Gabriele De Marco

Identification of the clinical features distinguishing psoriatic arthritis and fibromyalgia.

Objective. To identify the clinical features that can help to distinguish between psoriatic arthritis (PsA) and fibromyalgia (FM). Methods. Our cross-sectional study was carried out in 10 Italian rheumatology centers between January and September 2009, and enrolled all consecutive patients with PsA and FM who agreed to participate. Standard clinical and laboratory data for PsA and FM were collected from all patients. Records were made of somatic symptoms, response to nonsteroidal antiinflammatory drugs (NSAID), self-evaluated pain, general health, disability, and responses to the Fibromyalgia Impact Questionnaire. Data were statistically analyzed by univariate and multivariate analyses, and receiver-operating characteristic curves. The analysis concentrated on the clinical features shared by the 2 conditions. Results. Two hundred sixty-six patients with PsA (mean age 51.7 yrs; disease duration 10.2 yrs) and 120 patients with FM (mean age 50.2 yrs; disease duration 5.6 yrs) were evaluated. Univariate analysis showed that patients with FM had higher mean tender point and enthesitis scores, more somatic symptoms, and responded less to NSAID. Multivariate analysis showed that the presence of ≥ 6 FM-associated symptoms and ≥ 8 tender points was the best predictor of FM. Conclusion. The shared clinical features of PsA and FM that had the greatest discriminating power for FM were the number of FM-associated symptoms and tender point count.

Entheseal power Doppler ultrasonography: a comparison of psoriatic arthritis and fibromyalgia.

Objective. To compare the power Doppler ultrasonography (PDUS) pictures of peripheral entheses in patients with psoriatic arthritis (PsA) and fibromyalgia (FM). Methods. Thirty patients with PsA and 30 with FM participating in a study aimed at identifying the clinical features that distinguish the 2 conditions underwent the PDUS assessment of 14 major peripheral entheses. All of the detected entheseal changes were recorded and scored, and the data were statistically analyzed by means of univariate analysis and receiver-operating characteristic curves. Results. Four hundred twenty entheseal sites were assessed in each group of patients. At least 1 lesion was detected in each of the patients with PsA and in 80% of the patients with FM (p = 0.01), but inflammatory changes were present in respectively 70% and 23% (p = 0.001). A cutoff point of ≥ 3 involved sites had the greatest discriminating power in the patients with PsA, who were the only patients with bony erosions. PDUS signs of plantar fascia enthesopathy and Achilles tendon inflammation were highly specific of PsA. Conclusion. PDUS assessment of the peripheral entheses distinguishes patients with PsA and patients with FM in terms of the number and distribution of the involved sites, and the presence of inflammatory changes.

Tumour necrosis factor alpha inhibitor therapy and rehabilitation for the treatment of ankylosing spondylitis: A systematic review

OBJECTIVES To systematically review the evidence for a synergistic effect of combining rehabilitation with biological anti-tumour necrosis factor (TNF) therapy in patients with ankylosing spondylitis (AS). METHODS Data were analysed to identify the most effective rehabilitation programmes, the best endpoints for effectiveness, and patient subgroups most likely to benefit from combination therapy. Systematic MEDLINE and Embase searches were performed to identify studies evaluating rehabilitation programmes and biological therapy in patients with AS. Evidence was categorised by study type, and efficacy, adverse effects and other outcomes were summarised. RESULTS Of the 75 studies identified, 13 investigated the combination of a rehabilitation programme with TNF inhibitor therapy, while the remainder studied rehabilitation with standard therapy (often not specified). Data from these few studies suggest that combined rehabilitation plus anti-TNF therapy is more effective in terms of symptom severity, disease activity, disability and quality-of-life indices versus biologic alone or rehabilitation with standard medical therapy, or, in non-comparative studies, compared with baseline. The most effective rehabilitation appears to be supervised or in-patient programmes with an educational component. Available data do not provide guidance on most appropriate endpoints or identify patients most likely to benefit from combination therapy. Combined, TNF inhibitor and rehabilitation therapy appear to have a synergistic effect, possibly due to increased adherence to exercise. Exercise regimes are more effective if supervised and include an education component. CONCLUSIONS Further randomized, controlled trials comparing endpoints and investigating longer-term benefits of combining TNF inhibitors with rehabilitation in different AS subgroups are needed.

The problem in differentiation between psoriatic-related polyenthesitis and fibromyalgia

The recognition of the primacy of enthesitis in animal models of spondyloarthritis and the prevalence of clinically occult enthesopathy in psoriatic subjects and of persistent joint pain in PsA subjects who have ostensibly good reduction of joint swelling under biological therapy has highlighted the potential impact of polyenthesitis in psoriatic disease. In daily practice, the formal demonstration of enthesitis is challenging for the following reasons: the relatively avascular nature of enthesis, often leading to the absence of overt clinical inflammatory signs; the frequent lack of elevation of inflammatory markers; and finally, the limitations of current imaging techniques to provide supportive evidence for inflammation in these areas. Consequently, enthesitis may present as widespread pain indistinguishable from FM or may emerge as the dominant feature after successful biological therapy for suppression of synovitis. The unmet needs in the differentiation between FM and enthesitis in psoriatic disease patients are highlighted and critically evaluated in this article.

Demographic and clinical features related to a symptomatic onset of Paget's disease of bone.

