Rheumatoid Arthritis: Delle Sedie A

Meenagh G, Filippucci E, Delle Sedie A, Riente L, Iagnocco A, Scirè CA, Montecucco C, Bombardieri S, Valesini G, Grassi W. · Antrim Hospital, United Kingdom. · Clin Exp Rheumatol. · Pubmed #19327222 No free full text.

Abstract: The field of inflammatory arthritis owes much to the advances in imaging technology which have enlightened not only clinical specialists but also researchers worldwide. The most exciting developments in recent decades have centred upon rheumatoid arthritis (RA) and more specifically the ultrasound (US) and magnetic resonance imaging (MRI) findings at various stages of the natural history of this condition. Investigation of RA using the standard techniques of plain radiography (x-ray) and more sophisticated computerised tomography (CT) have now been superseded by the exponential growth of use of US and MRI and this has been born out by the profusion of scientific papers published on these subjects.This paper aims to review the array of imaging modalities available as investigative tools to the rheumatologist when presented with various clinical scenarios by patients with RA.

Meenagh G, Filippucci E, Delle Sedie A, Riente L, Iagnocco A, Epis O, Scirè CA, Montecucco C, Bombardieri S, Valesini G, Grassi W. · Antrim Hospital, Antrim, United Kingdom. · Clin Exp Rheumatol. · Pubmed #19210859 No free full text.

Abstract: One of the largest challenges to the field of musculoskeletal ultrasonography is attempting to accurately quantify the changes seen in chronic arthritis. With advances in ultrasound technology, researchers have been increasingly exploring ways of more accurately assessing these changes and attempting to reach consensus with agreed scoring systems. This review presents the main scoring systems developed for quantifying sonographic findings indicative of synovitis and joint damage in patients with rheumatoid arthritis. Further investigation is required to attain international consensus on such scoring systems and to evaluate their impact on therapeutic decision-making.

Di Munno O, Delle Sedie A. · U.O. Reumatologia, Dipartimento di Medicina Interna, Università di Pisa, 56126 Pisa, Italy. · J Endocrinol Invest. · Pubmed #18791351 No free full text.

Abstract: Rheumatoid arthritis (RA) is characterized by an extensive dysregulation in skeletal homeostasis recognized as 1) focal articular bone erosions, 2) iuxta-articular osteopenia, 3) systemic osteoporosis (OP) and fractures, as is well documented in both cross-sectional and prospective studies. The disease activity, as a consequence of new insights into the complex interaction between bone cells and a variety of cells of the immune system, has emerged as the main responsible for both focal and systemic bone loss. Given this background, the therapeutic approach to RA has become more aggressive, and a more widespread use of low-dose glucocorticoids (GC), recently categorized as disease modifying antirheumatic drugs (DMARD) because of their additional joint sparing effect on the long-term, has also been recommended from the early stages. Addressing the effects of GC on systemic bone loss in RA, GC are considered, in addition to inflammation and inactivity, the major risk factors for OP and fractures. As a consequence, among the most recent recommendations (i.e. dosing, timing, and tapering strategies) for patients receiving GC for more than 3 months, prevention and treatment of GC-induced OP (i.e. calcium, vitamin D, and bisphosphonates) are included. However, innovative GC, characterized by a more favorable risk/benefit profile such as selective GC receptor agonists (SEGRA), are currently in the pipeline. This article reviews the major points of evidence so far available, regarding the effects of GC on focal and systemic bone loss.

Filippucci E, Meenagh G, Epis O, Iagnocco A, Riente L, Delle Sedie A, Montecucco C, Valesini G, Bombardieri S, Grassi W. · Cattedra di Reumatologia, Università Politecnica delle Marche, Ancona, Italy. · Clin Exp Rheumatol. · Pubmed #18328139 No free full text.

