Susanna Maddali-Bongi

Liver stiffness correlates with methotrexate cumulative dose in patients with rheumatoid arthritis

BACKGROUND Liver stiffness values were recently proposed to identify patients with methotrexate-induced liver fibrosis. Aim of this study was to assess the clinical and laboratory determinants of the association between liver stiffness, measured by transient elastography, and methotrexate treatment in patients with rheumatoid arthritis in the absence of other factors contributing to liver damage and fibrosis. METHODS 100 patients with rheumatoid arthritis, with a cumulative methotrexate dose ranging from 1530 to 13,000 mg over a mean period of 7.07±3.89 yrs, were retrospectively evaluated. RESULTS The average liver stiffness value in the whole population was 4.93±1.8 kPa, excluding the presence of significant fibrosis. At univariate analysis, a significant correlation was found between liver stiffness and methotrexate cumulative dose, duration of treatment, alanine transaminases levels, body mass index, gamma glutamyl-transpeptidase and the presence of steatosis. At multivariate analysis, a significant association was detected only between liver stiffness and methotrexate cumulative dose. Out of 11 patients with liver stiffness >7.0 kPa, five were subjected to liver biopsy and mild or moderate perisinusoidal fibrosis was detected in two patients with a cumulative dose >4000 mg and liver stiffness >9 kPa. CONCLUSIONS Chronic methotrexate treatment induces a progressive increase in liver stiffness corresponding to mild or moderate perisinusoidal fibrosis for values >9 kPa.

Mind body therapies in rehabilitation of patients with rheumatic diseases.

Mind body therapies (MBT) share a global approach involving both mental and physical dimensions, and focus on relationship between brain, mind, body and behavior and their effects on health and disease. MBT include concentration based therapies and movement based therapies, comprising traditional Oriental practices and somatic techniques. The greatest part of rheumatic diseases have a chronic course, leading to progressive damages at musculoskeletal system and causing physical problems, psychological and social concerns. Thus, rheumatic patients need to be treated with a multidisciplinary approach integrating pharmacological therapies and rehabilitation techniques, that not should only aim to reduce the progression of damages at musculoskeletal system. Thus, MBT, using an overall approach, could be useful in taking care of the overall health of the patients with chronic rheumatic diseases. This review will deal with different MBT and with their effects in the most common chronic rheumatic diseases (Rheumatoid Arthritis, Ankylosing Spondylitis, Fibromyalgia Syndrome).

