Ultrasonography and magnetic resonance imaging of heel fat pad inflammatory-oedematous lesions in rheumatoid arthritis

OBJECTIVE: To study heel fat pad (HFP) inflammatory-oedematous lesions in selected patients with rheumatoid arthritis (RA) using ultrasonography (US) and power Doppler US (PDUS), to describe and compare US features of these lesions with those obtained with magnetic resonance imaging (MRI), and to describe changes in the lesions after a short-term follow-up with conventional or anti-tumour necrosis factor-alpha (TNFalpha) therapy. METHODS: Twelve heels of eight RA outpatients with HFP inflammatory-oedematous lesions were studied by US, PDUS, and unenhanced MRI. All the patients were followed up and US was performed after 3 months. Five patients started on anti-TNFalpha therapy. RESULTS: HFP lesions appeared at US as a heterogeneous and hypoechoic subcalcaneal mass, with loss of normal lobular structure and increased thickness of HFP, because of focal rupture of fibrous septae with oedema and fluid. PDUS showed peripheral vascularization of HFP lesions in 9/12 heels. In 3/12 heels some vascular signals was also detectable inside the lesion, always along the residual echoic septa. No detectable flow was observed within the central fluid-filled spaces. MRI of the HFP lesions showed areas of mean intensity in T1-weighted sequences and high intensity in T2-weighted sequences, with poorly or well-defined margins. After 3 months, PDUS showed reduction in HFP lesion vascularity (associated with reduction in pain) in 10/12 heels, while poor regression of grey-scale US abnormalities was observed. CONCLUSIONS: Both US and MRI are capable of demonstrating structural abnormalities in the HFP. PDUS is useful to assess and monitor inflammatory vascularization of the HFP lesions.     

The laboratory approach in the diagnosis of systemic autoinflammatory diseases

Systemic autoinflammatory diseases are a group of inherited disorders of the innate immunity characterized by the recurrence of febrile attacks lasting from few hours to few weeks and multi-district inflammation of different severity involving skin, serosal membranes, joints, gastrointestinal tube and central nervous system. The vast majority of these conditions is caused by mutations in genes involved in the control of inflammation and apoptosis mechanisms. The group includes familial Mediterranean fever, mevalonate kinase deficiency syndrome, tumor necrosis factor receptor-associated periodic syndrome, cryopyrin-associated periodic syndromes, hereditary pyogenic and granulomatous disorders. Their diagnostic identification derives from the combination of clinical and biohumoral data, though can be sometimes confirmed by genotype analysis.     

Evidences for Antinociceptive Effect of 17-Alpha-Hydroxyprogesterone Caproate in Carpal Tunnel Syndrome

Growing evidence of neuroprotective and analgesic effects by progesterone (PROG) has been obtained in experimental animal models of neuropathy. In this paper, we report the results of the first experimental study to test the efficacy of PROG in a human neuropathy. The effects of a local administration of 17-alpha-hydroxyprogesterone caproate (17HPC) has been studied in patients with carpal tunnel syndrome (CTS) and compared with those of a local administration of corticosteroid (CS) in a analogous CTS group. Sixteen women affected by mild CTS were selected. Clinical, electrophysiological and ultrasonographic data of the median nerve were quantified at 0 (pre-injection), 1 and 6 months after CS or 17HPC injection. One month after injection, both 17HPC and CS groups exhibited similar reduction in pain scores, whereas only the 17HPC-treated group still manifested symptoms relief 6 months after. Only in CS-treated patients, improvement of the clinical data correlated with ultrasonographic and electrophysiological changes of the median nerve. The present study indicates that intra-carpal injection with a long-acting PROG derivative is effective for relief of symptoms in CTS. This effect is apparently mediated by a mechanism distinct from that of the CS.     

Long-acting antipsychotic drugs for the treatment of schizophrenia: use in daily practice from naturalistic observations

