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Fibromyalgia or fibromyalgia syndrome (FMS) is defined as a central sensitization syndrome characterized by the dysfunction of neurocircuits detecting, transmitting and processing nociceptive stimuli; the prevalent manifestation is musculoskeletal pain. In addition to pain, there are multiple accompanying symptoms, in common with other algo-dysfunctional syndromes, which are reflected in a broad spectrum of somatic, neurocognitive and neuro-vegetative manifestations. An evidence-based approach is essential in FMS management, in order to improve patient health and to reduce its social burden. Since in the last ten years new international guidelines for clinical practice (Clinical Practice Guidelines or CPGs) concerning FMS diagnosis and pharmacological/ non-pharmacological management have been published, the Italian Society of Rheumatology (SIR) has decided to adapt them to the Italian national setting. The framework of the Guidelines International Network Adaptation Working Group was adopted to identify, appraise (AGREE II), synthesize, and customize the most recent CPGs on FMS to the needs of the Italian healthcare context. A working group of rheumatologists from SIR epidemiology unit and FMS experts identified relevant clinical questions to guide the systematic review of the literature. The target audience of these CPGs included physicians and healthcare professionals who manage FMS. The adapted recommendations were finally assessed by an external multidisciplinary panel. From the systematic search in databases (Pubmed/Medline, Embase) and grey literature, 6 CPGs were selected and appraised by two independent raters. The combination of the scientific evidence underlying the original CPGs with expert opinion lead to the development of 17 recommendations. The quality of evidence for each recommendation was reported and their potential impact on clinical practice was assessed. These SIR recommendations are expected to be a valuable aid in the diagnosis and treatment of FMS, as they will contribute to disseminate the best practice on the basis of the current scientific evidence.

Psoriatic arthritis (PsA) is a chronic inflammatory disease involving skin, peripheral joints, entheses, and axial skeleton. The disease is frequently associated with extrarticular manifestations (EAMs) and comorbidities. In order to create a protocol for PsA diagnosis and global assessment of patients with an algorithm based on anamnestic, clinical, laboratory and imaging procedures, we established a DElphi study on a national scale, named Italian DElphi in psoriatic Arthritis (IDEA). After a literature search, a Delphi poll, involving 52 rheumatologists, was performed. On the basis of the literature search, 202 potential items were identified. The steering committee planned at least two Delphi rounds. In the first Delphi round, the experts judged each of the 202 items using a score ranging from 1 to 9 based on its increasing clinical relevance. The questions posed to experts were How relevant is this procedure/observation/sign/symptom for assessment of a psoriatic arthritis patient? Proposals of additional items, not included in the questionnaire, were also encouraged. The results of the poll were discussed by the Steering Committee, which evaluated the necessity for removing selected procedures or adding additional ones, according to criteria of clinical appropriateness and sustainability. A total of 43 recommended diagnosis and assessment procedures, recognized as items, were derived by combination of the Delphi survey and two National Expert Meetings, and grouped in different areas. Favourable opinion was reached in 100% of cases for several aspects covering the following areas: medical (familial and personal) history, physical evaluation, imaging tool, second level laboratory tests, disease activity measurement and extrarticular manifestations. After performing PsA diagnosis, identification of specific disease activity scores and clinimetric approaches were suggested for assessing the different clinical subsets. Further, results showed the need for investigation on the presence of several EAMs and risk factors. In the context of any area, a rank was assigned for each item by Expert Committee members, in order to create the logical sequence of the algorithm. The final list of recommended diagnosis and assessment procedures, by the Delphi survey and the two National Expert Meetings, was also reported as an algorithm. This study shows results obtained by the combination of a DElphi survey of a group of Italian rheumatologists and two National Expert Meetings, created with the aim of establishing a clinical procedure and algorithm for the diagnosis and the assessment of PsA patients. In order to find accurate and practical diagnostic and assessment items in clinical practice, we have focused our attention on evaluating the different PsA domains. Hence, we conceived the IDEA algorithm in order to address PsA diagnosis and assessment in the context of daily clinical practice. The IDEA algorithm might eventually lead to a multidimensional approach and could represent a useful and practical tool for addressing diagnosis and for assessing the disease appropriately. However, the elaborated algorithm needs to be further investigated in daily practice, for evidencing and proving its eventual efficacy in detecting and staging PsA and its heterogeneous spectrum appropriately.

