Extra-articular manifestations in 587 Italian patients with rheumatoid arthritis.

The aim of the study was to evaluate the frequency of extra-articular manifestations (EAMs) of rheumatoid arthritis (RA) in a series of patients from nine Italian rheumatology clinics. A total of 587 patients underwent direct questioning, complete physical evaluation, and review of medical records and laboratory data. The relationships between EAMs and the eosinophilic count, IgM rheumatoid factor (RF), and antinuclear antibodies (ANA) were studied. EAMs were present in 240/587 (40.9%) patients. The most common features were sicca syndrome (17.5%) and rheumatoid nodules (16.7%). EAMs were significantly more frequent in male patients (OR = 1.68), patients with ANA positivity (OR = 2.82), high anatomical class (OR = 2.3), and rheumatoid factor seropositivity (OR = 2.22). EAMs were more common in patients from southern Italy than in those from northern Italy (P < 0.001). EAMs seem to be rarer in Italy than in the Anglo-Saxon populations of northern Europe and the USA. Differences in prevalence of EAMs can exist even within the same country.

Bisphosphonate therapy of reflex sympathetic dystrophy syndrome.

OBJECTIVE: The reflex sympathetic dystrophy syndrome (RSDS) is a painful limb disorder, for which a consistently effective treatment has not yet been identified. The disease is associated with increased bone resorption and patchy osteoporosis, which might benefit from treatment with bisphosphonates, powerful inhibitors of bone resorption. METHODS: Twenty patients with RSDS of foot and hand, were randomly assigned to blind administration of either alendronate intravenously (Istituto Gentili, Pisa, Italy) 7.5 mg dissolved in 250 ml saline solution or placebo saline infusions daily for three days. Two weeks later all patients had an identical treatment course with open labelled alendronate (7.5 mg/day for three days), independent from the results of the first blind treatment. RESULTS: In the patients treated with blind alendronate the diminution in spontaneous pain, tenderness, and swelling (circumference of the affected limb) and the improvement in motion were significantly different from baseline (p < 0.001), from those observed within the first two weeks in the control group (p < 0.01), and from week 2 to week 4 (p < 0.01). In the patients given blind placebo infusions no relevant symptomatic changes were observed after the first two weeks of follow up, but they responded to the open alendronate therapy given afterwards. In 12 patients with RSDS of the hand the ultradistal bone mineral content (BMC) of the affected arm was considerably lower than that of the controlateral arm (mean (SD)) (426(82) mg/cm versus 688(49)). Six weeks after the beginning of the trial BMC rose by 77(12) mg/cm (p < 0.001) in the affected arm, but it did not change in the controlateral. CONCLUSIONS: These results indicate that bisphosphonates should be considered for the treatment of RSDS, producing consistent and rapid remission of the disease.

Clinical differences between ANA/anti-ENA positive or negative primary Sjögren's syndrome.

Fifty female patients with primary Sjögren's syndrome diagnosed according to the Copenhagen criteria were evaluated for both glandular and extraglandular involvement. They were divided into two groups based on the presence or absence of antinuclear and anti-ENA antibodies (ANA/anti-ENA). ANA/anti-ENA negative patients presented with milder and later glandular and extraglandular disease and required less frequent corticosteroid treatment. No significant differences were noted in extraglandular manifestations with the exception of leukopenia which was noted only in ANA/anti-ENA positive cases.

Salivary gland echography in primary and secondary Sjögren's syndrome.

A series of different ultrasonographic abnormalities detected by salivary gland echography (SGE) were investigated for their discriminant power for Sjögren's syndrome (SS) in 53 patients with either primary SS (n = 27) or secondary SS (n = 26), as well as in 90 controls. Among the controls, 26 suffered from dry mouth and/or recurrent or persistent swelling of at least one parotid or submandibular gland due to other selected disorders, while 64 were healthy, asymptomatic subjects. Mild, evident or gross inhomogeneous parenchymal patterns were the only variables selected by stepwise discriminant analysis, when comparing patients to controls. However, a mild submandibular inhomogeneity did not prove useful for such a discrimination. Based on these data, a simplified evaluation and standardised quantification of salivary involvement, as detected by SGE, is proposed using an echographic score (range 0 to 6) which assigns points to the different degrees of glandular inhomogeneity. Score values above 0 showed a sensitivity of 88.8% in primary SS and of 53.8% in secondary SS, as well as a specificity of 84.6% and of 92.2% with respect to either symptomatic or healthy controls. The lower sensitivity of SGE for patients with secondary SS presumably was a result of their milder salivary involvement.