ABSTRACT: BACKGROUND: Current guidelines suggest specific criteria for oral or long-acting injectable antipsychotic drugs (LAIs). This review aims to describe the demographic and clinical characteristics of the ideal profile of the patient with schizophrenia treated with LAIs, through the analysis of nonrandomized studies. METHODS: A systematic review of nonrandomized studies in English was performed attempting to analyze the factors related to the choice and use of LAIs in daily practice. The contents were outlined using the Cochrane methods for nonrandomized studies and the variables included demographic as well as clinical characteristics. The available literature did not allow any statistical analysis that could be used to identify the ideal profile of patients with schizophrenia to be treated with LAIs. RESULTS: Eighty publications were selected and reviewed. Prevalence of LAI use ranged from 4.8% to 66%. The only demographic characteristics that were consistently assessed through retrieved studies were age (38.5 years in the 1970's, 35.8 years in the 1980's, 39.3 years in the 1990's, to 39.5 years in the 2000's) and gender (male > female). Efficacy was assessed through the use of various symptom scales and other indirect measurements; safety was assessed through extrapyramidal symptoms and the use of anticholinergic drugs, but these data were inconsistent and impossible to pool. Efficacy and safety results reported in the different studies yielded a good therapeutic profile with a maximum of 74% decrease in hospital admissions and the prevalence of extrapyramidal symptoms with LAIs consistently increased at 6, 12, 18, and 24 months (35.4%, 37.1%, 36.9%, and 41.3%, respectively). CONCLUSIONS: This analysis of the available literature strongly suggests that further observational studies on patients with schizophrenia treated with LAIs are needed to systematically assess their demographic and clinical characteristics and the relationships between them and patient outcome. Besides the good efficacy and safety profile of LAIs, health care staff must also take into account the importance of establishing a therapeutic alliance with the patient and his/her relatives when selecting the most appropriate treatment. LAIs seem to be a good choice not only because of their good safety and efficacy profile, but also because they improve compliance, a key factor to improving adherence and to establishing a therapeutic alliance between patients with schizophrenia, their relatives, and their health care providers.     

Headache at high school: clinical characteristics and impact

Although migraine (MH) and tension type headache (TTH) are the most common and important causes of recurrent headache in adolescents, they are poorly understood and not recognized by parents and teachers, delaying the first physician evaluation for correct diagnosis and management. The purpose of this study is to assess the knowledge about headache impact among the students of a Communication Private High School in Rimini city, and to evaluate the main different types of headaches interfering with school and social day activities. A self-administered questionnaire interview was given to students of the last 2 years of high school; ten items assessed the headache experience during the prior 12 months, especially during school time: the features and diagnosis of headaches types (based on the 2004 IHS criteria), precipitating factors, disability measured using the migraine disability assessment (MIDAS); therapeutic intervention. Out of the 60 students, 84 % experienced recurrent headache during the last 12 months. 79 % were females, aged 17-20 years; a family history was present in 74 % of headache students, in the maternal line; 45 % of subjects were identified as having MH and 27 % TTH; 25 % had morning headache and 20 % in the afternoon; fatigue, emotional stress and lack of sleep were the main trigger factors for headache, respectively in 86, 50 and 50 % of students; 92 % of headache students could not follow the lessons, could not participate in exercises and physical activity because of the headache; none had consulted a medical doctor and the 90 % of all students had never read, listened or watched television about headache. This study remarks on the need to promote headache educational programs, starting from high school, to increase communication between teachers-family-physician and patient-adolescents, with the goal to have an early appropriate therapeutic intervention, improvement of the quality of life and to prevent long-term headache disease in the adult age.     

Comparative efficacy between adalimumab and infliximab in the treatment of non-infectious intermediate uveitis,posterior uveitis,and panuveitis: a retrospective observational study of 107 patients

Clinical Rheumatology - To compare the efficacy of adalimumab (ADA) and infliximab (IFX) in patients with non-infectious intermediate uveitis, posterior uveitis, and panuveitis. Demographic,...     

Stepladder incision technique for radical excision of suprasternal thyroglossal duct remnant

Thyroglossal duct remnant localized to the suprasternal notch is an exceedingly rare condition. We report on a novel case occurring in an 8-year-old girl who presented with acute onset of a suprasternal abscess. After incision and drainage, a Sistrunk procedure was successfully carried out using 2 stepladder incisions. This approach combined optimal surgical exposure and satisfactory cosmesis.     

Jagged-1 mutation analysis in Italian Alagille syndrome patients.

Alagille syndrome (AGS) is an autosomal dominant disorder with developmental abnormalities affecting the liver, heart, eyes, vertebrae, and craniofacial region. The Jagged-1 (JAG1) gene, which encodes a ligand of Notch, has recently been found mutated in AGS. In this study, mutation analysis of the JAG1 gene performed on 20 Italian AGS patients led to the identification of 15 different JAG1 mutations, including a large deletion of the 20p12 region, six frameshift, three nonsense, three splice-site, and two missense mutations. The two novel missense mutations were clustered in the 5' region, while the remaining mutations were scattered throughout the gene. The spectrum of mutations in Italian patients was similar to that previously reported. We also studied in detail a complex splice site mutation, 3332dupl8bp, which was shown to lead to an abnormal JAG1 mRNA, resulting in a premature stop codon. With the exception of the missense mutations, the majority of the JAG1 mutations are therefore likely to produce truncated proteins. Since the phenotype of the patient with a complete deletion of the JAG1 gene is indistinguishable from that of patients with intragenic mutations, our study further supports the hypothesis that haploinsufficiency is the most common mechanism involved in AGS pathogenesis. Furthermore, our data confirmed the absence of a correlation between the genotype of the JAG1 gene and the AGS phenotype.