Osteoarthritis (OA) is the most common musculoskeletal disease leading to functional decline and loss in quality of life. Knees, hands and hips are frequently affected joints with a relevant clinical and socio-economic burden. An evidence-based approach to OA management is essential in order to improve patients’ health and to decrease social burdens. Since new international clinical practice guidelines (CPGs) focused on diagnosis or pharmacological/non-pharmacological treatment have become available in the last ten years, the Italian Society for Rheumatology (SIR) was prompted to revise and customize them for a multidisciplinary audience of specialists involved in the management of OA. The framework of the Guidelines International Network Adaptation Working Group was adopted to identify, appraise (AGREE II), synthesize, and customize the existing CPGs on OA to the needs of the Italian healthcare context. The task force, consisting of rheumatologists from the SIR epidemiology research unit and a committee with experience of OA, identified key health questions to guide a systematic review of published guidelines. The target audience included physicians and health professionals who manage OA. An external panel of stakeholders rated the guidelines. From a systematic search in databases (Pubmed/Medline, Embase) and grey literature, 11 CPGs were selected and appraised by two independent raters. Combining evidence and statements from these CPGs and clinical expertise, 16 guidelines were developed and graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. These revised guidelines are intended to provide guidance for diagnosis and treatment of OA and to disseminate best evidence-based strategies management of the disease.

The pain of osteoarthritis (OA) has multifaceted etiologies within and outside the joint. It is believed to be driven by both nociceptive and neuropathic mechanisms, as well as abnormal excitability in the pain pathways of the peripheral and central nervous system. Inflammation in the joint triggers a cascade of events that leads to peripheral sensitization, increased sensitivity of nociceptive primary afferent neurons, and hyperexcitability of the nociceptive neurons in the central nervous system. Pain receptors have been found in the synovium, ligaments, capsule, subchondral bone and surrounding tissues, with the exception of articular cartilage. The bone-related causes of pain in OA include subchondral microfractures, bone stretching with elevation of the periosteum due to osteophyte growth, bone remodeling and repair, bone marrow lesions, and bone angina caused by decreased blood flow and increased intra-osseous pressure. Central factors alter pain processing by setting the gain in such a way that, when a peripheral input is present, it is processed against a background of central factors that can enhance or diminish the experience of pain. As a complex phenomenon with a strong subjective component, pain can also be influenced by the nature of the underlying disease, personal predisposition (biological and psychological), and environmental and psychosocial factors. This review examines the current literature regarding the sources and mechanisms of pain in OA.

Patients with rheumatoid arthritis (RA) are frequently afflicted by pain, which may be caused by joint inflammation (leading to structural joint damage) or secondary osteoarthritis, and may be increased by central sensitisation. Non-inflammatory pain may also confuse the assessment of disease activity, and so the aim of treatment is not only to combat inflammatory disease, but also relieve painful symptoms. In order to ensure effective treatment stratification, it is necessary to record a patients medical history in detail, perform a physical examination, and objectively assess synovitis and joint damage. The management of pain requires various approaches that include pharmacological analgesia and biological and non-biological treatments. Although joint replacement surgery can significantly improve RA-related pain, it may only be available to patients with the most severe advanced disease.

Valid and reliable assessment of pain is fundamental for both clinical trials and effective pain management. The nature of pain makes objective measurement impossible. Chronic musculoskeletal pain assessment and its impact on physical, emotional and social functions require multidimensional qualitative tools and healthrelated quality of life instruments. The recommendations concerning outcome measurements for pain trials are useful for making routine assessments that should include an evaluation of pain, fatigue, disturbed sleep, physical functioning, emotional functioning, patient global ratings of satisfaction, and quality of life. Despite the growing availability of instruments and theoretical publications related to measuring the various aspects of chronic pain, there is still little agreement and no unified approach has been devised. There is, therefore, still a considerable need for the development of a core set of measurement tools and response criteria, as well as for the development and refinement of the related instruments, standardized assessor training, the cross-cultural adaptation of health status questionnaires, electronic data capture, and the introduction of valid, reliable and responsive standardized quantitative measurement procedures into routine clinical care. This article reviews a selection of the instruments used to assess chronic musculoskeletal pain, including validated newly developed and well-established screening instruments, and discusses their advantages and limitations.

Fibromyalgia (FM) is a complex syndrome that, in Italy, affects at least 2% of the adult population. It is characterized by chronic widespread musculoskeletal pain often accompanied by multiple other symptoms. The aim of this study was to identify a set of clinical domains for FM considered relevant by both clinicians and patients using a consensus process. Consensus was achieved using the Delphi method based on questionnaires and systematic, controlled opinion feedback. The Delphi exercise involved a panel of 252 rheumatologists and 86 patients with FM as defined by the American College of Rheumatology criteria. All of the patients and clinicians were asked to rank the relative different domains of FM in order of priority. The content validity index (CVI) was used to establish the percentage agreement. The importance of each item was ranked on a 0-3 Likert scale. The frequency, mean relevance scores, and frequency importance product were also calculated. The Delphi exercise showed that the domains ranked highest by patients were similar to those of the clinicians, with the exception of tender point intensity (considered relevant by the clinicians but not by the patients) and environmental sensitivity (considered important by the patients but not by the clinicians). A final 8-item model was developed which was considered to demonstrate adequate validity. The Delphi exercises identified and ranked relevant key clinical domains that need to be assessed in FM research. On the basis of these results, a new patient-reported composite outcome index can be developed and used in clinical trials.

