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Disease patterns and manifestations may vary among different populations and change over time. The purpose of our study was to define the demographic, clinical, roentgenologic, and laboratory findings in a recent cohort of psoriatic arthritis patients followed up in rheumatology clinics in northern Israel. We conducted a cross-sectional study of 149 psoriatic arthritis patients. Demographic, clinical, laboratory, and radiological data, with emphasis on the pattern of arthritis, treatment regimens, and co-morbidities were obtained from patient interviews and rheumatology file reviews. The mean age of our patients was 58.2, with a female preponderance (57.3%). Skin involvement preceded the arthritis or was diagnosed simultaneously in 90.1% of cases. The most common joint involvement was an RA-like arthritis (49.7% of the patients) correlating positively with age, female gender, and disease duration. Dactylitis and nail involvement were observed in 33.6 and 36.2% of the patients, respectively. Radiographic bone erosions were noted in a third of the patients, correlating with DIP and RA-like arthritis patterns. Most patients were treated with methotrexate (73.8%) and a combination therapy (41.4%). An increased incidence of hypertension, hyperlipidemia, and diabetes mellitus was noted in our cohort compared to the general Israeli population. Our survey, the first of its kind conducted in Israel, noted a relative increase in the polyarticular manifestation of PsA and a decrease in spondyloarthropathy, compared to historic series, with more aggressive disease found in women above the age of sixty. These findings are in line with recent surveys.

The clinical implications of computed tomography (CT) detected sacroiliac joint (SIJ) changes compatible with sacroiliitis has been rarely discussed in the literature. The aim of the present study was to describe prevalence and clinical correlations of sacroiliitis, noted incidentally by abdominal CT in patients referred for non-musculoskeletal complaints, utilizing the New York radiological grading criteria for reference. Five hundred ninety-eight CT scans of the abdomen of patients 18–55 years old, performed at a community medical center, were prospectively examined for the presence of imaging changes consistent with sacroiliitis. Patients with the evidence of bilateral sacroiliitis of grade ≥2 were interviewed and underwent a rheumatologic examination. Twenty-two patients (13 females) were enrolled. Only eight patients (six males) had a history and clinical picture compatible with previously undiagnosed axial spondyloarthritis (SpA). Only the presence of erosions/joint space irregularity and/or inhomogeneous osseous sclerosis around SIJs on CT correlated with the clinical diagnosis of axial SpA. Dense homogenous osseous sclerosis was unrelated to axial SpA and was seen almost exclusively in females. The prevalence of incidental CT sacroiliitis is low, while the New York radiological grading criteria for diagnosing sacroiliitis may be inappropriate for CT imaging. CT noted erosions of the SIJ appear to be a reliable diagnostic sign of sacroiliitis, while the significance of the osseous sclerosis, seen on CT adjacent to SIJs requires better understanding.

We evaluated the effects of hyperoxia on pulmonary inflammatory changes in sepsis induced by cecal ligation and puncture (CLP) in rats. Seven groups were studied: sham-operated rats breathing air for 20 or 48 h; CLP breathing air for 20 or 48 h; and CLP + 100% oxygen for 20 h, or 70% oxygen for 48 h, or 100% oxygen intermittently (6 h/d) for 48 h. Video microscopy was used to monitor lung macromolecular leak, microvascular flow velocity, and shear rates, and lung morphometry was used for leukocyte infiltration and solid tissue area. Cell counts, tumor necrosis factor α, and nitrites were determined in peripheral blood and lung lavage fluid. Expression of adhesion molecules in blood leukocytes was evaluated by flow cytometry. Cecal ligation and puncture induced inflammation manifested in leukopenia, left shift, thrombocytopenia, increased expression of L selectin and CD11, increased serum and lavage fluid tumor necrosis factor α and leukocytes, and increased lung tissue area, macromolecular leak, and sequestration of leukocytes. Inhalation of 100% oxygen for 20 h increased nitrites (P < 0.01) and decreased leukocyte count in lavage fluid (P < 0.05) and attenuated lung macromolecular leak and changes in solid tissue area (P < 0.01). Inhalation of 70% oxygen (48 h) attenuated expression of adhesion molecules (P < 0.001) but failed to attenuate markers of lung inflammation. In contrast, intermittent 100% oxygen exerted favorable effects on markers of inflammation, attenuated leukocyte expression of L selectin and CD11 (P < 0.01), decreased pulmonary sequestration of leukocytes (P < 0.001), and ameliorated changes in macromolecular leak (P < 0.01) and lung solid tissue area (P < 0.05). Our data support the beneficial effects of safe subtoxic regimens of normobaric hyperoxia on the systemic and pulmonary inflammatory response following CLP.

