great interest the article
by Riera et al., describing clinical and laboratory
characteristics of a large cohort of patients
with adult-onset Still disease (AOSD),
recently published in Clinical and Experimental
Rheumatology (1).
We agree that serum ferritin levels are very
useful both to diagnose and to monitor patients
with AOSD. Our work, previously
published in Seminars in Arthritis and Rheumatism
suggests that ferritin may be a useful
prognostic factor, perhaps in combination
with others (2). Interestingly, as shown in
Table I, comparing serum ferritin levels in
patients with chronic systemic and chronic
articular disease at the time of diagnosis and
6 months later, it is possible to infer that the
persistence of high ferritin levels, after adequate
treatment may predict a chronic articular
course.
Our experience with anti-TNF-α agents, partially
presented at the 2007 ACR meeting, is
also corroborated by that of Riera et al. Anti-
TNF-α medicines, in fact, may be helpful in
controlling systemic and articular symptoms
of refractory AOSD. Our data have suggested
that TNF-α blockade would not be as effective
in slowing down the articular damage
as in improving systemic and osteo-articular
symptoms This leads to the awareness that
anti-TNF-α agents should not be a conceivable
first line therapy in AOSD. Owing to a
more reassuring safety profile and a more targeted
action, as well as more evidence-based
effectiveness, we think that interleukin-1
receptor antagonist anakinra could actually
be considered a first line choice in AOSD
patients (3, 4).
Although AOSD has usually been considered
a benign disease, we think it is worth pointing
out that patients with the systemic form of the
disease should be closely monitored because
of the possibility of life-threatening complications,
that could also represent the heralding
manifestation of the disease (5-8).
In conclusion, we think that a multi-centre
study aimed at the identification and validation
of a set of diagnostic criteria should be
encouraged. There are currently several classification
criteria for AOSD, but those of
Yamaguchi are the most used (9). However, it
is worth recalling that the latter are not specified
in detail; in particular the exclusion criteria
provide only general recommendations
and there is no precise list of diagnoses or
set of laboratory tests to be performed. The
second important limitation is that serum ferritin
and its glycosylated component are not
included as is in Fautrel’s proposed criteria
(10). Besides, Yamaguchi’s criteria give the
possibilty to classify AOSD patients as having
no fever. As far as fever is concerned, we
think that a feverish polyarthritis should be a
sine qua non criteria for suspecting a diagnosis
of AOSD. Larger, prospective studies are
also needed to identify reliable prognostic
factors
Pamidronate and zolendronic acid in the treatment of Paget’s disease of bone.
No full textAbstract: Paget’s disease of bone (PDB) is a condition characterized by excessive and abnormal bone remodelling. Due to a high rate of bone remodelling, bisphosphonates, and especially pamidronate and the newer zolendronate, are indicated in the treatment of PDB. The presence of asymptomatic, but active PDB represents an indication for treatment aimed at preventing later complications.
An additional indication for treatment is the involvement of skeletal segments that may give rise to severe complications. Pamidronate has a long history in the treatment of PDB. The more utilised regimen is 3 to 6 i.v. infusion of 60 mg of pamidronate at an infusion rate of 1 mg/min within 3–21 days. Zolendronate (5 mg once yearly) is the most powerful amino-bisphosphonate currently used. This primacy recognizes both the ability to inhibit the farnesyl-pyrophosphate synthetase and the higher affinity to hydroxyapatite crystals as a cause.
Both pamidronate and zolendronate are effective in PDB, with an evidence-based superiority of the latter.
Keywords: Paget’
"Ultrasonography in Diagnosis and Follow-Up of Temporal Arteritis: An Update" In Challenges in Rheumatology"
No full textUpdate clinico sull'arterite gigantocellulare e sul ruolo della ecografia dopler nella diagnosi e follow-u
Adult onset Still’s disease
No full textAdult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder characterised by high spiking fever, an evanescent salmon pink rash and arthritis,frequently accompanied by sore throat, myalgias, lymphadenopathies,
splenomegaly and neutrophilic leukocytosis.
Aetiology is still unknown, however, it seems that an
important role is played by various infectious agents, which
would act as triggers in genetically predisposed hosts.
Diagnosis is a clinical one and may be lengthy because it
requires exclusion of infectious neoplasms, including
malignant lymphomas and leukaemias, and other autoimmune
diseases. Different diagnostic or classification criteria
have been proposed, but not definitely accepted. There are
no specific laboratory tests for AOSD, but they reflect the
systemic inflammation: the ESR is consistently high, while
the rheumatoid factors and antinuclear antibodies are negative.