To fully answer the complex question of what modes of non pharmacological treatments are useful for fibromyalgia (FM) one should ask different layers of questions, and as with peeling layers of onions, be prepared to shed some tears. The first painful question, or layer of the onion, is related to understanding patients’ complaints. Patients who experience recurrent as well as persistent physical symptoms without any objective evidence are too often classified as “psychosomatic disorders” or worse as “non disease” (see Sarzi this issue)...

Background: Vertebral fracture is one of the most commonly occurring osteoporotic fractures. Vertebral fractures associated with osteoporosis are a major cause of pain in elderly people and may hardly affect patient’s health-related quality of life (HRQOL), making this an important parameter for assessment in these patients. Studies comparing the performance of HRQOL instruments in osteoporosis are laking. Objectives: The purposes of this study were to assess the effect of vertebral fractures on health HRQOL in postmenopausal women with osteoporosis and to investigate the validity of the Italian version of the mini-Osteoporosis Quality of Life Questionnaire (mini-OQOL) in a clinical setting. Methods: Patients were divided into two study groups, according to fracture status: vertebral fractures (41 patients) and no vertebral fractures (27 patients). Baseline assessments of anthropometric data, medical history, and prevalent fracture status were obtained from all participants. All of the participants were evaluated using both disease-targered mini-OQOL and QUALEFFO, generic instrument (EUROQoL), disability scale (Roland Morris Disability questionnaire- RMDQ) and chronic pain grade questionnaire. Results: Vertebral fractures due to osteoporosis significantly decreases scores on physical function, socio-emotional status, clinical symptoms, and overal HRQOL. Both disease-targeted questionnaires showing an association between the number of prevalent vertebral fractures and decreased HRQOL. Significant correlations existed between scores of similar domains of mini-OQOL and the QUALEFFO, especially for symptoms, physical function, activities of daily living and social function. The receiver operating characteristic (ROC) curve analysis of mini-OQOL and the QUALEFFO indicated that both questionnaires were significantly predictive of vertebral fractures. Number of concomitant diseases presented a weak significant correlation with EUROQoL (p=0,041). Conclusions: Our study suggests that the patients with vertebral fractures due to osteoporosis have a relevant impairment in quality of life. Both disease-targeted questionnaires discriminated between patients with and without vertebral fractures though the mini-OQOL, originally developed to measure the effect of vertebral fractures on quality of life, showed slightly better discriminant power. The benefit of the mini-OQOL is that it is efficient, self administered, and requires 3-4 minutes to complete.

Fibromyalgia (FM) is currently classified as chronic widespread pain with widespread allodynia/hyperalgesia to pressure pain and is categorized among the large group of soft-tissue pain syndromes. FM remains an elusive condition of unknown etiology in which patients report not only chronic widespread pain but also a variety of other complaints, so that it is one of several relatively common overlapping syndromes characterized by otherwise unexplained chronic pain and fatigue (1, 2)...

Fibromyalgia (FM), also known as fibromyalgia syndrome (FMS), is a frequently observed systemic disorder characterized by widespread musculoskeletal pain (1, 2). Its prevalence in the general population is 1-3%, and it is more common among females than males. The American College of Rheumatology (ACR) classification criteria defines it as widespread pain with patients endorsing at least 11 of 18 tender points as painful (3). Although its defining feature is chronic, widespread pain, FM patients may also have a number of other symptoms including sleep disturbance, fatigue, irritable bowel syndrome, headache and mood disorders (1)....

Fibromyalgia (FM) is a central pain syndrome that is characterized, in part, by specific tender points (TPs) in the musculoskeletal system which are exceptionally sensitive to pressure. Pain, specifically characterized as hyperalgesia and allodynia, is the cardinal symptom of FM; however, most patients also experience additional symptoms such as debilitating fatigue, disrupted or nonrestorative sleep, functional bowel disturbances, and a variety of neuropsychiatric problems, including cognitive dysfunction, anxiety and depressive symptoms (1)....