Oral health in patients with systemic sclerosis

Orofacial manifestations due to fibrosis of the skin and soft tissues are typical in SSc and include amimia, disappearance of cutaneous wrinkles, vertical furrows around the mouth and sharpening of the nose. Facial and oral changes also include telangiectasia, sicca syndrome, thinning and reduction of mouth width (microcheilia) and opening (microstomia) worsened by temporo-mandibular joint involvement. Periodontal and dental abnormalities (decayed, filled and missing teeth) are also common. Orofacial modifications affect aesthetics and are ranked as the most worrying aspects of SSc [1]. They may alter the patient’s oral health-related quality of life (OHRQoL), as they hinder eating and cause difficulty in chewing and speaking. Microstomia also makes daily hygiene and dental treatment challenging [2]. Despite their high frequency, oral manifestations and OHRQoL (measured by questionnaires pertaining to oral health, capturing functional, social and psychological impacts of oral disease) in SSc patients are underrated and not comprehensively studied, probably because they are overshadowed by concomitant, sometimes severe, systemic symptoms. The article by Baron et al. [3] in this edition of Rheumatology plugs this gap with a multisite cross-sectional study assessing oral conditions and OHRQoL in a reasonable number of SSc patients taken from the Canadian Scleroderma Research Group registry and compared with ageand sex-matched healthy controls. An oral examination demonstrated that SSc patients have significantly more decayed teeth and periodontal disease, produce less saliva (examined by the Saxon test) and have a smaller interincisal distance than controls. SSc patients also show a significantly reduced OHRQoL compared with controls as assessed by the Oral Health Impact Profile (OHIP), both in its overall score and in its seven subscales [3]. Multivariate regression analyses confirm SSc as a significant independent predictor of missing teeth, periodontal disease, interincisal distance, saliva production and OHIP scores. This high-quality study [3] confirms the results of previous work that showed a higher prevalence of dental and periodontal disease in SSc patients than in controls. However, in contrast to these studies summarized in the article [3], which do not specify the professionals who examined the patients, Baron et al. evaluated 163 SSc patients by standardized examinations performed by dentists. Importantly, Baron et al. [3] demonstrated a significantly worse OHRQoL in SSc than in controls by using the OHIP, a self-administered questionnaire with excellent measurement properties that is valid and reliable in different populations and with high sensitivity to change. It is also potentially useful in both cross-sectional and longitudinal research in SSc, although it is not disease specific. However, Baron et al. [3] do not include the Mouth Handicap in Systemic Sclerosis (MHISS) scale [4], a selfadministered tool created for SSc patients to quantify disease-specific face and mouth disability. The MHISS assesses OHRQoL [4] with excellent reliability, construct validity and good sensitivity to change [5], examining handicap related to reduced mouth opening and sicca syndrome as well as aesthetic concerns. In SSc, OHRQoL evaluated by the MHISS contributes to 36% of the variance in global disability [4] and is an independent predictor of health-related quality of life (HRQoL) [6], depression and anxiety [7]. Altogether this evidence demonstrates that oral manifestations and impaired OHRQoL, although not life threatening, are important to SSc patients [1, 2] and need proper evaluation and treatment. The correlation of altered OHRQoL with global disability [4] and HRQoL [6] and mood impairment [7] substantiates the importance of oral concerns in SSc. The study of Baron et al. [3], although well performed, does not specify HRQoL, disability and organ involvement. It also does not characterize whether SSc patients were affected by SS, who, as described in Alantar et al. [8], report more prominent oral changes due to salivary gland hypofunctionality. Baron et al. [3] also use the Saxon text rather than the method of assessing unstimulated whole salivary flow, as suggested by the American and European Consensus Group classification criteria [9]. Moreover, the study does not classify subjects according to limited or diffuse subsets of SSc, which usually show more severe limitations in OHRQoL but a lower prevalence of sicca symptoms [6, 7]. As SSc may involve the whole mouth and facial tissues, a coordinated multidisciplinary approach involving rheumatologists, dentists, oral hygienists, physiotherapists and other professionals skilled in SSc evaluation and care is necessary to treat the issues related to oral problems [8] and OHRQoL [4]. In daily rheumatology

Is an intervention with a custom-made splint and an educational program useful on pain in patients with trapeziometacarpal joint osteoarthritis in a daily clinical setting?

Custom‐made splints may be useful in the conservative treatment of osteoarthritis (OA) of trapeziometacarpal (TMC) joint OA. Our aim was to evaluate usefulness of a custom‐made splint and educational program in patients with symptomatic TMC joint OA in daily clinical practice.

Clinical significance and usefulness of rehabilitation for systemic sclerosis

Systemic sclerosis is a multisystem connective tissue disorder characterized by excessive fibrosis of the skin and internal organs. Impairments in skin, the musculoskeletal system, and respiratory system require rehabilitation therapy because they may lead to disabilities and reduce the quality of life in daily activities. Rehabilitation for systemic sclerosis mainly comprises two distinct approaches that include local and global rehabilitation. Local rehabilitation is applied to maintain and/or improve hand and face functions, while global rehabilitation includes aerobic and resistance exercises. Although few high-quality randomized clinical trials have been conducted to date, previous studies indicated the effectiveness of rehabilitation therapy for decreasing local and systemic disabilities, resulting in improved quality of life. Rehabilitation for systemic sclerosis needs to be regularly and constantly performed at home as well as in hospitals. Physicians involved in the treatment of systemic sclerosis need to consider rehabilitation, and skilled physiotherapists and occupational therapists also play a crucial role in evaluating and treating systemic sclerosis patients.

Hand Function in Scleroderma

Systemic sclerosis or scleroderma (SSc) is characterized by immunologic abnormalities, microvascular alterations, and excessive collagen production, leading to fibrosis of skin and internal organs (lungs, heart, gastrointestinal tract).