Abstract: Despite its indubitable potential, ultrasonography still has limited diffusion in rheumatology related principally to the image acquisition process due to at least five main factors: the steep learning curve, lack of standardisation of the technique, intra- and inter-observer variability, time consumption and the high initial cost of top quality sonographic equipment. Of all these barriers, the first four are undoubtedly the most difficult to overcome. This review discusses the available evidence supporting the potential of three-dimensional ultrasound with high-frequency volumetric probe to overcome the first four barriers. The challenge to three-dimensional ultrasound is to prove itself to be a method that requires no particular skills that can be mastered in just a few minutes and is not operator-dependant [corrected]

Delle Sedie A, Riente L, Bombardieri S. · Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy. · Mod Rheumatol. · Pubmed #18306005 No free full text.

Abstract: Musculoskeletal sonography (MSUS) has played a growing role in the diagnosis and management of rheumatic diseases, enabling the imaging of synovitis, bone erosion, and cartilage damage in the early phase of arthritis. "Dynamic" evaluation of tendons and help in guiding needle positioning in interventional manoeuvres are some of the other reasons for its success. MSUS, particularly when coupled with power Doppler (PD) examination, has recently been shown to be an efficient tool for monitoring disease activity and progression in rheumatoid arthritis, spondyloarthritis, crystal-related arthropathy, and osteoarthritis, with general consensus on its interesting results. More specifically, the PD signal has proved to be a simple and promising tool for short-term monitoring of synovial vascularity changes induced by steroids or biological agents in RA patients. MSUS has some limits, because of the physical properties of US and the quality of the equipment; it is, moreover, an operator-related imaging technique, with few standardized protocols. Future goals should be standardization of the examining approach in grey scale and Doppler ultrasound (US), including use of new equipment (3D US), extensive use in other fields (i.e. connective tissue diseases and vasculitis), and possible new applications (e.g. thoracic US).

Filippucci E, Iagnocco A, Meenagh G, Riente L, Delle Sedie A, Bombardieri S, Valesini G, Grassi W. · Cattedra di Reumatologia, Università Politecnica delle Marche, Jesi, Italy. · Clin Exp Rheumatol. · Pubmed #17417983 No free full text.

Abstract: The present review provides an update of the available data and discusses research issues of ultrasound (US) imaging in rheumatoid arthritis (RA).Currently the principal indications for using US in the assessment of patients with RA include: detection of sub-clinical synovitis, demonstration of bone erosion undetected by conventional radiography, detailed assessment of tendon pathology and guided injection and aspiration of joints and soft tissues. Future potential applications are likely to include short and long term therapy monitoring and early detection of cartilaginous changes in RA.The main priorities requiring the attention of investigators include: addressing validity issues, especially those related to criterion and discriminator validity, development of international consensus on scoring systems, evaluation of the role of power Doppler in the assessment of disease activity, development of a specific training programme for rheumatologists performing US and investigation of the potential of 3D US using a volumetric probe.

Baldini C, Delle Sedie A, Bombardieri S. · U.O. Reumatologia, Department of Internal Medicine, University of Pisa, Italy. · Clin Exp Rheumatol. · Pubmed #16396713 No free full text.

Abstract: In the last few years management of rheumatoid arthritis (RA) has changed substantially due to the availability of new drugs and newer therapeutical strategies. Controlled randomised clinical trials (RCT) have allowed us to analyse the efficacy and safety of all these innovative approaches. Unfortunately, these RCTs are not free from criticisms and their rigid inclusion and exclusion criteria may increase the differences between the ideal patients enrolled and the majority of patients seen in standard clinical care. This review focuses on actual clinical practice, with particular attention on patient comorbidities and all the conditions which have been designated as exclusion criteria in the most important registration RCTs. We will attempt to provide an overview of the most widely used strategies in RA therapy.

Di Munno O, Delle Sedie A, Rossini M, Adami S. · Department of Internal Medicine, U O Reumatologia, University of Pisa, Pisa, Italy. · Clin Exp Rheumatol. · Pubmed #15895881 No free full text.