Le principali artriti croniche ad eziopatogenesi immunoflogistica, nelle quali trovano applicazione i farmaci “biologici” (v. oltre) sono la reumatoide e le sieronegative: artrite psoriasica, spondilite anchilosante, artriti reattive ed artriti “enteropatiche” (1-7). L’artrite reumatoide (AR) è una malattia cronica progressiva delle articolazioni associata a significativa morbilità, deformità e riduzione della qualità di vita. La prevalenza nella popolazione, a livello mondiale, è compresa tra 0,3 ed 1%. Pur interessando in modo elettivo le articolazioni, l’AR è una malattia sistemica che può condurre a severa disabilità ed a complicanze talora fatali. La terapia farmacologica tradizionale si basa su varie combinazioni di farmaci definiti sintomatici, come gli anti-infiammatori non-steroidei (FANS), gli analgesici ed i corticosteroidi e quelli “di fondo” chiamati correntemente DMARDs (disease modifying anti-rheumatic drugs)...

Functional disability and quality of life in rheumatoid arthritis (RA) are key outcomes that determine patient’s demand for care, and influence their compliance and satisfaction with treatment. In the recent years the demand to collect outcome data is ever increasing as a means for the validation of quality care, and the development of effective outcome measures has become a major thrust of health research and has contributed to better understanding the relationship between outcomes and specific elements of health care. There are several disease-generic and specific instruments available that have proven valuable in outcome testing in RA. The first instruments provide a broad picture of health status across a range of conditions, whereas the latter are more sensitive to the disorder under consideration and are therefore more likely to reflect clinically important changes. When necessary, this kind of scales can be supplemented with specialised domain-specific scales (for the assessment of psychological well-being, social role functioning, or other). As in other fields, these measurement instruments mainly focus on: a) clinical signs and symptoms (physiologic and biologic); b) physical and/or cognitive functioning; c) well-being and emotional functioning; d) social functioning; e) satisfaction with care and other personal constructs (life satisfaction, spirituality, etc.); f) health-related quality of life (HRQOL). Over the past 20 years, there has been a better recognition of the patient’s point of view as an important component in the assessment of health care outcomes, and an increasing interest in HRQOL as an important area of research, due to the rising burden of chronic diseases, longer expectation of life, the growing number of health intervention alternatives, and greater emphasis on humanising health care. In addition, decision-making on issues of cost-effectiveness across health inputs and resource allocation across health programs is likely to be more sound if informed by HRQOL evidence. This paper reviews the literature and discusses the major issues regarding mainly measures of physical function (e.g., mobility or daily activities) and health status, including some so called HRQOL instruments.

Sjögren’s syndrome (SS) is a chronic inflammatory disease with an autoimmune etiology, that affects exocrine glands, in particular salivary and lacrimal glands. Among the diagnostic criteria of SS, imaging tecniques play an important role. The aim of our study is to compare three imaging tecniques, such as sonography, scintigraphy and sialography in the evaluation of major salivary glands. The use of the these tecniques is of great importance for the diagnosis of SS. Sonography is the most frequently used for its prompt execution, non invasivity, great acceptance by the patient and low cost. In the diagnostic patient management of SS, sonography results are eventually confirmed by the other imaging tecniques, sialography and scintigraphy.

Fibromyalgia syndrome (FMS) is a common chronic condition of widespread pain with causal mechanisms that are largely unknown. It is characterized by moderate to severe musculoskel - etal pain and allodynia, but its pathogenesis appears confined to the nociceptive structures of the central nervous system. From a pathogenetic point of view, indeed, no clear muscle pathology has been demonstrated in FMS (1, 2), while increasing evidence suggests a disturbance in pain perception that is genetically conditioned. In our review we will consider five “keypoints” that we think determine the origin and maintenance of the pain syndrome that we define as fibromyalgia...

Fibromyalgia (FM) is a rheumatic disease characterized by musculoskeletal pain, chronic diffuse tension and/or stiffness from joints and muscles, easy fatigue, sleep and emotional disturbances, and pressure pain sensitivity in at least 11 of 18 tender points (TP) (1, 2). This disease has an incidence of 2% in the general population, but it is found more often in middle-aged women (3.4%) (3, 4). The etiopathogenesis of FM has not been clarified yet. FM patients have a dysregulation of pain neurotransmitters and neurohormone-mediated association with irregularities in the physiology of sleep...