High serum ferritin levels associated with a low fraction
of its glycosylated component are assessed as useful
diagnostic and disease activity markers. The clinical course
can be divided into three main patterns with diVerent
prognoses: self-limited or monophasic, intermittent or polycyclic
systemic and chronic articular pattern. Therapy
includes non-steroidal anti-inXammatory drugs, corticosteroids
and disease modifying anti-rheumatic drugs: biological
agents have recently been introduced and they seem tobe very promising not only for the treatment but also for
understanding the pathogenic mechanisms underlying the
disease
Semeiotica della caviglia
No full textTrattazione di taglio didattico della semeiotica clinica ed ecografica della cavigli
Epidemiology of gout and chondrocalcinosis
No full textGout is the most common cause of inflammatory arthritis affecting at least 1% of the population in industrialized countries. It is closely associated with hyperuricemia and is characterized by formation and reversible deposition of monosodium urate crystals in joints and extra-articular tissues. Several studies suggest that the prevalence and incidence of gout are rising. Numerous risk factors may in part explain this increasing trend including dietary and lifestyle changes, genetic factors, diuretic use and comorbid conditions such as hypertension, diabetes, cardiovascular disease, chronic renal disease and the metabolic syndrome. Chondrocalcinosis is characterized by the deposition of calcium pyrophosphate crystals in articular tissues, most commonly fibrocartilage and hyaline cartilage. Sporadic chondrocalcinosis is a common condition in the elderly and frequently associates with osteoarthritis. Hereditary haemochromatosis, hyperparathyroidism and hypomagnesaemia are metabolic disorders that predispose to secondary chondrocalcinosis.The prevalence of chondrocalcinosis is still rather uncertain and varies depending on the diagnostic criterion used in different studies
Rehabilitation Treatment Strategies in Ankylosing Spondylitis
No full textWe read with great interest the recent article by Masiero, et al regarding the
efficacy of exercise combined with an educational-behavioral program in
patients with stabilized ankylosing spondylitis (AS)1.
We agree that physical therapy has remained a mainstay for the treatment
of AS in order to reduce pain, preserve spinal flexibility, prevent postural
deformities, and improve muscle strength. Although tumor necrosis
factor-α (TNF-α) antagonism has dramatically changed the therapeutic
opportunities for patients with AS by providing symptom relief and thus
improving quality of life, it is very expensive for the national health system.
In this perspective, rehabilitation combined with an educationalbehavioral
program could represent an effective choice for those AS
patients in remission after the discontinuation of anti-TNF-α agents. We
agree with Masiero, et al that the “old” rehabilitation therapy is regaining
credit in this “new” biologic era.
Our work2 indicated that combination treatment with etanercept and an
intensive spa rehabilitation program was more effective than pharmacological
therapy alone in a large group of patients with AS. In particular, our
data demonstrated that the quality of life, as measured by EQ-5D visual
analog scale, showed a statistically significant improvement in favor of the
combination therapy group. The main limitation of our study was that it
was not randomized.
Rehabilitation treatment should be conducted in all AS patients because
of its effectiveness and its safety, even more if carried out in a supervised
spa setting3. But to date we have no data permitting us to understand
whether this therapeutic strategy can yield a consistent benefit over the very
long natural history of AS, and further studies with longer followup are
required. It would be of great interest to evaluate the efficacy of the combination
therapy in patients with early axial spondyloarthropathies, in whom
a greater improvement would be expected. It is also worth recalling that, in
Italy and in other countries, rehabilitation represents an additional fee for
patients. Therefore, a joint effort to establish the effectiveness of rehabilitation
in AS and to ensure patients’ access to rehabilitation programs is needed.
Indeed, there is the possibility that these combined strategies may result
in substantial longterm savings by the national health syste
The Role of Micro-RNAs in Rheumatic Diseases: An Update
No full textIn this article we summarize the new acquisitions about the growing importance of miRNAs in rheumatic diseases as pathogenetic factors, potential biomarkers and possible new therapeutic targets. We also focus on new developments about the possible role of miRNA in the pathogenesis of psoriatic arthritis (PsA) on the basis of our recent experimental results
Note su cristianesimo e modernità
No full textRecensione a "In lotta con l'angelo : la filosofia degli ultimi due secoli di fronte al cristianesimo", a cura di Claudio Ciancio, Giovanni Ferretti, Annamaria Pastore, Ugo Peron
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