Objectives: To evaluate the level of education and participation in an internship abroad and to European league against rheumatism (EULAR) on line course of young rheumatologists. To define new tools for learning., Methods: Questionnaires were administered to 170 trainees and young specialists in 2008-2009 during official EULAR meetings or using the mailing list of European young rheumatologists in training. The questions with related visual analogical scale (VAS score 0-10) for satisfaction encompassed the following issues: languages, computer, daily hours employed, different items of medical culture, internship abroad, EULAR on-line course and bursaries. VAS>6 was considered a good level of satisfaction., Results: 170 young rheumatologists (113 trainees and 57 specialists, 33±4.2 years old) from 32 EULAR countries did not approve their own national training (42.3%), believed in an European common education system (90.5%), had a good knowledge of English (85.7%) and computer (90.5%) and spent the majority of time in clinical practice (57.5%) in comparison with study and research. The young rheumatologists had higher competence in drug management (93.5%) than in clinical assessment and knowledge of imaging and anatomy, and mostly suggested new ways of communication (61.4% on-line courses and 66.1% DVD) to improve their education. 38% made stage abroad and participated to EULAR on-line course, with high satisfaction, but only half of them were granted by bursaries., Conclusions: Young rheumatologists are low confident in their own education and believe that visits to other training centers and new ways of learning (on line and DVD) might improve their competence.

A cohort of patients with recently diagnosed axial spondyloarthritis (SpA) was characterized with emphasis on gender differences and factors leading to delay in diagnosis. Clinical, laboratory, and imaging data of 151 consecutive patients diagnosed with ankylosing spondylitis or undifferentiated SpA in 2004-2009 and satisfying the new ASAS classification criteria for axial SpA, was collected and analyzed. Seventy-nine men and 72 women were enrolled. Both groups (men and women) had similar age of onset of disease-related symptoms, as well as similar delay time to diagnosis, follow-up duration and frequency of anti-TNF treatment. Inflammatory back pain, as a first symptom related to SpA, was reported more often by men, while women had more pelvic, heel, and widespread pain (WP) during the course of the disease. At the time of diagnosis, men were more limited in chest expansion and showed increased occiput-to-wall distance compared to women. Elevated erythrocyte sedimentation rate and/or C-reactive protein were detected in a similar proportion of men and women. Presence of WP in women almost doubled the delay in the diagnosis of SpA. No other differences in disease presentation or burden were demonstrated to correlate with delay in diagnosis.

The purpose of this study is to characterize the chronic liver disease (CLD) that may be associated with familial Mediterranean fever (FMF). Twenty-seven patients (mean age, 48 ± 18 years; F/M, 16:11) with FMF who were referred for assessment of CLD were studied. Data regarding FMF and CLD were obtained from patient medical files. Liver biopsy was performed in 21 of 27 patients and deferred in six (cirrhotic coagulopathy in five and one who improved after colchicine dose reduction). Patients with FMF and non-alcoholic fatty liver disease (NAFLD) were compared to matched controls from a cohort of 150 patients with NAFLD per liver biopsy but without FMF. The mean Tel Hashomer severity score was 1.7 ± 0.9. The mean daily dose of colchicine was 1.4 ± 0.4 mg over a mean duration of 21 years ± 10. Seven of ten patients who underwent mutation analysis for FMF were homozygous for M694V. In 15 patients, there was evidence of NAFLD: five with "simple" steatosis, three with non-alcoholic steatohepatitis (NASH), and seven with NASH-cirrhosis. An additional five patients had "cryptogenic" cirrhosis, which in most patients represents the end result of unrecognized NASH, and one had normal liver tissue. Comparing FMF patients with NAFLD to matched controls with NAFLD did not reveal excess of metabolic syndrome in FMF patients. Of our FMF patients, 74% had evidence of NAFLD, 75% of which with severe manifestation. The extremely high proportion of NAFLD in our cohort of FMF patients without overt metabolic syndrome may indicate an unappreciated novel association between FMF and NAFLD.

Gout is rare among young women. The prevalence of gout is increasing in the western world and the Far East, probably owing to life style changes. The association between hyperuricemia and gout, the metabolic syndrome and atherosclerosis is stronger in women. 40 years ago, the increased prevalence of hyperuricemia and gout in Filipino men living in the United States was described. Recently, Filipino men and women living in the western world were found to have increased risk of the metabolic syndrome and atherosclerosis. We describe two unusual cases of gout in premenopausal Filipino women living in Israel, both of which suffered from hypertension. We also describe the current knowledge about gout in women, in general, and in migrant Asian women, in particular, with an emphasis on its relations to the metabolic syndrome and atherosclerosis. The occurrence of gout in relatively young migrant Filipino women might signal a change in the epidemiology of this disease, and might signal that these women are more prone to develop the metabolic syndrome and its complications.