Abstract: This article reviews the effects of DMARDs (including biologic agents) on bone metabolism in rheumatoid arthritis (RA). At present there is no evidence that methotrexate, at least at dosages ranging from 5 to 20 mg/week, negatively affects bone mass as measured by DXA (BMD) as documented in both cross-sectional and longitudinal studies. Most studies of cyclosporine (CyA) use reporting a reduction in erosions and joint damage with no adverse effects on bone, did not measure BMD; CyA treatment is associated with a dose-dependent increase of bone turnover as well as a decrease in both animal and human studies; however, its use in RA setting at a dose < or =5 mg/Kg/ day has so far not been associated with clinical relevant adverse effects on bone metabolism. Anti-TNF-alpha agents, infliximab reduced markers of bone turnover in two longitudinal studies. Data on BMD are not available in RA; nevertheless, an increase in BMD has been documented in spondyloarthropathies with infliximab and etanercept. No clinical data concerning BMD are available on leflunomide as well as on the newer biologic agents (adalimumab, rituximab, anakinra).

Filippucci E, Meenagh G, Delle Sedie A, Salaffi F, Riente L, Iagnocco A, Scirè CA, Montecucco C, Bombardieri S, Valesini G, Grassi W. · Cattedra di Reumatologia, Università, Politecnica delle Marche, Jesi, Italy. · Clin Exp Rheumatol. · Pubmed #19473557 No free full text.

Abstract: In the rheumatology literature, most of the available evidence on three-dimensional ultrasound (3D US) is related to the acquisition process and highlights the virtual operator independence and shortening of the US examination time. The main aim of this study was to compare 3D US using a high-frequency volumetric probe and conventional 2D US at the wrist and hand in patients with rheumatoid arthritis (RA). The 3D US examinations were performed using a Logiq 9 (General Electrics Medical Systems, Milwaukee, WI) with a high-frequency (8-15 MHz) volumetric probe. Overall, there is good-to-excellent agreement between the two modalities relating to both joint inflammation and bone erosion. This study is an initial step towards establishing a methodology necessary for developing multi-centre US studies which are aimed at assessing hand involvement in patients with RA.

Anzilotti C, Riente L, Pratesi F, Chimenti D, Delle Sedie A, Bombardieri S, Migliorini P. · Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy. · Rheumatology (Oxford). · Pubmed #17717033 No free full text.

Abstract: OBJECTIVES: Anti-citrullinated protein/peptide antibodies (ACPA), a family of antibodies with overlapping specificities, represent a specific marker of rheumatoid arthritis (RA). The aim of the present study is to investigate the prevalence and clinical significance of IgG, IgA and IgM ACPA by a newly described assay employing a viral citrullinated peptide (VCP). METHODS: IgG, IgA and IgM anti-VCP antibodies have been measured in sera from 146 patients affected by RA and 404 controls, including 204 chronic arthritides, 111 connective tissue disorders and 89 healthy subjects. The affinity of the different isotypes for VCP was analysed by liquid phase inhibition assays. RESULTS: Among RA patients, 40 were single positive for IgG anti-VCP, five for IgA and 11 for IgM. Ten patients were double positive for IgG and IgA, four for IgG and IgM, six for IgA and IgM. In 15 RA patients IgG, IgA and IgM anti-VCP antibodies were detected. No correlation could be found between the isotype and the clinical manifestations or duration of the disease. IgA anti-VCP were strongly associated with RA, whereas IgM anti-VCP were detected also in a low percentage of systemic lupus erythematosus, psoriatic arthritis and mixed cryoglobulinaemia (MC) patients. IgG anti-VCP displayed a higher affinity for the antigen than IgA or IgM. CONCLUSIONS: These data show that anti-VCP of IgG and IgA isotype discriminate RA from other chronic arthritides and disease controls and suggest an independent production of each isotype.

Riente L, Delle Sedie A, Iagnocco A, Filippucci E, Meenagh G, Valesini G, Grassi W, Bombardieri S. · Cattedra di Reumatologia, Università di Pisa, Pisa, Italy. · Clin Exp Rheumatol. · Pubmed #17181916 No free full text.

