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Effetti della fango-balneoterapia sulle manifestazioni cliniche e sull'infiammazione sinoviale valutata mediante ecografia con mezzo di contrasto (CEUS) in pazienti con artrite psoriasica in trattamento con farmaci inibitori del tnf-alfa
Full text linkBackground
Mud and thermal baths have been used for millennia for the treatment of rheumatic diseases and musculoskeletal disorders in general.
The effects of these therapies on inflammation are complex and are not fully understood. However, recent basic research has shown favorable results on animal models of chronic inflammation.
Numerous scientific publications demonstrated utility of thermal therapy in combination with pharmacological treatment in some chronic inflammatory rheumatisms, especially in ankylosing spondylitis. Less is reported for psoriatic arthritis (AP), although psoriasis is a very common disease and profits from thermal water.
This study aims to evaluate the effects of mud-bath therapy, in addition to pharmacological therapy with inhibitors of TNF-alpha, on the clinical manifestations of psoriatic arthritis (PA). Further it intends to test effects of thermal therapy on residual articular inflammation as measured by contrast-enhanced ultrasound (CEUS) at synovial level.
Methods
This is a single-center, experimental, controlled, randomized, open-label pilot study.
After obtaining permission from the local ethics committee, 32 patients with AP (24 women and 8 men, mean age 53.2 years and mean duration of illness of 11.8 years), in follow-up in the rheumatology clinics of Padua, who had peripheral joint involvement and were treated with anti TNF-alpha for at least six months were enrolled. Patients were randomized into two groups: patients in group A were subjected to a series of mud-bath therapy in combination with pharmacological therapy, while patients in group B (controls) continued pharmacological therapy alone. Both groups were evaluated at time 0 (T0: baseline) and after 45 days (T1).
The mud-bath therapy treatment was performed in a spa of Montegrotto, according to the classical scheme used at the Terme Euganee.
All patients underwent clinical evaluation index, biochemical parameters, and validated questionnaires to measure disease activity and health status perceived by the patient (DAS28, inflammatory markers, number of swollen and tender joints, GH, VAS pain, BASDAI, PASI, HAQ, SF-36).
Both patients in group A and control group B underwent in time T0 and time T1 with CEUS in order to detect the residual joint inflammation. The films obtained were evaluated first by a blinded experienced radiologist and then processed with dedicated software, developed in collaboration with the Institute of Bioengineering.
Results
In the group of patients treated with pharmacological therapy alone (group B), most of the examined parameters (CRP, DAS28, swollen joints, tender joints, VAS, BASDAI, and PASI SF36) showed no statistically significant variations between T0 and T1 .
In contrast, in the group of patients undergoing thermal therapy (group A), the number of swollen joints and tender joints were reduced, and DAS28, VAS, BASDAI, HAQ, SF36 and PASI improved.
The radiologist analyzed films in T0 and T1 and did not detect differences between the group of subjects treated with the combination mud-bath therapy - anti-TNF alpha (group A) and those treated only with anti-TNF alpha (group B). However, software processing of contrast enhancement detected a more favorable variation of kinetic parameters in group A in agreement with the clinical and subjective improvement reported by patients undergoing the cycle of thermal therapy.
Discussions and Conclusions
The improvement in DAS28 and other indexes in the clinical assessment of the group of patients undergoing mud-bath therapy and their deterioration in the group treated only with anti-TNF-alpha demonstrates the favorable effect of thermal treatment in psoriatic arthritis.
This beneficial effect occurred also on the skin lesions, as confirmed by the improvement of PASI index that defines the extent and severity of psoriasis.
These results are consistent with those of the few controlled studies published in literature.
CEUS, an imaging method highly sensitive to evaluate the joint inflammation, showed that locally in the joints examined there was no worsening of arthritis due to mud-bath therapy.
The processing of movies with a dedicated software, specifically designed to assess more accurately contrast enhancement, has instead found a different variation of kinetic parameters between the two groups. In particular, patients treated with drug therapy alone would seem to present a slight increase in joint inflammation at time T1 compared to baseline, while those also treated with mud-bath therapy would show the opposite trend.