A patient with ankylosing spondylitis, after demonstrating incomplete clinical response to adalimumab, received three monthly infusions of pamidronate along with continuing TNF-alpha blockade. Complete disappearance of the back pain was reported after the second pamidronate infusion. The perspectives of the combination therapy with TNF-alpha inhibitor and pamidronate are discussed.

Pamidronate, along with other bisphosphonates, has been used for treatment of bone pain secondary to malignant involvement or metastatic disease for years. Some data, however, have also accumulated on the utility of pamidronate in a variety of benign conditions frequently handled by rheumatologists. This study aims to review the available published data regarding the potential use of pamidronate in rheumatology practice. Methods include the review of relevant articles retrieved by a PUBMED search utilizing the index term "pamidronate". All available randomized control trials, open trials, and case series, as well as properly reported case studies evaluating usage of pamidronate in rheumatic disorders, have been included in the literature review. The efficacy of pamidronate in patients with spondyloarthropathies; synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome; hypertrophic osteoarthropathy; osteoporotic vertebral fractures; chronic back pain due to disk disease or spinal stenosis; Charcot arthropathy; transient osteoporosis; and complex regional pain syndrome-I, has been demonstrated in more than 40 reports, the majority of which, however, were not controlled studies. In some of reviewed conditions, aside from providing analgesic relief, pamidronate may also have disease-modifying properties. While used in different doses in a variety of rheumatic disorders, pamidronate was generally reported to be well tolerated with an overall good safety profile. Pamidronate may represent an effective and safe choice for a spectrum of rheumatic patients, suffering from intractable musculoskeletal pain, unresponsive to traditionally recommended therapies. Large randomized, controlled studies examining the efficacy of pamidronate in the rheumatic conditions are urgently needed.

Objective: We assessed cardiac conduction properties in patients with psoriatic arthritis (PsA)., Methods: Electrocardiogram (ECG) scans of 92 patients with PsA were compared to 92 age and sex matched nonpsoriatic, nonarthritic patients from general practice serving as controls., Results: PR interval was found to be significantly longer in the PsA group compared to controls, 159.6 +/- 21 ms versus 151.3 +/- 26 ms, respectively (p = 0.021). No statistical difference was found with respect to the QRS interval or other atrial or ventricular conduction disturbances studied. No correlation was found between the PR interval and disease duration or PsA subtype. The use of nonsteroidal antiinflammatory drugs did not affect the PR interval. Methotrexate was not found to influence the PR interval, compared to other disease modifying antirheumatic drugs. Two PsA patients (2.1%) had a PR interval > 0.2 ms. Their prolonged PR interval could not be explained by medication use. The abnormal prolongation of the PR interval was asymptomatic, requiring no additional intervention. No patient had complete heart block., Conclusion: Our study may suggest subtle involvement of the atrioventricular node in patients with PsA.

Reiter's syndrome is an eponym used to denote the triad of arthritis, urethritis and conjunctivitis. This syndrome is named after Hans Conrad Julius Reiter, who was involved in the activities of the Nazi Racial Hygiene Program related to involuntary sterilization, euthanasia and criminal research projects. Reiter defamed the entire medical profession and it was therefore suggested that the term Reiter's syndrome be changed to reactive arthritis. We undertook to investigate the use of the eponym Reiter syndrome in medical literature, medical schools in Israel and medical textbooks, compared to the term reactive arthritis, by searching Medline between the years 2003 and 2007, 14 current medical textbooks, curricula of the four medical schools in Israel, and computerized patient file systems in Israel. We found a decline in the use of the eponym in articles published between 2003 (18%) and 2007 (9%); however, most textbooks (13/14) still use it. Two of the four medical schools in Israel continue to use the eponym. The eponym appears in the computerized patient files of all four healthcare providers in Israel. We hold that the continued use of the eponym Reiter syndrome in medical textbooks, medical schools and computerized patients files in Israel is honoring an abomination and is inconsistent with medical principles. Awareness is still lacking and we suggest deleting the Reiter syndrome eponym from use, and replacing it with the more appropriate term--reactive arthritis.

