Suboptimal methotrexate use in rheumatoid arthritis patients in Italy: the MARI study.

OBJECTIVES: Methotrexate (MTX) is the first choice in the treatment of rheumatoid arthritis (RA), but the doses and regimens vary significantly. For this purpose, we conducted an observational study on the use of MTX for RA in Italy (MARI study). METHODS: The MARI study included 1,327 RA patients on MTX treatment for at least 12 months, at 60 Italian rheumatology units. Concomitant medications with corticosteroids, other DMARDs or biological therapies were recorded. The clinical assessment included the Disease Activity Score 28 (DAS28) and the serological positivity for the rheumatoid factor or for the anti-citrullinated protein antibodies. RESULTS: The included patients were treated with either oral (n=288) or parenteral (n=1039) MTX. Only 15.5% of the total number of the patients was on adequate MTX dose (i.e. ≥ 15 mg for the oral route of administration and >12 mg for the parenteral one). The initially established MTX dose was modified in 37.1% of the patients, for intolerance or clinical criteria. A DAS28 remission (DAS28 <2.6) was observed only in 58.5% of the cases, while 52.9% of the patients still presenting an active form of the disease were on suboptimal doses of MTX. CONCLUSIONS: The weekly dose of MTX prescribed for the treatment of RA is often suboptimal, even in conditions of inadequate control of the disease activity. The recommendations for the use of MTX in RA patients should take into account the efficacy and tolerability data derived from its use in real clinical practice.

[Informed consent forms in medical practice: the results of a knowledge survey]. / Il consenso informato scritto nella pratica medica: i risultati di una indagine conoscitiva.

"Federico II" University of Naples Hospital Management's Staff considered 47 informed consent forms in order to evaluate quality and quantity of the information transmitted to patients. Every form, distinguished by procedure (surgical, pharmacological, anesthesiologic or related to blood transfusions) was evaluated for the accuracy and validity of information related to: diagnosis, prognosis, diagnostic and therapeutic opportunities, expected benefits, adverse-side effects, iatrogenic risks, privacy policy on personal data. The forms were judged by information completeness criteria "conformed" or "not conformed" with standards. Our analysis demonstrate that physicians often are unaware of legal and ethical topics related to constructing informed consent forms. They usually omit crucial information or would use strict technical language. So far, we conclude Hospital Management's Staff definitively has a role in improving informed consent forms by establishing guidelines and promoting ethical issues. Final result could be to deserve stronger patient confidence in medical institutions.

A comparison of different culture media for the membrane filter quantification of Aeromonas in water.

A comparative assessment of culture media for the membrane filter enumeration of Aeromonas spp. in water was performed, testing the effects of different incubation conditions (aerobic and anaerobic), temperatures (30 and 37 degrees C) and times (24 and 48 h). Different water samples seeded with test suspensions of Aeromonas spp., fecal material or raw sewage were examined. Results indicate clearly that plates should be incubated aerobically at 30 degrees C for 24 h. If the bacterial contamination is likely to be low, the use of most sensitive culture media, such as SAA, mA, ADA or PADE Agar, is recommended. By contrast, samples with an expected high level of background microbial flora should be analysed through more selective media, such as MIX Agar. However, the low selectivity of all media tested and the high likelihood of false negatives based upon the macroscopic examination of colonies means that further research directed to the development of more efficient media is needed.

Ossification of the posterior longitudinal ligament in one of a pair of identical twins concordant for ankylosing spondylitis.

A pair of identical twins suffering from ankylosing spondylitis is reported. One brother developed an earlier-onset disease and showed ossification of the posterior longitudinal ligament and the flavum ligament in his cervical spine.

Psoriasis and psoriatic arthritis. Dermatological and rheumatological co-operative clinical report.