The study has finally confirmed the effectiveness of mud-bath therapy in addition to anti-TNF-alpha therapy in psoriatic arthritis.Background
I fanghi ed i bagni termali sono utilizzati da millenni per la cura delle malattie reumatiche e in generale delle affezioni dell'apparato locomotore.
Complessi e ancora non del tutto chiariti sono gli effetti delle applicazioni termali sui fenomeni infiammatori. Recenti ricerche di base hanno comunque evidenziato risultati favorevoli delle applicazioni di fango su modelli sperimentali animali di flogosi cronica.
Numerosi lavori della letteratura scientifica pubblicati negli ultimi anni hanno dimostrato l'utilità della terapia termale anche in alcuni reumatismi infiammatori cronici, in associazione alla terapia farmacologica. In particolare, numerose esperienze sono state condotte nella spondilite anchilosante, mentre poco è stato riportato per l'artrite psoriasica (AP), nonostante la psoriasi sia una patologia molto diffusa e siano stati dimostrati gli effetti favorevoli di alcune acque termali sulle lesioni cutanee.
Questo studio si propone di valutare gli effetti della fango-balneoterapia, in aggiunta alla terapia farmacologica con inibitori del TNF-alfa, sulle manifestazioni cliniche dell'artrite psoriasica (AP). Intende inoltre verificare gli effetti di un ciclo di cura termale sulla flogosi articolare residua, valutata mediante ecografia con mezzo di contrasto (CEUS).
Metodi
Si tratta di uno studio pilota monocentrico, sperimentale, controllato, randomizzato, in aperto.
Dopo aver ottenuto l'autorizzazione dal comitato etico locale, sono stati arruolati 32 pazienti affetti da AP (24 donne e 8 uomini, di età media 53,2 anni e con durata media di malattia di 11,8 anni), in follow-up negli ambulatori della Reumatologia di Padova, che presentavano interessamento articolare periferico ed erano in trattamento con farmaci anti TNF-alfa da almeno sei mesi. I pazienti sono stati randomizzati in due gruppi: i pazienti del gruppo A sono stati sottoposti ad un ciclo di fango-balneoterapia in associazione alla terapia farmacologica, mentre i pazienti del gruppo B (controlli) hanno continuato la sola terapia farmacologica. Entrambi i gruppi sono stati valutati al tempo 0 (T0: baseline) e dopo 45 giorni (T1).
Il trattamento fango-balneoterapico è stato effettuato in uno stabilimento termale di Montegrotto, secondo lo schema classico utilizzato alle Terme Euganee.
Tutti i pazienti sono stati sottoposti a valutazione di indici clinici, parametri bioumorali e questionari validati per misurare l'attività di malattia e lo stato di salute percepito dal paziente (DAS28, indici di flogosi, numero di articolazioni tumefatte e dolenti, GH, VAS del dolore, BASDAI, PASI, HAQ, SF-36).
Sia i pazienti del gruppo A sia quelli di controllo del gruppo B sono stati sottoposti al tempo T0 e al tempo T1 ad ecografia con mezzo di contrasto (CEUS), in grado di rilevare anche l'infiammazione articolare residua. I filmati ottenuti sono stati valutati prima in cieco da un Radiologo esperto e successivamente elaborati con un software dedicato, sviluppato in collaborazione con l'istituto di Bioingegneria.
Risultati
Nel gruppo dei pazienti trattati con la sola terapia farmacologica (gruppo B), la maggior parte dei parametri esaminati (PCR, DAS28, articolazioni tumefatte, articolazioni dolenti, VAS, BASDAI, SF-36 e PASI) non ha mostrato variazioni statisticamente rilevanti tra T0 e T1.
Nel gruppo dei pazienti sottoposti a terapia termale (gruppo A), nelle valutazioni effettuate 30 giorni dopo il ciclo di cura, si è ridotto il numero delle articolazioni tumefatte e delle articolazioni dolenti, e sono migliorati DAS28, VAS, BASDAI, HAQ, SF-36 e, PASI.