Abstract: Ultrasonography (US) is a useful tool for imaging, which can be used for the assessment of joints and periarticular structures in all rheumatological disorders. In patients with pain and/or swelling of the ankle and foot, US provides information about the presence of joint effusion, synovitis, tenosynovitis, tendinosis, and tendons tears, helping in the differential diagnosis between joint or tendon/enthesis involvement. Moreover, US allows clinicians to monitor and guide needle positioning to inject pharmaceutical substances more safely and effectively even in hard-to-reach sites. US represents an accurate, safe and low-cost technique that can be used for the examination of the ankle and foot in rheumatic disorders.

Antonelli A, Delle Sedie A, Fallahi P, Ferrari SM, Maccheroni M, Ferrannini E, Bombardieri S, Riente L. · From the Department of Internal Medicine and the Rheumatology Unit, University of Pisa, and the Endocrinological Laboratory, Azienda Ospedaliera Pisana, Pisa, Italy. · J Rheumatol. · Pubmed #17014017 No free full text.

Abstract: OBJECTIVE:To evaluate the prevalence of thyroid disorders in a group of patients with psoriatic arthritis (PsA). METHODS: A complete thyroid investigation was carried out in 80 patients with PsA, in gender- and age-matched subjects (1:5) drawn from the general population (controls), and in 112 patients with rheumatoid arthrtitis (RA) with similar iodine intake. RESULTS: Anti-thyroid peroxidase antibodies (AbTPO), a hypoechoic thyroid, and subclinical hypothyroidism were significantly more frequent in women with PsA than in control women, and their frequency was similar to that in patients with RA (positive AbTPO titer 28%, 12%, and 31%; hypoechoic thyroid 31%, 16%, and 36%; subclinical hypothyroidism 25%, 8%, and 12%, respectively). Among men, positive AbTPO titers and a hypoechoic thyroid were found more frequently in the patients with PsA and RA than in controls (positive AbTPO titer 14%, 5%, and 2%; hypoechoic thyroid 16%, 10%, and 3%, respectively). All patients with PsA with subclinical hypothyroidism had polyarticular involvement (p </= 0.05) and a longer disease duration (years 19 +/- 15 vs 11 +/- 8, p = 0.03) than patients with euthyroid PsA. The prevalence of subclinical hyperthyroidism, thyroid nodules, and thyroid enlargement was not significantly different among the 3 groups.CONCLUSION: Our results demonstrate a significantly higher prevalence of thyroid autoimmunity (positive AbTPO, hyoechoic thyroid) findings in men and women with PsA and of subclinical hypothyroidism in women with PsA than in the general population. Therefore, thyroid function tests, an AbTPO assay, and thyroid ultrasound should be performed as part of the clinical evaluation, particularly in women with PsA.

Iagnocco A, Filippucci E, Meenagh G, Delle Sedie A, Riente L, Bombardieri S, Grassi W, Valesini G. · Cattedra di Reumatologia, Università di Roma La Sapienza, Roma, Rome, Italy. · Clin Exp Rheumatol. · Pubmed #16870087 No free full text.

Abstract: Ultrasonography (US) is a reliable and useful diagnostic tool for the assessment of hip pathology. It depicts changes within the coxo-femoral joint (synovitis, erosions, osteophytes) and in the adjacent peri-articular tissues (calcifications, tendonitis, enthesitis, bursitis) in many rheumatic diseases (rheumatoid arthritis, spondyloarthritis, osteoarthritis, polymyalgia rheumatica ) and in some orthopaedic disorders (septic arthritis, trauma, abscess, painful hip after arthroplasty). It is commonly used both in adults and in children. In the assessment of hip joint pathology, US exerts considerable diagnostic supremacy over physical examination. In fact, by virtue of its size and position, reliable physical examination of the hip is often difficult thus making US particularly useful as a bedside tool for the evaluation of a painful hip. Hip US has also proven to be of great practical benefit when performing aspiration and injection within the joint and in the periarticular soft tissues. The relatively limited acoustic windows available to the US beam is the principal limitation to hip US thereby making detailed examination of some important structures impossible together with the interpretation of power Doppler signal sometimes unreliable. In addition, the deep location of the hip can confer further problems to US scanning in obese or particularly muscular subjects.

