Does magnetic resonance represent the gold-standard of imaging for the follow-up of arthritis?

Several studies suggest that MRI is between 2 and 10 times superior to conventional radiology in the visualization of erosions. This higher sensibility is dependent on the specific joint assessed, the precocity of the disease, and the timing of follow-up. In addition, MRI can depict bone oedema, which is an early and reversible bone lesion, and evaluate the degree of inflammation of the synovial membrane. A single examination could therefore evaluate disease activity and damage. The sensitivity to change of articular MRI is good, as demonstrated by a number of follow-up studies. In view of these advantages, it may be surprising that MRI has not yet become the gold standard of imaging of the arthritic joint. The three main reasons are low availability of high field machines, examination's costs, and lack of standardization of the technique. Low field extremity-dedicated MRI machines are probably the answer to the first two concerns. They have been shown to obtain reliable results for the clinician, and to be relatively cheap and patientfriendly, allowing repeated follow-up examinations. As far as standardization is concerned, there are many studies addressing the problem, with OMERACT as the driving force. MRI is likely to represent the future of the follow up of arthritis for the evaluation of its pace of progression and the effect of treatment. The advent of new and potent biologic therapies has incremented the need for more sensible imaging methods and will probably drive their diffusion in clinical practice

EPIDEMIOLOGY OF PSORIASIS AND PSORIATIC ARTHRITIS

SUMMARY Psoriasis is widely diffused in the World, with the exception of a few populations, such as the natives from Alaska and Australia, where it is unknown. Its average prevalence is about 3-4%. This is probably an underestimate, for it is mostly based on self-reports. In fact, on the one hand minimal psoriasis, e.g. nail disease, could remain undiagnosed; on the other, precise classification criteria for psoriatic arthritis (PsA) are lacking and the skin disease is often of elusive nature. The frequency of PsA may be higher than commonly believed, as suggested by recent studies reporting a prevalence of up to 0.42%. There are no major differences in the frequency of psoriasis between sexes, nor specific time trends. Indirect data suggest that PsA may be more frequent in the old than in the new World, a point that could be clarified only by standardized international studies. In practice, both psoriasis and PsA are relatively common conditions, with major impact on the patients’quality of life, and requiring appropriate intervention strategies. An important advance should be the adoption of univocal definitions of psoriasis and PsA, including guidelines for patterns of skin and joint involvement. Key words: Epidemiology, psoriasis, psoriatic arthriti

Magnetic resonance imaging of the joints: a revolution for the practicing rheumatologist

In the last 15 years, new imaging techniques have changed the life of practicing rheumatologists in terms of both diagnostic approach and knowledge of disease mechanisms. Clinical symptoms, disease signs and the results of physical examination have been more closely related to their anatomical basis. In particular, magnetic resonance imaging allow diagnosis of disease in its early phase and its follow-up with a previously unknown sensitivity. Novel imaging studies have contributed to elucidate several pathogenetic mechanisms in musculoskeletal diseases, such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, polymyalgia rheumatica and osteoarthritis; allow evaluation of the real degree of joint inflammation, which is often uncoupled from clinical signs; and possibly reduce the need for large clinical trials. In conclusion, new imaging techniques and refinements of the established techniques have opened exciting perspectives in our understanding and treatment of many rheumatic diseases. Much attention should be paid to the training of new generations of rheumatologists in this field

