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RISCHIO CARDIOVASCOLARE NELL' ARTRITE PSORIASICA: FOLLOW-UP A 24 MESI DI TERAPIA CON ANTI TNF α
Full text linkINTRODUCTION
Increased cardiovascular morbility and mortality and accelerated atherosclerosis have been observed in several rheumatic diseases, including psoriatic arthritis (PsA). There are few data about the influence of TNF blockers on the evolution of subclinical atherosclerosis.
OBJECTIVES
The aim of this study was to evaluate the presence of subclinical atherosclerosis in patients with PsA before and after a follow-up of 24 months of therapy with TNF blockers and to investigate whether the treatment works not only on the control of disease activity, but also improving atherosclerosis indexes.
METHODS
Thirty-two PsA patients were studied before and after 24 months from the start of TNF blockers treatment. The presence of subclinical atherosclerosis was investigated by evaluation of intima-media thickness (IMT), flow-mediated dilation (FMD) and endothelial independent dilatation (GTN), using carotid duplex scanning. IMT values were expressed as IMT mean (cumulative mean of all the IMT mean in every analysed carotid segment) and M-MAX (cumulative mean of all the higher IMT in every analysed carotid segment). Patients were also divided into normotensive and hypertensive as hypertension is a confounding factor that can induce by itself the progression of carotid lesions and endothelial dysfunction. Response to the therapy was studied by the evaluation of tender and swollen joints (Tj and Sj), DAS 28 (disease activity score), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The lipid profile of patients before and after 24 months was also evaluated.
RESULTS
After a follow-up of 24 months we did not observe any improvement in ultrasonographic parameters versus baseline, indeed, there was a significant deterioration in both IMT-mean and M-MAX (p<0.01), while no changes were observed for FMD and GTN. Even after division in normotensive and hypertensive similar results were observed.
Conversely, there was a good response to therapy with significant reduction of Tj (p<0.001), Sj (p<0,001) and DAS 28 (p<0.001) and of ESR (p<0.001) and CRP (p<0.001). No significant changes was observed with regard to lipid profile in the two years of follow up.
CONCLUSION
Our data revealed that in patients with PsA, despite treatment with TNF blockers, there is still a gradual, albeit slight, progression of subclinical atherosclerosis assessed by ultrasonography. Both the IMT mean and the M-MAX show a slight worsening in two years, while FMD is stable against an expected improvement. Other inflammatory mechanisms not related to TNF may be responsible of the progression in atherosclerotic disease and the possible role of a genetic predisposition is not to be underestimated. Indeed it has been shown that people with PsA have a higher risk of atherosclerosis compared with other inflammatory rheumatic diseases.RISCHIO CARDIOVASCOLARE NELL' ARTRITE PSORIASICA: FOLLOW-UP A 24 MESI DI TERAPIA CON ANTI TNF α
INTRODUZIONE
Un' aumentata morbilità e mortalità cardiovascolare è stata descritta in pazienti con numerose malattie reumatiche quali il lupus eritematoso sistemico, l'artrite reumatoide e la spondilite anchilosante. Anche nell'artrite psoriasica (AP) è stata evidenziata una aumentata mortalità per cause cardiovascolari, ma tale argomento non è stato studiato approfonditamente. Alla base dell'aumentata mortalità sembra esservi un'accelerata aterosclerosi legata sia a fattori di rischio tradizionali che non tradizionali, quali la presenza di flogosi cronica.
SCOPO DELLA TESI
Obiettivo di questo studio è stato quello di valutare la presenza di aterosclerosi subclinica in pazienti con AP e la sua modificazione dopo 2 anni di terapia con farmaci anti TNF, per indagare se tali trattamenti, riducendo il processo flogistico articolare favoriscano il miglioramento dei parametri vascolari analizzati.
MATERIALI E METODI
Trentadue pazienti affetti da AP sono stati sottoposti a valutazione ultrasonografica prima e dopo 2 anni di terapia con anti TNF, per indagare la presenza di aterosclerosi subclinica. I parametri presi in considerazione sono stati l'ispessimento medio-intimale (intima-media thickness, IMT), la dilatazione indotta dal flusso (flow mediated dilation, FMD). I valori di IMT sono stati espressi come media cumulativa degli IMT medi (IMT mean) e degli IMT massimi (M-MAX); i valori della FMD sono stati espressi come incremento percentuale del diametro dell'arteria brachiale rispetto al basale. I pazienti sono stati inoltre divisi in normotesi ed ipertesi poichè l'IPA è un fattore confondente in grado di indurre di per se la progressione delle lesioni carotidee e disfunzione endoteliale. Per valutare la risposta dell' artrite alla terapia con anti TNF sono stati considerati la conta delle articolazioni tumefatte (AT) e dolenti (AD), il DAS 28, la velocità di eritrosedimentazione (VES) e la proteina C reattiva (PCR). Sono inoltre stati analizzati il profilo lipidico e la glicemia al basale ed a 24 mesi di trattamento.