[Osteosclerotic micromolecular plasmacytoma]. / Plasmocitoma micromolecolare osteosclerotico.

We describe a patient with a k light-chain myeloma revealed by an apparently solitary mixed lytic and sclerotic rib lesion. This rare manifestation may be explained by a still balanced bone remodeling in the early phases of the disease.

Treatment of idiopathic inflammatory myopathies with cyclophosphamide pulses: clinical experience and a review of the literature.

Short-term cyclophosphamide pulse therapy was administered to five patients with idiopathic inflammatory myopathies (IIM) which were refractory to corticosteroids and, in two cases, to other aggressive therapies. Both disease remission and a reduction in corticosteroid dosage were obtained in four patients. Three of them have been in remission over since, taking only minimal doses of steroids during the subsequent two years. In the fourth patient a less intensive, maintenance pulse therapy could not be continued due to unacceptable side effects. On the basis of these results and of data from the literature, herein reviewed, cyclophosphamide pulse therapy may be recommended for adult patients with IIM who do not respond to or who do not tolerate conventional corticosteroid treatment, as well as when a steroid-sparing effect is desired.

Combined therapy with cyclobenzaprine and ibuprofen in primary fibromyalgia syndrome.

Non-steroidal antiinflammatory drugs are not very effective, even if commonly used, in primary fibromyalgia syndrome (PFS), whereas cyclobenzaprine (C) has proved to be quite useful. The aim of this open randomized study was to compare low-dose C alone or in combination with ibuprofen (I) in 32 female patients suffering from PFS. Fifteen patients were given C 10 mg, and 17 patients C 10 mg plus I 600 mg. All patients received the drugs orally at night and were evaluated at baseline and at days 5 and 10. Assessment of efficacy included the number of tender points (max. = 16), muscle tightness (score 1-5), sleep difficulty (score 1-10), pain intensity (visual analogue scale 0-10) and duration of morning stiffness (min). At the end of the study all symptoms were found to be improved to the same extent in both treatment groups. An exception was morning stiffness, which became significantly more reduced in the patients taking C plus I. No patient discontinued the trial owing to adverse side-effects. In conclusion, C and I given concomitantly at night proved to be safe and advantageous in relieving the discomfort of PFS in the short term.

Misoprostol-induced urinary incontinence.

In a young woman with rheumatoid arthritis misoprostol induced urinary incontinence. The urodynamic study described here revealed a deficiency in urethral resistance which may explain the phenomenon. This side-effect may be more common than expected, and misoprostol should be administered with caution to patients suffering from urinary stress incontinence.

The prevention of corticosteroid-induced osteoporosis with nandrolone decanoate.

The effects of nandrolone decanoate (ND; 50 mg IM every three weeks) on calcium metabolism and forearm bone density were studied in a randomized trial in 35 women receiving long-term therapy with corticosteroids (CST) for rheumatic disease. The 17 patients who served as controls were on CST therapy for less years and their bone density was higher. Thus a second control group, pair-matched with the active treatment group for age, duration of CST therapy and bone density, was selected retrospectively. At the end of the 18 months' treatment course with ND, forearm bone density was increased by 5.1% (P less than 0.01) but fell by 11.3% (P less than 0.01) and 6.7% respectively in the first and second control group. The patients on ND differed significantly from both control groups in the changes at 6, 12 and 18 months (P less than 0.01). Urinary excretion of hydroxyproline fell significantly in patients receiving ND, whereas the biochemical indices of bone formation did not change (alkaline phosphatase) or increased (osteocalcin; P less than 0.01). In conclusion, nandrolone decanoate therapy may be used in the prevention of CST-induced osteoporosis. It also seems to exert mild inhibition of bone resorption without affecting or even stimulating bone formation.