Background: Many researchers have used paper diaries in an attempt to capture patient experience. However, patient non-compliance with written diary protocols is a serious problem for researchers. Electronic patient experience diaries (eDiary) facilitate Ecologic Momentary Assessment (EMA) study designs by allowing the researcher to administer flexible, programmable assessments and mark each record with a time and date stamp. Objectives: The objectives of the current study were to evaluate methodological issues associated with real-time pain reports (EMA) using electronic patient experience diaries, to quantify compliance (percentage of the total number of diary reports scheduled that were actually completed), and to examine the circadian rhythm in pain and stiffness of patients with rheumatic diseases in an ecologically valid manner. Methods: In this cross-sectional study we examined 49 patients with rheumatic diseases (14 patients with rheumatoid arthritis, 18 with fibromyalgia and 17 with osteoarthritis of the knee), attending the care facilities of the Department of Rheumatology of Università Politecnica delle Marche. All patients fulfilling the American College of Rheumatology (ACR) criteria. The assessment of pain and stiffness in all patients were repeated seven times a day (8 A.M., 10 A.M., 12 A.M., 2 P.M., 4 P.M., 6 P.M. and 8 P.M.) on seven consecutive days using an electronic diary (DataLoggerÒ - Pain Level Recorder). A datalogger is newly developed electronic instrument that records measurements of pain and stiffness over time. Dataloggers are small, battery-powered devices that are equipped with a microprocessor. Specific software is then used to select logging parameters (sampling intervals, start time, etc.) and view/analyse the collected data. Compliance is based on the time and date record that was automatically recorded by the devices. Results: Using the data from the electronic diary, we determined that the average verified compliance rate for pain and stiffness were 93.8 and 93.6%, respectively. The two highest compliance rates were observed in patients with rheumatoid arthritis (95.6 and 95.2%, respectively). There were no statistically significant difference in compliance between females and males or patients above or below 60 years old. Significant circadian rhytms in patients with RA and OA of the knee were detected in pain and stiffness. No rhythm in pain or stiffness was observed in subjects with fibromyalgia. Conclusions: We conclude that collection of subjective data using electronic diary in rheumatologic setting is a feasible method than can be adopted with high compliance rates across a range of patient demographic subgroups. The identification of diurnal cycles of self-reported pain and stiffness, using EMA method, has important implications for patients with respect to planning their daily activities and in developing individual therapeutic programs with respect to diurnal variability, which therefore may be more effective.

The recommendations for the management of osteoarthritis (OA) of the hip were proposed by EULAR in 2005. Among the most important objectives of the expert charged to provide these recommendations were their wide dissemination and implementation. Thus, the information generated can be used by each individual country to produce their own set of management guidelines and algorithms for treatment in primary care. According with that previously executed for the EULAR recommendation 2003 for the knee, the Italian Society of Rheumatology (SIR) has organised a Consensus on the EULAR recommendations 2005 for the management of hip OA. To obtain an acceptability as large as possible, the group of experts was composed by many physicians interested in the management of hip OA, including Orthopaedics, Rheumatologists, Physiatrists, and General Practitioners. Main aim of the Consensus was to analyse the acceptability and applicability of the recommendations according to own experience and local situations in the Italy. The results of this Consensus have demonstrated that a large majority of the EULAR recommendations are endorsed by the Italian experts. Furthermore, the final document of the Italian Consensus clearly indicated the need that the specialists involved in the management of hip OA strongly encourage the dissemination of the EULAR 2005 recommendations also in Italy.

The algorithm for imaging of the salivary glands depends on the clinical scenario with which the patient presents to the clinician. Ultrasound has been increasingly used in recent years and thanks to high performance, easy to use apparatus, it can now be used for exploration of the salivary glands. This non invasive, painless and relatively inexpensive examination provides rapid visualisation of the salivary glands and is a useful adjunct to computed tomography and magnetic risonance imaging examination, particularly in tumour pathology. In recent years, publications have highlighted the potential uselfulness of salivary gland ultrasonography as a simple and non-invasive adjunctive test for the detection of gland involvement in Sjögren’s syndrome (SS). SS is a chronic inflammatory disease of the salivary glands characterised by focal lymphocytic infiltrates that cause progressive destruction of the acinar structures. The findings of a previous study lead us to believe, in agreement with other examiners, that semiquantitative assessment of ultrasonographic images of the salivary glands is a sensitive and very useful means of evaluating salivary involvement in SS. Color Doppler sonography is a recently introduced method which makes it possible to evaluate intra- and perilesional vascularization and to perform a hemodynamic study of the area being explored. The color Doppler sonography can provide a useful adjunct to conventional ultrasound, increasing diagnostic accuracy in submandibular- parotid masses and to analyze physiologic changes that occur during salivary stimulation in normal subjects and the flow alterations that occur in diseased glands of SS patients. This article reviews the normal ultrasound anatomy of the salivary glands along with lithiasic, inflammatory, tumoral, and autoimmune disease such as SS.