RISULTATI
Sorprendentemente a distanza di 24 mesi dall'inizio della terapia si è osservato un lieve, ma progressivo peggioramento dell'IMT mean e dell' M-MAX (per entrambi p<0,01), mentre nessuna differenza si è osservata per la dilatazione flusso mediata. Anche dopo suddivisione fra pazienti normotesi ed ipertesi i dati hanno mantenuto un analogo trend, anche se una maggior tendenza alla progressione si è osservata negli ipertesi. Questo in contrapposizione ad un significativo miglioramento del quadro clinico (AT, AD e DAS28, per tutti p<0,001) e dei parametri bioumorali, analogo andamento hanno presentato gli indici di flogosi (VES e PCR, entrambi p<0,001). Nessuna differenza si è osservata per il profilo lipidico e la glicemia.
CONCLUSIONI
Dai dati emersi risulta che nei pazienti con AP, nonostante la terapia con anti TNF, vi sia comunque una progressiva, seppur lieve progressione dell' arterosclerosi subclinica valutata mediante ultrasonografia. Sia l'IMT mean che l' M-MAX mostrano a due anni un lieve peggioramento, mentre la FMD rimane stabile, a fronte di un significativo e vistoso miglioramento clinico e bioumorale dell' artrite e a nessuna sostanziale variazione dei lipidi. Sicuramente gli psoriasici hanno una maggior tendenza al dismetabolismo rispetto alla popolazione sana e anche rispetto ad altre patologie infiammatorie, come anche dimostrato in letteratura. Un ruolo chiave potrebbe essere svolto da meccanismi infiammatori non collegati al TNF e/o una particolare predisposizione genetica
Multiple paradoxical adverse events in a patient affected with ankylosing spondylitis treated with TNF blockers.
No full textTrattamento riabilitativo in pazienti con spondilite anchilosante trattati con farmaco biologico: studio randonizzato controllato.
No full textINTRODUZIONE La spondilite anchilosante (SA) è una malattia che colpisce elettivamente lo scheletro, a carico del quale col passare del tempo determina una diffusa rigidità, esito di infiammazione cronica del tessuto connettivo fibroso e dell’osso nelle sedi inserzionali di tendini e ligamenti. L’utilizzo dei farmaci biologici ha notevolmente migliorato il controllo sul dolore, la mobilità, il grado di disabilità, e la qualità di vita dei pazienti con SA.
SCOPO DEL LAVORO Lo scopo del presente studio è stato quello di valutare il ruolo della riabilitazione in pazienti affetti da SA.
MATERIALI E METODI Sono stati arruolati 58 pazienti affetti da SA in terapia con farmaco biologico (anti- TNFα) da almeno 9 mesi, randomizzati in tre gruppi, A, B e C, rispettivamente 19, 19 e 20 soggetti. I pazienti del gruppo A hanno partecipato a un programma riabilitativo con due incontri di educazione sulle caratteristiche e sulla prevenzione delle disabilità e con un ciclo di 10 sedute di cinesiterapia in palestra, effettuata a piccoli gruppi sotto la supervisione del fisioterapista. I pazienti del gruppo B hanno partecipato esclusivamente alle due sedute di educazione. I pazienti del gruppo C (gruppo di controllo) non hanno effettuato alcun intervento educativo o riabilitativo.