L'analisi visiva dei filmati al tempo T0 e T1 da parte del Radiologo non ha rilevato diversità tra il gruppo dei soggetti trattati con l'associazione fangobalneoterapia - anti-TNF alfa (gruppo A) e quelli trattati solo con anti-TNF alfa (gruppo B). Le elaborazioni software dei filmati hanno inoltre rilevato una differente variazione di alcuni parametri cinetici tra i due gruppi nell'enhancement del mezzo di contrasto, concordi con il miglioramento clinico e soggettivo riferito dai pazienti sottoposti al ciclo di terapia termale.
Discussione e conclusioni
Il miglioramento del DAS28 e degli altri indici clinici di valutazione nel gruppo di pazienti sottoposti al ciclo di fango-balneoterapia e il loro peggioramento nel gruppo trattato solo con farmaci anti-TNF-alfa dimostra l'effetto favorevole della cura termale nell'artrite psoriasica.
Tale effetto benefico ha riguardato anche le lesioni cutanee, come confermato dal miglioramento del PASI, indice che definisce l'estensione e la gravità della psoriasi.
Questi risultati sono in linea con quelli dei pochi studi controllati pubblicati in letteratura.
La CEUS, metodica di imaging molto sensibile nel valutare l'infiammazione articolare, ha dimostrato che anche a livello locale nelle articolazioni esaminate non vi era accentuazione dell'artrite nei due gruppi di pazienti.
Le elaborazioni dei filmati con un software dedicato, creato appositamente per valutare in modo più fine l'enhancement del mezzo di contrasto, hanno invece rilevato una differente variazione di alcuni parametri cinetici tra i due gruppi. In particolare, i pazienti trattati con la sola terapia farmacologica sembrerebbero presentare un lieve aumento della flogosi articolare al tempo T1 rispetto al basale, mentre quelli sottoposti anche alla fango-balneoterapi mostrerebbero una tendenza inversa.
Lo studio ha in definitiva confermato l'efficacia della fango-balneoterapia in aggiunta alla terapia farmacologica anti-TNF-alfa nell'artrite psoriasica
Toward Early Detection and Differentiation of Arthritic diseases: Quantification of Haemodynamics Changes in Small Joints
No full textInflammatory rheumatic diseases, such as rheumatoid arthritis (RA), are leading causes of disability and constitute a frequent medical disorder, leading to inability to work, high co-morbidity and increased mortality; RA involves indirect expenses secondary to disability, loss of productivity and early retirement. The gold-standard for diagnosing RA is based on patient conditions and radiographic findings, as joint erosions or decalcification. Recently, it has been shown that development of microvessels in the synovia is the earliest sign of RA, so that identification of prognostic factors such as persistent synovial hyperaemia is fundamental. By using immersion contrast-enhanced ultrasound with a steady probe to analyse the perfusion of those joints that are the most important for early detection of RA, we propose a quantitative analysis of the contrast kinetics in the synovial and peri-synovial tissues. This analysis allows the identification and differentiation of rheumatoid arthritis from other diseases that involve synovial activity such as psoriatic arthritis. We show the results of the proposed immersion-CEUS with a semi-automatic quantification procedure of the contrast kinetics in the synovia on a set of 16 metacarpophalangeal (MCP) joints of consecutive patients affected either by RA or psoriatic arthritis. Estimated kinetics parameters allows an accurate separation of the two classes of patients, that can be further improved by using serologic data
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Pixel-based approach to assess contrast-enhanced ultrasound kinetics parameters for differential diagnosis of rheumatoid arthritis
Full text linkVariations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Identification 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
Appropriate Similarity Measures for Author Cocitation Analysis
Full text linkWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Dispelling the Myths Behind First-author Citation Counts
Full text linkWe conducted a full-scale evaluative citation analysis study of scholars in the XML research field to explore just how different from each other author rankings resulting from different citation counting methods actually are, and to demonstrate the capability of emerging data and tools on the Web in supporting more realistic citation counting methods. Our results contest some common arguments for the continued
use of first-author citation counts in the evaluation of scholars, such as high correlations between author rankings by first-author citation counts and other citation
counting methods, and high costs of using more realistic citation counting methods that are not well-supported by the ISI databases. It is argued that increasingly available digital full text research papers make it possible for citation analysis studies to go beyond what the ISI databases have directly supported and to employ more
sophisticated methods
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