Objectives: The Bath Ankylosing Spondylitis Functional Index (BASFI) and the Dougados Functional Index (DFI) are the most commonly used instruments to measure functioning in ankylosing spondylitis (AS). The aim of this study was to translate, adapt and validate these instruments into the Italian language. Methods: The BASFI and DFI questionnaires were translated into Italian by two independent bilingual physicians who were familiar with the medical aspects of AS and by one professional translator. Two rheumatologists familiar with instrument validation, and who were aware of the purpose of the study, examined semantic, idiomatic and conceptual issues and produced by consensus unified versions of each instrument. English back-translations from the Italian were done by a professional translator unaware of the original version. Both English versions were compared, and where needed, modifications to the Italian versions were made. Results: A total of 95 patients were included: 77 males, age (mean±SD) 47.9±9.3years, and disease duration 12.4±6.6 years, and 18 females, age 45.9±8.7 years, and disease duration 11.3±8.2 years. Reliability, measured in 23 patients participating a physiotherapy program, showed an acceptable one-week test-retest intraclass correlation coefficient (ICC) - BASFI ICC: 0.91, 95% CI: 0,87-0.94 and DFI ICC: 0.86, 95% CI: 0.83-0.90. The internal consistency was 0.90 (Cronbach’s alpha) for the BASFI and 0.87 for the DFI. For validity the functional indices were correlated with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Patient Global Score (BAS-G), modified Health Assesment Questionnaire (HAQ-S), SF-36 physical component summary (SF-36 PCS), stiffness, pain, physician’s assessment of disease activity, Bath AS Radiology Index-total (BASRI-t), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). The functional indices (BASFI and DFI) were correlated with each other (p

Although the term “fibromyalgia” (FM) is relatively new, the condition characterised by chronic musculoskeletal pain that is accompanied by numerous extra-skeletal symptoms has been described in the medical literature for many years under different names. The term “fibrositis,” which was originally used in 1904 by Sir William Gowers to define a type of lumbalgia, became a synonym for diffuse musculoskeletal pain until 1976 (1). In the mid-1970s, Smythe and Moldofsky used the term “fibrositic syndrome” to describe the presence of tender points (TPs), sleep disturbances and other accompanying symptoms such as asthenia...

Objectives. To evaluate the characteristics of pain in a cohort of Italian patients with osteoarthritis (OA) of the hip and knee. Methods. The 657 general practitioners participating in the study were asked to enroll 10 consecutive patients with OA diagnosed according to the American College of Rheumatology (ACR) clinical criteria. A questionnaire evaluating demographic data, clinical characteristics of OA, including the “Questionario Semantico Reumatologico” (QSR) pain questionnaire, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Lequesne indices, and information on previous diagnostic and therapeutic interventions was administered. Results. A total of 4,109 patients were enrolled. Of them, 2356 were affected by knee OA and 1817 by hip OA. There were 2863 (69.7%) women and 1246 (30.3%) men. Median age was 68.2 years (range 50-103 years). Of the 4109 enrolled subjects, 3128 (76.1%) reported one or more medical comorbidities, mostly cardiovascular (52.7%), endocrinological (14.7%), gastrointestinal (13.4%), and respiratory (11.2%) disorders. The median pain visual analogue scale (VAS) score was 58.1±22.6 mm, higher in women (60.2±22.3 mm) than in men ( 53.3±22.6mm) (p

Background: Patients with rheumatoid arthritis (RA) have a reduced life expectancy and high cardiovascular morbidity and mortality as compared to the general population. A number of possible factors for the atherogenesis in this disease have been described, such as homocysteine, altered serum levels of selected lipopotroteins and treatment. Recent findigs indicate that the systemic inflammation may contribute to the development of atherosclerosis and confer an additional risk for cardiovascular death among patients with RA. The aim of our study was to evaluate the ability of high resolution Bmode ultrasoud and color Doppler to assess the existence of subclinical atherosclerosis in RA patients, measuring the intima- media thickness (IMT) and resistence index of the common carotid arteries. Methods: Carotid IMT and carotid plaque were measured using high-resolution B-mode ultrasound in 40 patients with RA and 40 age- and sex-matched healthy persons. We used color Doppler ultrasound to assess vascular damage of the common carotid arteries and the resistence index (RI) was determined by analysis of the spectral waveforms. Serum total cholesterol, trygliceridies, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, rheumatoid factor, body mass index (BMI), visual analogue scale (VAS) were determined in patients and controls. C-reactive protein (CRP) and the DAS28 were used to measure systemic inflammation. Results: Common carotid IMT were significantly higher (p=0.0009) in RA patients (0.83 ± 0.23) compared with controls (0.66 ± 0.22). In RA patients common carotid IMT was significantly correlated with serum total cholesterol (p=0.0008), low-density lipoprotein cholesterol (p=0.006), trygliceridies (p=0.042), age (p=0.031) and disease duration (p=0.019). No significant correlation was found with clinical and laboratory parameters reflecting disease activity. The prevalence of plaques was higher in RA patients compared with controls (25% vs 12.5%). There was no significant difference in color Doppler findings, and in particular in RI, between patients and controls. Conclusions: Our results confirm an accelerated atherosclerosis, as shown by increased common carotid IMT, in patients with RA compared with controls and it is related mainly to lipid levels. High-resolution B-mode ultrasound may be considered a promising, sensitive and non invasive tool for assessing the existence of subclinical atherosclerosis in RA patients.