Dopo la raccolta dei dati demografici (sesso, età, durata di malattia), tutti i partecipanti sono stai sottoposti, al tempo 0, dopo 2 e 6 mesi, alle seguenti valutazioni: dolore e rigidità del rachide con la scala Visuo-Analogica (VAS), numero di articolazioni tumefatte e dolenti, espansione toracica, attività di malattia con l’indice metrologico specifico BASMI (Bath Ankylosing Spondylitis Metrology Index), articolarità del rachide (globale e divisa per distretti) attraverso misure di superficie fatte con un goniometro tascabile a indice pesante e ago-bussola (Inclimed®), e nastro centimetrato. L’indagine si concludeva con la somministrazione di alcune scale di autovalutazione riguardanti il dolore e la rigidità BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), grado di funzionalità BASFI (Bath Ankylosing Spondylitis Functional Index) e la qualità di vita HAQ (Health Assessment Questionnaire) e MOS SF-36 (Medical Outcomes Study 36-Items Short-Form Healthy Survey).
RISULTATI A 6 mesi è stato evidenziato un miglioramento significativamente maggiore nel gruppo A, rispetto ai gruppi B e C, per mobilità del rachide, BASMI, espansione toracica, BASFI e HAQ e gran parte dei domini della scala SF-36. E’interessante sottolineare che il miglioramento del gruppo A era per gran parte già presente al 2° mese. Per quanto riguardava VAS e BASDAI, non sono risultate differenze statisticamente significative tra i gruppi A e B, ma entrambi presentavano un miglioramento significativo rispetto al gruppo C.
CONCLUSIONI Alla luce dei risultati di questo studio si ritiene che il trattamento riabilitativo possa ancora essere considerato un valido supporto terapeutico nei pazienti affetti da SA in trattamento con farmaco biologico
Evaluation of spinal mobility by pocket goniometer (Inclimed R) in patients with ankylosing: preliminary report.
No full textBackground: Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting sacroiliac joints and whole the spine. The clinical instrument of functional evaluation of spine in AS is mainly based on BASMI score.
Objectives: The aim of our study was to verify the usefulness of new gravity-dependent and compass-needle pocket goniometer (IncliMed R, University of Padua) for AS spinal mobility measurement.
Methods: Forty one consecutive out-patients with AS (New York modified criteria) entered the study; 33 males and 8 females, age 46.5±12.3 years (range 21-73). Their active range of motion (AROM) of whole spine were evaluated by the same metrologist (B.L.) throughout the IncliMed R. The results of angular measures in 3 plane (frontal, coronal and sagittal) of cervical, thoracic and lumbo-sacral spine were expressed in grades and then summarized. At the same visit the classical BASMI evaluation was performed and VAS (last week), BASDAI and BASFI were applied.
The simple linear regression were performed for BASDAI, BASFI and VAS in the function of AROM and BASMI. The results were expressed as a coefficient of determination (r2) and the level of significance of p<0.05. The data were elaborated by SPSS 12.0.
Results: The AROM was 395±136.4° and BASMI was 3.9±2.3. The Pearson correlation between these tests were r=-0.78 (p<0.000). BASDAI, BASFI and VAS were respectively 41.3±26.2 mm, 30.5±23.7 mm and 27.1±23.2 mm. BASDAI, BASFI and VAS were more correlated with AROM, (respectively r2=0.30, p<0.000; r2=0.39, p<0.000; r2=0.14, p<0.05) than with BASMI (respectively r2=0.09, p=ns; r2=0.24, p<0.01; r2=0.06, p=ns).
Conclusion: AROM was significantly correlated with BASMI. The self-assessed questionnaires were better correlated with AROM than with BASMI. Probably BASMI as a simplify score reflects incompletely the disease activity and functional impairment of AS. We propose that the AROM by IncliMed R may be utilised as an objective method for the evaluation of AS, useful for the research and for clinical trials
Twelve-month follow-up of rehabilitation treatment forthe management of patients with ankylosing spondylitisin anti-TNF treatment. A randomized controlled trial
No full textIntroduction. Management ankylosing spondylitis (AS) requires a
combined pharmacological and non-pharmacological therapy. The
aim of this study was to assess the long term effects on pain, spine
mobility, physical function outcome of the rehabilitation program.