Six hundred and forty-seven patients with psoriasis were studied in order to define prevalence and clinical features of psoriasis and psoriatic arthritis. After medical history review all patients were observed by a dermatologist and a rheumatologist. Successive laboratory tests and radiological and scintiscan examinations of joints were also performed. Diagnosis of arthritis was made according to Wright and Moll. In our district, the prevalence of psoriasis in respect to other dermatological diseases was 1.86%. Vulgaris pattern occurred in 85% of the total cases while eruptive was found in 10.5%. Erythrodermic and pustular forms were uncommon, occurring in 2.47% and in 1.23%, respectively. In 84.8% of the total cases, psoriasis onset was clinically evident while in 10.8% it affected non-evident cutaneous sites. Onycopathic onset occurred in 4.3%. Altogether 138 psoriatic patients exhibited arthritis and spondylitic and polyarticular patterns were very common (occurring in 42.7% and 33.3%, respectively). Psoriasis antedated arthritis in 68.4% of the cases but followed it in 21%. Synchronous onset occurred in 10.8%. The data obtained strengthen those of our previous reports. In particular, the marked articular involvement of psoriatic patients is confirmed. Moreover, our results, when compared with data of other authors, show a different distribution among the arthritic subtypes.

The management of 138 psoriatic arthritic patients.

Clinical experience obtained in the management of 138 patients of psoriatic arthritis is reported. The correct recognition of arthritic subtype (according to Moll and Wright classification) always resulted essentially in the choice of the therapy. Our programme included rehabilitative, pharmacologic and surgical approaches. Our data suggest that psoriatic arthritis is a mild articular disease when compared to other affections such as rheumatoid arthritis or ankylosing spondylitis. Notwithstanding an accurate therapeutical programme, it is necessary to control atypical cases which not infrequently can occur.

The clinical spectrum of psoriatic spondylitis.

Forty-three psoriatic patients with spondylitic involvement (19 women and 24 men, mean age 41 years) have been reviewed. Three different subsets were recognized. The first (PS1), with predominant involvement of the axial skeleton, occurred in 22 (seven women and 15 men, mean age 39). The second (PS2) and the third (PS3) showed an overlap of spondylitis and peripheral articular disease. In PS2 this consisted of distal interphalangeal (DIP) arthritis (five women and three men, mean age 41), while in PS3 there was symmetrical polyarthritis (seven women and six men, mean age 42). Spinal involvement, present in every case, was characterized by unilateral and asymmetrical syndesmophytes, often nonmarginal and randomly affecting the vertebral column. Sacroiliitis, absent in the PS2 subset, was present in 15 of the PS1 and in two of the PS3 subgroup and was bilateral in six and unilateral in 11. The HLA-B27 antigen, absent in the PS2 subgroup, was found in 12 of the PS1 and in two of the PS3 subset. It was associated with sacroiliitis in 13 cases and with spondylitis without sacroiliitis in only one case. Nail changes were recorded in 30% of the total cases and showed a strict relationship with the PS2 subset (40%). Extra-articular symptoms, consisting almost exclusively of ocular involvement, occurred in three patients only (two cases of conjunctivitis and one of acute anterior uveitis). The clinical course of psoriatic spondylitis appeared less disabling than that of the idiopathic form.

Cyclophosphamide treatment in polyarteritis nodosa.

Five male patients with polyarteritis nodosa were treated with cyclophosphamide as follows: 3 mg/Kg/die i.v. up to maximum of 3 g.; subsequently, 200 mg/die per os for two weeks, then 100 mg per os every other day for three months; finally, 100 mg every fourth day until the 18th month. One patient, who also had fever, received 25 mg/die of prednisone for the initial three weeks of treatment. Before treatment ESR, WBC, and circulating immune-complexes were increased, while C3a, C3c and C4 serum complement components levels were normal. Skin ulcers healed within 4 months. A progressive marked improvement of visceral damages in the first months of therapy have been noted (e.g. blood pressure values in normal range after suspension of concomitant antihypertensive treatment, regression of peripheral neuropathy, etc. etc.). No further ischemic lesions occurred during treatment. Significant decreases of ESR and serum immune-complexes levels were detected. No untoward effects due to cyclophosphamide were observed. These findings support the effectiveness of this drug in polyarteritis. The possibility of association with glucocorticoids during the acute phase of disease is also discussed.

Psoriatic arthritis in psoriatic patients.