Objective. Paget’s disease of bone (PDB) is a focal disorder of skeletal remodeling that can lead to bone pain, deformity, and fractures, but it can often be asymptomatic for a long time. This study investigated which factors may distinguish patients with clinical manifestations from asymptomatic patients. Methods. The study group consisted of 224 patients with PDB referred to our Bone Disease Unit. For all patients, data were collected about clinical and demographic variables and diagnostic procedures. Logistic regression analyses were used to assess the role of recorded variables on the odds of being diagnosed clinically rather than by chance. Results. Among the 124 patients with clinical manifestations leading to the diagnosis (55.4%), 36 subjects complained of bone pain, 32 articular pain, 42 back pain, 2 headache; 9 had fractures in Paget bone, and 3 had bone deformity. In 100 patients (44.6%) PDB was diagnosed by chance. At the multivariate analysis, only the number of bones involved (OR for 1 site increment = 1.18, 95% CI: 1.007–1.402; p = 0.04) acted as an independent predictor for a clinical diagnosis. Some skeletal localizations were associated with a clinical diagnosis: the involvement of lumbar spine (OR = 2.085, 95% CI: 1.024–4.224; p = 0.043) was more likely in symptomatic patients; pelvis and tibia showed a borderline statistical significance. The skull was predictive for asymptomatic PDB. Conclusion. A systematic laboratory screening including serum alkaline phosphatase of an older subject complaining of bone pain, articular pain, or back pain is the sole strategy to improve the diagnostic sensitivity for PDB.

Evidence of response to IL-6 inhibition in some cases of refractory spondyloarthritis-associated peripheral synovitis

Spondyloarthritis (SpA) is a complex polygenic disorder with mixed clinical phenotype. Pro-inflammatory cytokines, including tumour necrosis factor (TNF), interleukin (IL)-17 and IL-23, play key pathogenetic roles in SpA, with their blockade being effective in many, but not all cases. Inhibition of IL-6 effectively suppresses synovitis in rheumatoid arthritis (RA)1 but has failed to show efficacy in ankylosing spondylitis (AS), the prototype SpA, in two controlled clinical trials.2 ,3 This is surprising since genetic and experimental studies indicate a potential role for IL-6 in some SpA subsets.4–6 Here, we report our experience in four men with AS and severe, recurrent peripheral synovitis. Detailed clinical and laboratory characteristics are summarised in table 1 but briefly they all fulfilled the modified New York criteria for AS with two cases (2 and 4) …

The EPIPSOFIRE project: A Preliminary Report

Postmarketing Phase IV

SAT0392 Clinical Features of Fibromyalgia and Chronic Widespread Pain Syndrome in Patients with Mild Psoriasis. Application and Comparison of the 1990 and 2010 ACR Classification Criteria

Background Fibromyalgia (FM) is a frequent cause of chronic widespread pain (CWP). Although its occurrence in psoriatic subjects represents a clinical challenge in terms of diagnosis and management, such issue is still poorly investigated. Objectives Our aim was to describe the features of CWP syndromes in a series of patients wild mild psoriatic subjects and to compare the existing classification criteria for FM. Methods In a cohort of psoriatic patients followed in a dermatological clinic dedicated to psoriasis care, 307 were consecutively enrolled for an epidemiological study. Patient on biological treatment and those unable to give informed consent were not eligible. All candidates underwent a thorough rheumatological evaluation. Details about history of pain and somatoform symptoms (SS) were collected as well. Imaging and laboratory investigations were performed as needed. Diagnosis was established through expert opinion. Results The 307 studied patients had mean age of 53.8 years (SD 16.4); 188 (61.2%) were males. Median psoriasis duration was 11 years (IQR 4.5-20), median PASI score was 3.1 (IQR 1.6-6.5). Systemic therapies were prescribed to 91 (29.6%) subjects. Chronic pain history was reported by 151 patients (49.2%), in 34 (11.1%) cases it was widespread. Median number of SS was 2 (IQR 1-3), median SS scale score was 2.5 (IQR 1-4). Pain on examination was observed in 105 patients (34.2%) and it was widespread in 13 (4.2%) cases. Two hundreds-forty-eight subjects (80.8%) had no tender point. In this series, 21 patients (6.8%) were diagnosed as CWP syndromes, only 3 satisfied the 1990 ACR criteria for FM (sensitivity 14.3%), 9 satisfied the 2010 criteria (sensitivity 42.9%), none satisfied both, 8 cases were close to satisfy at least one set of criteria. CWP syndromes were more frequent in females (P<0.001), but there was no difference in terms of age, psoriasis duration or PASI score from the rest of studied patients. Scores of SS scale, WPI, tender points, reported or objective widespread pain were significantly more frequent (all P<0.001) in CWP syndrome patients. After logistic regression analysis only the number of SS (OR 54.7, 95% CI 1.4-2076.8; P=0.03) and reported widespread pain (OR 178.8, 95% CI 1.7-18533; P=0.02) remained significant. ROC curve analysis of SS yielded AUC=0.95 with a cut off of 4 (sensitivity 80.4%, specificity 93%). Conclusions In this study, CWP was not common in psoriatic patients. The more recent classification criteria for FM proved to be were more sensitive than the older criteria, but problems of classification with borderline cases remained. The number of SS correlates well with CWP syndromes, representing a potential help in the diagnostic work up. Disclosure of Interest None Declared