pure analgesics in a rheumatological outpatient clinic

Objective: Pure analgesics are only rarely used by Italian clinicians and this holds true also for rheumatologists. This work is concerned with an evaluation of the use of analgesics in a rheumatological outpatient clinic during the period 1989-1999. Methods: The records of 1705 patients consecutively seen at the clinic were downloaded on a specifically built website. Results: 4469 visits were considered. In 260 of them (5.8%), analgesics were prescribed to 234 (13.7%) patients. The number of patients with a prescription of analgesics steadily increased during the years 1989-1999. The diagnoses in patients assuming analgesics were: osteoarthritis (47.1%), inflammatory arthritis (24.2%), soft tissue rheumatisms (13.7%), nonspecific arthralgia/myalgia (7.5%), and connective tissue diseases (2.6%). Peripheral analgesics were used in 188 (82.5%) patients and central analgesics were used in the remaining 40 patients (17.5%). Analgesic drugs were used mainly in degenerative joint conditions. The indications for analgesics in the 55 patients with inflammatory arthrits were: (a) partial or total remission of arthritis; for this reason non-steroidal anti-inflammatory drugs were no longer required in 18 patients; (b) to increase the analgesic effect of NSAIDs in 23 patients; (c) contraindications to NSAIDs in 14 patients (renal failure in 2 patients, gastritis in 10, allergy and bleeding in the remaining two). Conclusions: About 14% of our outpatients were treated with analgesics with an increasing trend in the examined period. The main indications for analgesics are degenerative conditions but they can be used also in selected patients with arthritis

Reumatismo : cambio della guardia

Cosa significa prendere nelle mani la direzione di una delle pi\uf9 antiche riviste di reumatologia al mondo? Un ritorno al passato ed un tuffo nel futuro: nel passato ritrovo il ricordo di uno specializzando in reumatologia alle prime armi coinvolto nella redazione di Reumatismo, diretta allora dal Prof. Vittorio Bianchi. Nel futuro alcune idee e progetti ambiziosi per rendere la nostra rivista sempre pi\uf9 incisiva nel mondo della reumatologia. Questi sono stati suggeriti e discussi con i due codirettori Roberto Caporali e Piercarlo Sarzi-Puttini: sapere che loro facevano parte del team ha reso di molto pi\uf9 facile la decisione di accettare questo incarico, del quale sono, ovviamente, onorato. Il momento \ue8 senza dubbio propizio ed entusiasmante: la reumatologia italiana sta confermando il suo ruolo in Europa (EULAR 2010 a Roma, primato nella partecipazione scientifica dei reumatologi italiani ai congressi europei, pubblicazioni internazionali, presidenze di commissioni, ecc.) e questo non potr\ue0 non avere ricadute anche su Reumatismo

Multimodality imaging of chronic tophaceous gout

The diagnosis of gout is usually based on clinical presentation and laboratory findings. Imaging plays a role in the assessment and grading of articular damage related to chronic, long-standing disease, which is characterized by granulomatous synovitis, tophi, and erosions. Multimodality imaging of chronic tophaceous gout may be useful in clinical practice for a variety of purposes, including assessment of disease-related anatomical changes and monitoring of articular and soft-tissue lesions over time, especially in response to urate-lowering therapy. Radiography remains the primary imaging technique. Ultrasonography may detect monosodium urate crystals on cartilage, is helpful to assess small joint effusion, to guide to joint aspiration, and to evaluate the volume of tophi. Computed tomography is considered to be more sensitive than plain radiography in the detection and evaluation of cortical bone erosions associated with tophi. MRI represents the only imaging modality which provides visualization of bone marrow oedema associated with erosions and may be useful to characterize and distinguish tophi from other soft tissue nodules

Clinical features of gout in a cohort of Italian patients

Objective: To assess the clinical characteristics of gout and its diagnostic approach in a group of Italian patients. Methods: In a retrospective analysis, we evaluated 72 consecutive gouty patients examined in the years 2000-2007.We recorded demographic data, family history, comorbidities and disease characteristics (seasonality of the attacks, joints affected, serum uric acid concentration, and treatment). Result: 63/72 (87.5%) patients were men and 9 women, with mean age 61.9±13.7 years. 8/72 (11.1%) patients reported a familial history of gout. The first attack occurred mainly in the months of June, July and December. The first metatarsophalangeal joint was affected in 59.7% of patients and the hand in 25%. Treatment changed over the follow- up period, with a decreased use of NSAIDs (p<0.0001) and an increased use of colchicine (p=0.015) and allopurinol (p<0.0001). In 9 (12.5%) patients, joint aspiration was performed and monosodium urate crystals were found in synovial fluid or tophi. 42/72 (58.3%) patients fulfilled a minimum of 6 clinical criteria of the American College of Rheumatology, necessary for gout diagnosis. 47/72 (65.3%) patients, met the EULAR recommendations and had an 82% probability of being affected by gout. Conclusions: The diagnosis of gout is not always easy because of its changing clinical spectrum. Identification of MSU crystals in joint aspirates was obtained only in a minority of patients. In this setting the diagnosis with gout was often based on the observation of an acute intermittent monoarthritis involving mainly the first metatarsophlangeal joint, associated with hyperuricaemia and responsive to colchicine