Radiolabelled semisolid test meal clearance in the evaluation of esophageal involvement in scleroderma and Sjogren's syndrome.

Esophageal involvement by scleroderma is frequent. Investigation by manometry or radiography is invasive and nonphysiological. Scintigraphy of the clearance of small radiolabelled liquid boluses in the supine position, while sensitive and noninvasive, may also be nonphysiological and does not allow the simultaneous determination of gastric emptying. We thus studied the esophageal clearance of a semisolid test meal ingested in the upright position. Forty-seven patients with scleroderma and 24 with Sjogren's syndrome were compared with ten normal controls and ten patients with gastric emptying abnormalities but no esophageal involvement. Results of scintigraphy were also correlated with manometry and contrast radiography. Quantitative evaluation of esophageal tracer retention at ten minutes postingestion was: (mean +/- SD), 2.8 +/- 1.0% in normals, 2.9 +/- 0.9% in gastric dysmotility, 4.8 +/- 2.9% in Sjogren's syndrome, and 22.3 +/- 25.0% in scleroderma; similar results were found at 20 and 60 minutes. The T 1/2 of gastric emptying was 47.1 +/- 5.7 minutes in normals, 95.9 +/- 25.3 minutes in gastric dysmotility, 62.9 +/- 19.5 minutes in Sjogren's syndrome, and 52.9 +/- 13.5 minutes in scleroderma. We conclude that esophageal clearance of a semisolid test meal is a sensitive index of esophageal dysmotility and correlates well with results from manometry and contrast radiography but is noninvasive and quantifiable. The simultaneous measurement of gastric emptying is also possible in many cases.

Sequential salivary scintigraphy in Sjögren's syndrome: proposal for a new method of evaluation.

Thirty-seven non-elderly primary Sjögren's syndrome (I SS) patients, and 27 controls complaining of xerostomia and/or recurrent or persistent swelling of at least one parotid or submandibular gland due to other selected disorders, were studied. A new scintigraphic score (scsc) is proposed for a standardised semiquantitative evaluation of salivary involvement by qualitative sequential salivary scintigraphy (SSS), and is compared with two other well-known methods generally used for this purpose. The scsc proved to be much more suitable for such an evaluation: the other criteria did not allow us either to classify or to score a great number of cases. Furthermore, the scsc allowed us to obtain better SSS sensitivity (89.2%) and specificity (96.3%) values for I.SS (33 of the 37 I SS patients and 26 of the 27 controls were correctly classified by discriminant analysis, for scsc values greater than 8). This was made possible by the different "weights" which we assigned to the various glandular and oral parameters in the scsc determination.

Efficacy and tolerability of nimesulide in elderly patients with osteoarthritis: double-blind trial versus naproxen.

A double-blind trial was carried out to assess the therapeutic efficacy and tolerability of nimesulide versus naproxen in the treatment of elderly patients with osteoarthritis. A total of 40 elderly female patients with osteoarthritis of the hip and/or knee were entered into the study and treated with either 200 mg/day nimesulide or 500 mg/day naproxen for 28 days. Both treatments were very effective in alleviating spontaneous pain, pain on movement, morning stiffness and joint mobility. Nimesulide was better tolerated than naproxen with fewer and less serious side-effects being reported. The results of this study show nimesulide to be effective and well tolerated in the treatment of elderly patients with osteoarthritis.

[Chloroquine-resistant Plasmodium falciparum malaria imported into Italy]. / Malaria da Plasmodium falciparum clorochino-resistente importata in Italia.

A case of chloroquine-resistant falciparum malaria imported into Italy from Angola is reported. It represents a further demonstration that R III resistance to 4-aminoquinolines has spread to countries of the Central Africa Atlantic Coast with important implications for the treatment of patients and individual chemoprophylaxis.