Materials and methods. Thirty-eight outpatients (8 women and 30
men, mean age 47.5±10.6 years) with clinically stabilized AS, in treatment
with a standard dose of TNF drugs for at least 9 months, were
consecutively enrolled into the study and randomly recruited to rehabilitation
(n=18; Rehabilitation Group, RG) or no rehabilitation treatment
(n=20; Control Group, CG). Rehabilitation treatment included 2
educational meetings and 12 exercise sessions (60 min. session, 2
times/week), including exercises for spine/hip joint flexibility, stretching,
chest and breathing expansion. The patients were taught the
programmed exercises and encouraged to perform them at home at
least three times per week. Outcome assessment after rehabilitation
treatment and 12-months follow-up included: spinal pain intensity by
the Visuo-Analogue Scale, Bath Ankylosing Spondylitis Metrology
Index, Bath Ankylosing Spondylitis Functional Index, Bath
Ankylosing Spondylitis Disease Activity Index, chest expansion, active
range of motion of cervical and lumbar spine measured by a
pocket goniometer (IncliMed®). Results. The 2 groups were comparable
in demographic characteristics and no significative differences
were found in clinical evaluations at baseline. Intragroup comparison
after the rehabilitation treatment (after 2 moths from the start)
showed that the RG significantly improved (p ≤ 0.050) in pain, functional
and spine mobility, compared to CG, and the results were
maintained to check at 12-month follow-up. Conclusion. Our results
show that the combination of an intensive group exercise and an
educational-behavioural program can provide promising results in
the long-term functional and mobility outcomes for the management
of patients with clinically stabilized SA in treatment with TNF
Atherosclerosis in psoriatic arthritis
No full textThe atherosclerotic process is accelerated in several autoimmune rheumatic diseases. Effector cells of innate and adaptive immunity along with pro-inflammatory cytokines and other immune mediators are found in atherosclerotic lesions, where they play an important role in induction, progression and rupture of plaques. Psoriatic arthritis (PsA) is a chronic inflammatory disease, characterized by arthritis, enthesitis, dactilytis, osteitis, and axial involvement, along with skin manifestations. PsA is frequently associated with obesity, diabetes, dyslipidemia, hypertension, accelerated atherosclerosis and with increased cardiovascular morbidity and mortality. Disease-specific and traditional risk factors seem to account for the atherosclerotic burden in PsA patients. Some immunological factors which are involved in PsA can also contribute to atherosclerosis including C reactive protein (CRP), TNF-α, IFN-γ, IL-1, Il 6, IL23, and Th17
The natural history of ankylosing spondylitis in the 21st century
Full text linkAnkylosing spondylitis (AS) is a chronic inflammatory disease that affects the axial skeleton and evolves in stiffnes followed by ankylosis and disability. However, it may be difficult to exactly establish the natural history of the disease and the influence of risk factors of progression, since most patients are treated with various pharmacologic or non-pharmacologic agents, which may potentially influence the natural progression of the disease. In this context, we report here a very interesting case of a 40 year old man, presented to our outpatient clinic, 28 years after the onset of AS. Previously for personal reasons, did not choose not to undergo any treatment. This case allows us to evaluate the natural radiological progression of the disease and the influence of predictive risk factors
Rehabilitation treatment in patients with ankylosing spondylitis stabilized with tumor necrosis factor inhibitor therapy: a randomized controlled trial.
No full textObjective. To assess the 2- (T1) and 6-month (T2) followup effects on pain, spine mobility, physical
function, and disability outcome of a rehabilitation intervention in patients with ankylosing
spondylitis (AS) stabilized with tumor necrosis factor (TNF) inhibitor therapy.
Methods. Sixty-two outpatients (49 men, 13 women, mean age 47.5 ± 10.6 yrs) were randomized to
rehabilitation plus an educational-behavioral (n = 20) program, to an educational-behavioral program
only (n = 20), or to a control group (n = 22). The educational-behavioral program included 2
educational meetings and 12 rehabilitation exercise sessions (stretching, strengthening, chest and
spine/hip joint flexibility exercises), which patients then performed at home. Outcome assessment
at the end of rehabilitation training (T1) and at T2 was based on spinal pain intensity in the previous
4 weeks by self-report visual analog scale (VAS; 100 mm: 0 = no pain, 100 = maximum pain),
BASMI, BASFI, BASDAI, and on chest expansion and the active range of motion of the cervical
and lumbar spine measured by a pocket goniometer.
Results. The 3 groups were comparable at baseline. On intragroup comparison at T1, the rehabilitation
group showed significant improvement in the BASMI and BASDAI, in chest expansion, and in
most spinal active range of motion measurements. BASFI and cervical and lumbar VAS scores
improved in both the rehabilitation and educational-behavioral groups. The positive results achieved
in the rehabilitation group were maintained at the 6-month followup.
Conclusion. Combining intensive group exercise with an educational-behavioral program can provide
promising results in the management of patients with clinically stabilized AS on TNF inhibitor
treatment
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
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