Plantar pain is not always fasciitis

The case is described of a patient with chronic plantar pain, diagnosed as fasciitis, which was not improved by conventional treatment. Magnetic resonance imaging revealed flexor hallucis longus tenosynovitis, which improved after local glucocorticoid injection

Dynamic contrast-enhanced magnetic resonance imaging of the wrist in early arthritis

Objectives: MRI has been proposed as the imaging method of choice to evaluate the long-term outcome in patients with early arthritis. The role of dynamic MRI, performed at presentation, in predicting the outcome of patients with early arthritis has been addressed in the present study. Methods: 39 patients with early arthritis, involving at least one wrist, were studied with clinical visits and laboratory investigations, every 3 months. Dynamic MRI was performed with a low-field (0.2T), extremity-dedicated machine (Artoscan, Esaote, Genova, Italy) equipped with a permanent magnet and with a dedicated hand and wrist coil. During the intravenous injection of Gd-DTPA, twenty consecutive fast images of 3 slices of the wrist were acquired. The synovial contrast enhancement ratio was calculated both as rate of early enhancement (REE) per second during the first 55" and as relative enhancement (RE) at t seconds. Results: In our cohort of patients, REE and RE were significantly lower than those observed in a historical cohort of 36 patients with active rheumatoid arthritis. In univariate analysis, low RE predicted complete remission of arthritis. In multivariate analysis, fulfillment of RA criteria during follow-up was predicted by high RE. The need for immunosuppressive treatment at the end of follow-up was predicted by both low RE and high REE. Conclusions: Dynamic MRI may be used to predict several outcomes of early arthritis involving the wris

Comorbidities in rheumatoid arthritis: analysis of hospital discharge records

Objective: Arthritis is often associated with comorbidities. For many of them, such as hypertension, cardiovascular disease, chronic pulmonary disease, and upper gastrointestinal disease, arthritis and its treatment may also represent a risk factor. This study is concerned with an evaluation of the frequency of comorbidities in a cohort of patients with rheumatoid arthritis (RA). Methods: The discharge diagnoses of patients with RA during the period 1 January 1997 to 31 December 2000 were retrieved from the database of the Department of Internal Medicine of the University of Genova, Italy. The diagnosis of RA was made if the patient's discharge record contained the code 714 of the International Classification of Diseases, IX revision, as first 3 numbers. The other diagnoses were also recorded along with demographic data, type and duration of hospital stay, and performed procedures. Results: During the study period, 427 patients with RA were admitted to the hospital for a total number of 761 admissions, which represented 2.2% of total admissions. Ninety-one (21.3%) patients did not have comorbidities, whereas 336 (78.6%) had one or more comorbidities. The most frequently observed comorbidities were cardiovascular diseases (34.6%), including hypertension (14.5%) and angina (3.5%), followed by gastrointestinal (24.5%), genito-urinary (18.7%) and respiratory (17%) diseases. There was a male predominance (p=0.004) within patients with comorbidities, who were significantly older (64.2±3.2 years vs. 57.2±4.2 years; p<0.001) and required longer periods of hospital stay (22.7 days vs. 12.5 days; p<0.001). Conclusions: Comorbidities are present in nearly 80% of RA inpatients. Comorbidity is a good predictor of health outcome, health services utilization, and medical costs. Because RA comorbidity can act as confounder, it should be considered in epidemiologic studies and clinical trials