0Over last few years, the ultrasonography (US) generated an increasing popularity among rheumatologists due to excellent potentiality and numerous applications in rheumatology. Most of the published papers focus mainly to demonstrate the utility of US in early and chronic arthritis, short-term therapy monitoring and guidance for invasive procedures. Less attention has been paid to the potential of this technique in the field of crystal-related arthropathies. By virtue of the high resolution of “new generation” equipments, minimal crystal deposits can be detected even sometime when the radiography was negative. The aim of this paper was to present the principal findings in patients with crystal-related arthropathies.

Over the last decade, several new biologic agents have become available for the treatment of patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and psoriasis (Ps). In contrast to conventional disease modifying anti-rheumatic drugs (DMARDs), these biological agents have rapid onset of action and pronounced disease reducing activity when administered as monotherapy or in combination with MTX. Pre-registration randomised clinical trials have compared biological agents against placebo over a limited time span (1-3). Wider use of biologics has resulted in reports of a wide range of adverse events (4), including evidence of reactivation of latent tuberculosis, increased incidence...

The research carried out by Censis Foundation, in collaboration with SIR (Italian Society of Rheumatology) and ANMAR (National association of rheumatic patients) involved 646 patients, diagnosed with rheumatoid arthritis (RA) by a rheumatologist according to ACR criteria. The patients were recruited through a representative sample of 300 general practitioners (GP). A cross-sectional survey was conducted to study the current status of health-related quality of life (HRQL) of patients using a revised Italian version of a revised version of the Arthritis Impact Measurement Scales 2 (AIMS2). The AIMS2 was administered to the 646 patients with (RA) attending arthritis clinics at various hospitals across the country. Self-report functional disability scores were calculated for all 12 specific scales, summary components, and overall impact measures. The AIMS2 has been validated for the Italian language. Ranging from 0 (perfect health) to 10 (poor health), the mean scores of the AIMS2 showed an important impact of the disease on the 4 components of the health status of these patients: walking and bending, mean score = 5.1; nervous tension = 5.0, arthritis pain = 5.0, and social activity = 4.6. Among other dimensions, the impact of RA was moderate for mood, work, hand and finger function and mobility (mean score: 3.7, 3.7, 3.5 and 3.4, respectively) and low for household tasks, arm function, self-care tasks and family support (3.0, 2.9, 2.5 and 2.1, respectively). There was a tendency for the scores of younger patients to be better than those of olders patients. In conclusion, RA have a clearly detrimental effect on the HRQL in both physical and mental components. Prevention and management of physical disability should be seriously planned in consideration of the changes in these conditions in RA patients. Use of the AIMS2 makes it easier and less costly to collect data and reduces the burden on RA patients.

The research carried out by Censis Foundation, in collaboration with SIR (Italian Society of Rheumatology) and ANMAR (National Association of Rheumatic patients), with the sponsorship of Roche S.p.A., involved more than 600 patients, diagnosed with arthritis by a rheumatologist according to ACR criteria. The patients were recruited through a representative sample of 300 general practitioners. A number of different research and survey tools were used to collect data, helping to identify several of the problems that affect Italian patients: a survey form to be filled by the GPs, in order to verify the diagnosis and the comorbidity level; a questionnaire for the self-assessment of the disease activity, Rheumatoid Arthritis Disease Activity Index (RADAI), and a sociological questionnaire set up for the analysis of the main aspects of the patients’ path. Among the most serious criticalities found, the difficulties and the time needed for the patients to get a clear AR diagnosis, the problems in interacting with health structures, and the differences in accessing pharmaceutical therapies (only a slight majority of patients use DMARDs drugs, a small amount takes biological drugs, while a large number of patients is treated exclusively with symptomatic drugs) stand out. The differences in patients’ condition appear then to be exaggerated, regarding the chances to get an early diagnosis, the access path to specialised centres, and in receiving the most appropriate treatments. Moreover, these differences appear to be strongly dependent on both the social characteristics of the patients and the supply arrangement in their area.