Riente L, Chimenti D, Pratesi F, Delle Sedie A, Tommasi S, Tommasi C, Bombardieri S, Migliorini P. · Rheumatology and Immunology Units, Department of Internal Medicine, University of Pisa, Pisa, Italy. · J Rheumatol. · Pubmed #15124251 No free full text.

Abstract: OBJECTIVE: Subclinical gut inflammation has been described in patients with ankylosing spondylitis (AS) or psoriatic arthritis (PsA). Joint involvement has also been reported related to celiac disease. We investigated IgA antibodies to bovine tissue tranglutaminase (tTg) and IgA and IgG antibodies to human tTg and to Saccharomyces cerevisiae (ASCA) in patients with AS and PsA. METHODS: We evaluated the frequency of IgA antibodies to bovine tTg, and of IgA and IgG antibodies to human tTg and to ASCA in 43 patients with AS and 75 with PsA. As control groups we considered 79 patients with rheumatoid arthritis (RA) and 78 healthy blood donors. RESULTS: We detected antibodies as follows: IgA antibodies to bovine tTg in 1/43 patients with AS, 3/75 with PsA, 1/79 with RA, and in 9/78 healthy controls; IgA antibodies to human tTg in 1/43 patients with AS, 1/75 with PsA, 1/79 with RA, and in 3/78 healthy controls; IgG antibodies to human tTg in 1/43 patients with AS, 4/75 with PsA, 5/79 with RA, and in 7/78 healthy controls. IgA ASCA were confirmed in 10/43 patients with AS, 7/75 with PsA, 14/79 with RA, and in 7/78 healthy controls; IgG ASCA were present in 5/43 patients with AS, 4/75 with PsA, 8/79 with RA, and in 8/78 healthy controls. No statistically significant difference was observed in the prevalence of IgA or IgG antibodies to bovine and human tTg and in the frequency and in mean level of IgA or IgG ASCA between the studied groups or between each group and healthy controls. CONCLUSION: Our data fail to show an increased prevalence of autoantibodies associated with celiac and Crohn's disease in patients with AS and PsA.

Taglione E, Vatteroni ML, Martini P, Galluzzo E, Lombardini F, Delle Sedie A, Bendinelli M, Pasero G, Bencivelli W, Riente L. · Department of Biomedicine, University of Pisa, Italy. · J Rheumatol. · Pubmed #9972971 No free full text.

Abstract: OBJECTIVE: To study the prevalence of hepatitis C virus (HCV) infection in 2 groups of patients, one group with psoriasis and the other with psoriatic arthritis (PsA). METHODS: We detected anti-HCV antibodies by ELISA and by a recombinant immunoblot assay (RIBA) in the sera of 50 patients with psoriasis and 50 with PsA. As controls we used a group of 76 patients with rheumatoid arthritis (RA), and referred to data on the prevalence of HCV in the general Italian population. RESULTS: By ELISA, anti-HCV antibodies were detected in 6/50 (12%) patients with PsA, in 5/50 (10%) patients with psoriasis, and in 4/76 (5.2%) patients with RA. All the reactive PsA and RA sera also tested positive on RIBA, while only 3 of the 5 positive results for sera of patients with psoriasis were confirmed by RIBA. The prevalence of HCV infection in patients with psoriasis was not significantly higher than in controls. In contrast, the rate of HCV infection observed in the 50 patients with PsA was higher than that in the other groups, the difference being statistically significant between patients with PsA and the general population. CONCLUSION: Our data do not support the hypothesis that HCV infection may play a role in the pathogenesis of psoriasis. On the other hand they show a statistically significant difference between the prevalence of HCV infection in patients with PsA and the general population.