Hepatic encephalopathy and myxedema coma share clinical features: coma, ascites, anemia, impaired liver functions, and a "metabolic" electroencephalogram (EEG). Hyperammonemia, a hallmark of hepatic encephalopathy, has also been described in hypothyroidism. Differentiation between the 2 conditions, recognition of their possible coexistence, and the consequent therapeutic implications are of utmost importance. We describe a case of an 82-year-old woman with a history of mild chronic liver disease who presented with hyperammonemic coma unresponsive to conventional therapy. Further investigation disclosed severe hypothyroidism. Thyroid hormone replacement resulted in gain of consciousness and normalization of hyperammonemia. In patients with an elevated ammonia level, altered mental status, and liver disease, who do not have a clear inciting event for liver disease decompensation, overwhelming evidence of hepatic decompensation, or who do not respond to appropriate therapy for hepatic encephalopathy, hypothyroidism should be considered and evaluated.

Today, more than 10 years and 2000 articles since human herpesvirus 8 was first described by Chang et al., novel insights into the transmission and molecular biology of HHV-8 have unveiled a new spectrum of diseases attributed to the virus. The association of HHV-8 with proliferative disorders--including Kaposi's sarcoma, multicentric Castleman disease and primary effusion lymphoma--is well established. Other aspects of HHV-8 infection are currently the subject of accelerated research. Primary HHV-8 infection may manifest as a mononucleosis-like syndrome in the immunocompetent host, or in various forms in the immunocompromised host. The association of HHV-8 with primary pulmonary hypertension was observed by Cool et al. in 2003, but six clinical trials evaluating the role of HHV-8 in pulmonary hypertension have not been able to replicate this intriguing observation. It has been speculated that HHV-8 may secondarily infect proliferating endothelium in patients with pulmonary hypertension. HHV-8 epidemiology, modes of transmission, new spectrum of disease and treatment are presented and discussed.

Purpose: It was the aim of this study to evaluate the results of a prospective study in a single medical center using ceftazidime monotherapy in cancer patients with chemotherapy-induced grade IV febrile neutropenia and a low risk for gram-negative bacteremia., Subjects and Methods: Thirty-eight patients were admitted with low-risk grade IV febrile neutropenia after chemotherapy for solid tumors. The median patient age was 57 years (range 18-74). Sixteen patients (42%) developed febrile neutropenia after the first cycle of current chemotherapy line, 9 patients (24%) received 2-3 cycles and 13 patients (34%) received more than 3 chemotherapy cycles before manifesting febrile neutropenia. Five patients were treated with prophylactic granulocyte colony-stimulating factor commenced 24 h after completion of the chemotherapy cycle. Empiric monotherapy with intravenous ceftazidime was started on admission and administered 2 g every 8 h., Results: The mean polymorphic nuclear cell count on admission was 231 cells/mm(3). Ceftazidime therapy was well tolerated. Twenty-five (66%) patients responded with clinical improvement and complete resolution of fever within 48 h after initiation of ceftazidime therapy. Thirty-two (84%) patients were afebrile after 72 h of therapy. Thirty-three patients (87%) remained on unmodified ceftazidime therapy throughout their hospitalization. Five patients (13%) subsequently required modification of the treatment regimen for various reasons. Mean duration of fever and neutropenia were 2 (1-10) days and 4 (1-11) days, respectively. None of the patients discontinued therapy because of adverse effects. No positive blood cultures were obtained. No events of septic shock were observed. Mean duration of hospitalization was 6 days (range 3-12)., Conclusion: In our series, monotherapy with intravenous ceftazidime appears safe and effective in cancer patients with low-risk grade IV febrile neutropenia after cytotoxic chemotherapy and may appreciably reduce antibiotics costs.

Major depression is a risk factor, associated with a twofold increase in the incidence of ischemic heart disease (IHD). One of every 6 patients suffers from major depression following acute myocardial infarction (AMI). This connection is of major concern, considering that major depression is an independent risk factor for cardiac morbidity and mortality after AMI, increasing overall mortality fourfold. Activation of the immune system has a significant role in the pathogenesis of IHD and depression. Vast physiological responses, mediated mostly by activation of the immune system, accompany post MI depression and may account for increased prevalence of arrhythmias and high mortality. This includes activation of the hypothalamic-pituitary-adrenocortical axis, endothelial dysfunction, platelets activation and alterations of phospholipid composition in cell membranes. On the other hand, activation of the immune system after AMI includes elevated levels of interleukin-1 and interleukin-6. which induce "sickness behavior", characterized by symptoms similar to those observed in major depression. The key question raised by this data, whether inflammation is the common ground for both AMI and depression, or if it is accompanying one and sets the ground for the other, remains unanswered at this time. The significance of major depression as an independent risk factor for post MI mortality and morbidity raises the practical question, whether treatment of depression can reduce mortality after AMI. Several recent studies that evaluated this presumption, failed to prove it. In this review we present an overview of the cross interaction between depression, AMI and inflammation and its diagnostic and therapeutic implications.