Pain, a complex phenomenon influenced by a series of genetic, biological, psychological and social factors, is a major component of many rheumatological conditions and the result of physiological interactions between central and peripheral nervous system signalling. It may be acute or chronic (generally defined as lasting ≥ three months): acute pain is often primarily attributable to inflammation and/or damage to peripheral structures (i.e. nociceptive input), whereas chronic pain is more likely to be due to input from the central nervous system (CNS). The many different aspects of pain mean that rheumatologists and other clinicians need to have enough expertise to diagnose the type of pain correctly and treat it appropriately. However, most rheumatologists receive little formal training concerning contemporary theories of pain processing or management, and this may affect the clinical results of any specific target therapy.

The recommendations for the management of osteoarthritis (OA) of the knee firstly proposed by the EULAR in 2000, have been updated in 2003. One of the most important objectives of the expert charged to provide these recommendations was their dissemination. Thus, the information generated may be used by each individual country to produce their own set of management guidelines and algorithms for treatment in primary care. The Italian Society of Rheumatology (SIR) and the Italian League against Rheumatism (LIMAR) have organised a Consensus on the EULAR recommendations 2003 with the aim to analyse their acceptability and the applicability according to our own experience and local situations in the Italy. The results of this Consensus have demonstrated that a large majority of the EULAR recommendations are endorsed by the Italian experts. Furthermore, the final document of the Italian Consensus clearly indicated the need that the specialists involved in the management of knee OA strongly encourage the dissemination of the EULAR 2003 recommendations also in Italy.

The aim of this pictorial essay was to demonstrate the diagnostic efficacy of high-resolution sonography in detecting bone erosions in a patient with rheumatoid arthritis. Standard X-Ray of the feet did not reveal clearly evident erosions. Ultrasonography was able to detect the presence of bone erosions of the metatarsal heads of both the first toes and of the V toe of the left foot. Because the appearance of bone erosions on radiographs of a patient with a recent onset arthritis indicates a poor prognosis, the possibility of demonstrating small hidden erosions at the level of the early targets of the disease is of relevant practical value.

Pannus formation is a fundamental event in the pathogenesis of rheumatoid arthritis and its hypervascularisation seems to be crucial to the development of joint damage. High-resolution greyscale ultrasonography is a safe, quick, and inexpensive imaging tool that allows an accurate detection of even minimal morphostructural changes in patients with rheumatoid arthritis, including joint effusion, thickening of synovial membrane and bone erosions. More recently, power Doppler sonography has proved to be a reliable tool for semiquantitative assessment of the vascularity of the synovial tissue. The contrast-enhanced power Doppler sonography seems to be a helpful adjunct in assessing synovitis and the therapeutic response to the different therapies in patients with rheumatoid arthritis. The aim of this radiological vignette was to show a representative example of use of power Doppler sonography with contrast agent in assessing rheumatoid synovitis.

Pulmonary involvement is one of the most frequent extra-articular manifestations of rheumatoid arthritis (RA) and represents a serious complication, being the second cause of death after infection. High-resolution computed tomography (HRCT), owing to its increased sensitivity and diagnostic accuracy respect to the conventional chest radiograph (CXR), allows to detect pulmonary abnormalities in RA patients more frequently than CXR. The aim of this study was to assess pulmonary involvement by HRCT in lifelong non-smoking RA patients without symptoms and clinical signs of pulmonary disease. Seventy-two patients (54 women and 18 men) with a mean age of 56.8±10.4 years (range, 40- 77 years) and mean duration of disease of 6.9±4.7 years (range, 2-12 years) entered the study. 52/72 (72%) were positive for rheumatoid factor (> 20 UI/ml). Standard CXR and HRCT were carried out in each patient. CXR showed a mild interstitial fibrosis in 7 patients (9.7%), whereas HRCT demonstrated pulmonary abnormalities in an higher number of them (22/72 = 30.5%). The most frequent abnormal findings on HRCT were irregular pleural margins (13.8%) and septal/subpleural lines (18%), both compatible with pulmonary fibrosis. Ground-glass opacities were found in 8.3% of the patients. Pulmonary nodules (diameter, range 0,5-2 cm) predominantly located in the subpleural portions of the lung, were demonstrated in the same percentage (8.3%) of patients. Small airway involvement, represented by bronchiectasis/bronchioloectasis, was shown in 15.2% of patients. Subpleural cysts were present in two cases (2.8%). No patient had evidence of honeycombing on HRCT. In conclusion, HRCT is an accurate, non-invasive and safe method of diagnosing lung abnormalities in RA patients without signs and clinical symptoms of pulmonary disease...