One hundred and eighty patients with psoriasis have been studied in the Neapolitan area to find the prevalence of arthritis in psoriasis. Wright and Moll's criteria for the diagnosis of arthritis were applied. Of 180 psoriatic patients, 62 exhibited arthritis (34.4% of total cases) According to Moll and Wright's five broad clinical forms of arthritis, the following distribution was found: polyarticular in 38.7% of arthritic patients, mono-oligoarticular in 16.1%, distal interphalangeal in 7.5%, deforming or mutilans in 2.3% and spondylitic and/or sacro-iliitic in 20.9%. In 14.5% of arthritic patients an overlap of the spondylitic form and peripheral involvement was also found. Stratification by age of patient populations shows that cutaneous pathology has a homogeneous distribution in the various age decades, while joint symptoms are seen maximally in the sixth decade and are absent in the first two decades. The relationship between the onset of skin lesions and joint pathology demonstrates that skin lesions preceded arthritis in 64.5% of the cases, whilst arthritis antedated psoriasis in only 19.35%. In 16.1% of cases psoriasis and arthritis began almost simultaneously. Nail changes were present in 63% of arthritic patients and in 37% of psoriatic subjects without arthritis. Furthermore, in 88% of arthritic patients in whom arthritis preceded skin lesions, nail changes antedated the onset of clinically apparent psoriasis. Extra-articular features were not found. This absence might be associated with the usual seronegativity for rheumatoid factor in psoriatic arthritis, also confirmed in this survey.

Supportive laboratory findings in psoriatic arthritis.

Serum copper, iron and ceruloplasmin concentrations were determined in 45 subjects (22 males and 23 females, medium age 50.3, range 25-76) diagnosed as psoriatic arthritic patients (20 with poliarticular, 12 with mono-oligoarticular and 13 with spondyloarticular form), in 63 patients (30 males and 33 females, medium age 32.4, range 10-78) with psoriasis, and in 60 blood donors (32 women and 28 men) as reference group. Mean serum copper, iron and ceruloplasmin was significantly increased (p less than .001) in psoriatic arthritis as compared with controls or subjects with psoriasis alone. The number of synovial joints affected was significantly correlated to changes in these serum parameters. Indeed, serum copper, iron and ceruloplasmin were found to be significantly different from that of normals in the polyarticular subgroup (p less than .001), while only copper and ceruloplasmin were different in the mono-oligoarticular form (p less than .001 and p less than .01 respectively). No significant changes were found in a spondyloarticular subgroup. In the polyarticular subgroup a direct correlation was found between another disease activity marker (e.g. ESR) and serum changes in iron, ceruloplasmin and copper (p less than .001). Our data indicate that psoriatic arthritis is a multifaceted disease: the polyarticular form behaves like seronegative rheumatoid arthritis, while the monoarticular forms shows a lesser involvement of serum iron; spondylitic arthritis does not show any significant change in serum copper, ceruloplasmin and iron concentrations.

[Hypercupremia: a marker of articular phlogosis?]. / L'ipercupremia: un marker della flogosi articolare?

Serum copper, iron and ceruloplasmin concentrations were determined in 45 subjects (20 males and 23 females, medium age 50.3, range 25-76) diagnosed as psoriatic arthritis patients, 63 patients (30 males and 33 females, medium age 32.4, range 10-78) with psoriasis, and in 60 blood donors (32 women and 28 men) as reference value group. Mean serum copper, iron and ceruloplasmin were significantly different (p less than .001) in psoriatic arthritis when compared with controls or subjects with psoriasis alone. The number of synovial joints affected was significantly correlated to changes in these serum parameters. Indeed serum copper, iron and ceruloplasmin were found significantly different from normals in the polyarticular subgroup, (p less than .001) while only copper and ceruloplasmin were different in mono-oligoarticular form (respectively p less than .001 and p less than .01). No significant changes were found in the spondiloarticular subgroup. In the polyarticular subgroup a direct correlation was found between another disease activity marker (e.g.ESR) and serum changes in iron, cerulosplasmin and copper (p less than .001).

Serum copper and caeruloplasmin are higher in seropositive than seronegative rheumatoid arthritis.

Increased serum copper (sCu) and alpha 2 caeruloplasmin (alpha 2 sCP) concentrations have been reported in patients with rheumatoid arthritis and other inflammatory conditions. Close parallel changes of sCu and alpha 2 sCP in rheumatoid arthritis have recently been observed by us in 30 subjects. The 'IgM rheumatoid factor positive (IgM-RF)' patients showed higher sCu and alpha 2 sCP concentrations when compared with 'IgM-RF negative'. Moreover a significant correlation was found between sCu alpha 2 sCP and other humoral indexes altered in rheumatoid arthritis. Therefore it seems useful, as further index of inflammation, to test both sCu and alpha 2 sCP.