Reumatizam最新文献

Tumor necrosis factor-alpha inhibitors have become an established therapeutic regimen for patientswith rheumatoid arthritis. Regarding their harmful potential they are classified as category B medications. Animalreproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlledstudies in pregnant women. Disease-modifying antirheumatic drugs (DMARDs) are often used in combination withbiological therapy and treatment with methotrexate has shown good results. This antimetabolite is classified as acategory X drug and its teratogenic effect is well known. The incidence of inflammatory rheumatic diseases is significantly higher in women. There are many reports on pregnant patients treated with biological therapy, oft en in combinationwith DMARDs. The effects of such a therapy on reproductive health is a theme of debate, with controversialviews on the matter. We present a patient with rheumatoid arthritis whose pregnancy was discovered at 31 weeks ofgestation. During that period she had been treated with methotrexate and infliximab, with no adverse effects.

Spondyloarthritis (SpA) is a group of inflammatory rheumatic diseases that share some common genetic,clinical, serological, radiological, and prognostic features. Since the early 1960s, several classification criteria forSpA have been proposed, and some of them were also used for diagnostic purposes. The ASAS international group ofexperts established a set of classification criteria for SpA, dividing them into axial or peripheral, according to predominantinvolvement. The paradigmatic entity of axial SpA is ankylosing spondylitis, which is diagnosed in clinicalpractice with significant delay. Therefore the ASAS classification introduced the term “non-radiographic axial SpA”,which refers to changes in the sacroiliac joints seen on MRI, but not on radiograph. Although the ASAS classificationhas been widely accepted in the professional community, recently initiatives were raised suggesting changes and aimingat improvements. In this paper these objections are discussed, as well as the responses of experts who consider thatthese changes are not necessary.

In recent years, diagnostic ultrasound of the musculoskeletal system (MSUS) has become almost inevitablein everyday clinical practice in rheumatology. Due to the efforts of the European League Against Rheumatism(EULAR), the use of MSUS has significantly increased in Europe. Unfortunately, there are still certain open issues relatedto MSUS, primarily regarding different ways of interpretation of US findings, the standardization of MSUS findings,and the lack of clear criteria for assessing the competency of sonographers and their certification.

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disorder in children and one of themost common causes of part-time or long-term disability. The term juvenile idiopathic arthritis defines the main characteristicsof the disease: joint inflammation of unknown origin manifested before the 16th birthday and lasting for morethan six weeks. JIA is very rare in infancy, with highest frequency in preschool age. It is not a single disease, but a groupof disorders with some common features of different immunopathogenesis and with different clinical manifestations. Accordingto the revised International League of Associations for Rheumatology (ILAR) criteria, JIA is classified into 8subtypes, but this classification is still a “work in progress“ because with new knowledge gained in genetics and immunology,the classification will obviously have to be changed and refined. New research of the disease pathogenesis is the basisfor the development of new and better treatments for JIA. The goal of such treatments is not just to relieve pain, but alsoto control inflammation and stop irreversible joint damage and long-term disability. Biological agents have significantlyimproved the disease prognosis.

Juvenile spondyloartrhritis is a group of multifactorial diseases in which a disturbed interplay occursbetween the immune system and environmental factors on a predisposing genetic background, which leads to inflammationand structural damage of the target tissue. First symptoms of jSpA rarely involve the spine, while asymmetricaloligoarthritis of lower extremities, dactylitis, and peripheral enthesitis are much more common. There are many classificationcriteria for jSpA, but the majority of pediatric rheumatologists currently use the International League AgainstRheumatism (ILAR) criteria according to which most patients with jSpA are classified into the enthesitis-related arthritisgroup of juvenile idiopathic arthritis. To meet these criteria, a patient should have arthritis and/or enthesitis,with two or more symptoms such as sacroiliac joint tenderness and/or inflammatory back pain, HLAB27 genotype,HLA B27 genotype-associated disease in a first- or second-degree relative, uveitis, and male sex with eight or moreyears of age. Therefore, diagnosis is most oft en made only based on clinical examination and medical history. Anti-nuclear antibodies (ANA), rheumatoid factor (RF), and HLA testing with B27, B7, and DR4 alleles are preferred. Sincesubclinical gut inflammation is present in many patients, it is recommended to check fecal calprotectin levels. In patientswith signs of peripheral enthesitis it is warranted to perform power Doppler musculoskeletal ultrasound (PDUS),and in patients with signs of axial involvement radiographic and contrast-enhanced magnetic resonance imaging.Most patients are treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy, while in refractorycases with peripheral disease synthetic disease- modifying antirheumatic drugs (DMARDs), such as sulfasalazine,are used. In patients with axial involvement, biological DMARDs such as adalimumab, infliximab, and etanercept areobligatory. Although a number of studies gave us a good insight into the disease pathogenesis, the response to treatmentand prognosis are still difficult to predict.

Even though in the last ten years pediatric cardiology and rheumatology have formally separated inCroatia as well, strong links still remain between them. They are no longer manifested through rheumatic fever, butthrough other rheumatic entities: systemic lupus erythematosus, antiphospholipid syndrome, systemic scleroderma,Kawasaki disease, polyarteritis nodosa, and some forms of granulomatous vasculitis. We take special note of the occurrenceof complete congenital atrioventricular block (CCAVB) in pregnant women who, due to systemic connectivetissue diseases, develop distinctive ANA antibodies (anti-SSA/Ro and/or anti SSB/La), but who are also likely to havethe same inflammation within the heart, leading to the development of restricted cardiomyopathy associated withCCAVC. Although rheumatology has thus been involved with early fetal age for some time now, there are also someissues relating to the embryonal stage (the association between methotrexate/folic acid and heart development in embryos),as well as to the late fetal stage (antiprostaglandin anti-infl ammatory agent impact on premature ductus arteriosusclosure). We gave special attention to the neonatal lupus syndrome, the most serious complication in the fetalperiod. Thus the multiple association between cardiology and rheumatology in all age groups, from the embryonal andfetal stage to adulthood, is being realized. The aim of this paper is to present some important links and thus furtheremphasize the new cooperation between pediatric cardiology and rheumatology from fetal stage to adulthood.

The objective of this review is to present outcome measurement tools for chronic musculoskeletalpain in rheumatology patients and to provide an overview of local pharmacological pain treatment.Reliable and valid assessment of pain is fundamental for both clinical trials and effective pain management. Thecomplex nature of pain makes objective measurement impossible. Evaluation of chronic musculoskeletal pain and itsimpact on physical, emotional, and social functions requires multidimensional qualitative tools and health-relatedquality of life instruments. The main recommendation concerning outcome measurements of pain is that they shouldinclude an evaluation of pain, fatigue, disturbed sleep, physical functioning, emotional functioning, and patient globalratings of satisfaction and quality of life. Despite the growing field of new instruments and publications related to measuringthe various aspects of chronic pain, there is still little agreement on the topic among researchers and clinicalexperts and no unified approach has been adopted. There is still considerable need for the development of a core set ofmeasurement tools and response criteria regarding chronic pain management.It is well known that pain in articular joints and soft tissues of the musculoskeletal system represents the mostcommon symptom presenting to rheumatologists. Therefore, local pharmacological pain tretment has an importantrole in rheumatology treatment algorithms. Topical administration, as well as injection administration in joints andsoft tissue trigger points, can be done under the control of musculoskeletal ultrasound. The most frequently prescribeddrugs include NSARs and corticosteroids, with their effectiveness being well-proven in evidence-based practice.

Objective: Electrical stimulation of the vagus has proven effective in various inflammatory conditions in animalmodels. The aim of this study is to show the effect of vagal nerve neurostimulation on clinical and laboratory parameters in two patients with active rheumatoid arthritis (RA) and an inadequate response to methotrexate.

Patients and methods: The research was conducted as part of an international pilot study. Patients were implanted with the Cyberonics system for electrical stimulation of the vagus. After an initial in-clinic stimulation, the patientsperformed the stimulations at home for 42 days, when the device was inactivated. On day 56 the stimulations were reinitiated. The following parameters were evaluated: tender and swollen joint count, physician’s (PGA) and patient’s (PtGA) global score, intensity of pain, disease activity (DAS28), functional ability (HAQ), serum CRP level, and EULAR response.

Results: In the period from the screening visit to the day 42 visit, both patients experienced an improvement ofDAS28 (7.00 and 6.22 vs. 4.03 and 2.13), PGA (70 and 53 vs. 27 and 16), PtGA (48 and 43 vs. 15 and 14), tender joint count (26 and 28 vs. 4 and 0), swollen joint count (24 and 14 vs. 8 and 2), intensity of pain (72 and 87 vs 21 and 7), HAQ score (2.25 and 2.25 vs. 1.5 and 1.375), and CRP levels (23.8 and 5.58 vs. 13 and 4.61). After the device deactivation, DAS28 and VAS pain worsened in both patients.

Conclusion: Vagal neural stimulation in the treatment of patients with active RA and an inadequate response tomethotrexate is effective in reducing clinical symptoms and parameters of inflammation. Our results are in accordance with the results obtained in other centers. Research on a larger number of subjects is necessary for a better evaluation of the effect of this new approach to the treatment of patients with rheumatoid arthritis.

Autoimmune diseases and primary immunodeficiencies share a common pathogenesis characterizedby dysregulation of immunity. Although most autoimmune diseases show a polygenic inheritance pattern, it has beenshown that monogenic defects of various immune system components could lead to autoimmunity as well. These findingshave opened a new pathway for understanding the development of autoimmune diseases and the overlap betweenimmunodeficiency and autoimmunity. Th e mechanism of how a single gene defect leads to autoimmunity is not completelyknown. The purpose of this clinically-oriented review is to describe the incidence, clinical presentation, andpossible mechanisms of autoimmunity in patients with primary immunodeficiencies relevant to rheumatologists.