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Idiopathic inflammatory myopathies (IIM) are rare connective tissue diseases, which can lead to internal organ involvement. IL-33/ST2 pathway is involved in the pathogenesis of numerous diseases including autoimmune disorders. IL-33 fulfils cardioprotective function, while soluble ST2 (sST2) is a decoy receptor that reduces protective impact of IL-33. The aim of the study was to evaluate the concentrations of sST2 and IL-33 in sera of patients with IIM and evaluate its associations with the clinical course of the disease. Patients with IIM as well as age- and sex-matched healthy controls were recruited. Concentrations of sST2 and IL-33 were assessed with ELISA in sera of both patients and controls. Patients were asked to fill in the questionnaires concerning clinical symptoms and physical functioning. Concentrations of sST2 and IL-33 were correlated with the results of laboratory tests and clinical symptoms. Concentrations of sST2 were significantly higher in IIM group than in healthy subjects (median sST2 in IIM 26.51 vs in healthy controls 21.39; p = 0.03). In the majority of patients, IL-33 concentrations did not exceed the detection limit. Anti-SRP-positive patients presented significantly higher concentrations of sST2 as compared to anti-SRP-negative patients (p = 0.04). In patients with anti-Ro52 antibodies, sST2 concentrations were significantly lower than in anti-Ro52-negative patients (p = 0.02). Concentrations of sST2 correlated with the degree of disability evaluated with Health Assessment Questionnaire. sST2 is increased in patients with IIM and its concentration correlates with the degree of disability. In patients with anti-SRP antibodies, levels of sST2 are exceptionally high. Electronic supplementary material The online version of this article (10.1007/s00296-020-04554-z) contains supplementary material, which is available to authorized users.

The objective is to determine the prevalence of self-reported physician-diagnosed osteoarthritis (OA) and musculoskeletal symptoms (pain, stiffness or discomfort) in specific joints among adults in British Columbia (BC), Canada. We carried out a cross-sectional mixed-mode survey in a random population sample of persons 18 years of age and older. Estimates were weighted to reflect the age and sex distribution of the population of BC. We obtained responses from 2,233 individuals. Overall, 18.4% (95% CI 16.8-20.1) of the adult population reported OA. Of those, more than 40% had OA in multiple sites. Prevalence ranged from 8.8% (95% CI 7.6-10.1) in the knee to 2.7% (2.1-3.5) in the foot. One-year prevalence of symptoms ranged from 49.1% (47.0-51.2) in the lower back to 23.3% (21.5-25.1) in the hip. Females reported more symptoms and OA than males in all joints. The most common site of self-reported physician-diagnosed OA in BC is the knee, but OA in the hands, hips, and feet is also common. Having OA in one joint is a strong predictor of OA in other joints.

Musculo-skeletal complaints in a patient suffering from systemic lupus, with co-existing chronic renal failure, undergoing immunosuppressive treatment after kidney transplantation, can have a varied etiology. The aim of this work was to present a case based review of differential diagnosis of knee pain in such a patient. A literature search was carried out using MEDLINE/PubMed, Google Scholar and EBSCO, with no time limit. We undertook a systematic review of the literature published in English, limited to full-text publications of original articles, letters to the editor, and case reports in peer-reviewed journals, for a discussion and analysis of studies reporting arthralgia in patients with lupus after kidney transplantation. We present a case report of a 45-year-old woman with lupus nephritis, after kidney transplantation, who started to complain of increasing pain in the knees, most pronounced at night and after physical activity approximately 2 years after transplantation. Extensive causal diagnostics were carried out, which revealed bilateral extensive regions of bone infarction in the femur and tibia, chondropathy, degenerative changes of medial meniscuses in the body and posterior horn as well as chondromalacia of the patella. Establishing the right diagnosis is crucial for implementing appropriate treatment.

The objective of this study is to assess the impact of inflammatory arthritis on young adults' activity participation using quantitative and qualitative methods to advance the field's conceptualization of functional status. Young adults diagnosed with juvenile idiopathic arthritis or rheumatoid arthritis completed (1) the Health Assessment Questionnaire-Disability Index to determine functional status and (2) the day reconstruction method to explore experiential dimensions of function, including functional performance, functional satisfaction, and severity of arthritis symptoms during activities on the previous day. Bivariate analyses were conducted to examine relationships between functional status, experiential variables, and demographic variables. Open-ended questions were provided for participants to report ways that arthritis affected their participation that were not otherwise reflected within survey questions; responses were numerically coded using summative content analysis. Among 37 participants (24.8 ± 3.3 years old), 70% reported moderate-to-severe disability. On average, participants experienced pain, stiffness, or fatigue for more than 50% of their waking hours. Functional status significantly correlated with functional performance (r = - 0.39, p = 0.02) and satisfaction (r = - 0.39, p = 0.02), yet did not correlate with stiffness or fatigue severity or duration of symptoms throughout the day. Participants described strategies that improved their ability to participate in certain activities but reduced their overall quality of activity engagement and caused emotional distress. Young adults with arthritis may experience more significant functional limitations than previously reported. Traditional measures of functional assessment may not capture experiential components of activity that affect participation, such as severity of stiffness or fatigue or the duration of symptoms throughout the day.

The coronavirus disease-2019 (COVID-19) pandemic is likely to pose new challenges to the rheumatology community in the near and distant future. Some of the challenges, like the severity of COVID-19 among patients on immunosuppressive agents, are predictable and are being evaluated with great care and effort across the globe. A few others, such as atypical manifestations of COVID-19 mimicking rheumatic musculoskeletal diseases (RMDs) are being reported. Like in many other viral infections, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection can potentially lead to an array of rheumatological and autoimmune manifestations by molecular mimicry (cross-reacting epitope between the virus and the host), bystander killing (virus-specific CD8 + T cells migrating to the target tissues and exerting cytotoxicity), epitope spreading, viral persistence (polyclonal activation due to the constant presence of viral antigens driving immune-mediated injury) and formation of neutrophil extracellular traps. In addition, the myriad of antiviral drugs presently being tried in the treatment of COVID-19 can result in several rheumatic musculoskeletal adverse effects. In this review, we have addressed the possible spectrum and mechanisms of various autoimmune and rheumatic musculoskeletal manifestations that can be precipitated by COVID-19 infection, its therapy, and the preventive strategies to contain the infection.

There is a high percentage of error in the approach of patients with joint pain by primary care physicians. An algorithm can help improve this misdiagnosis problem. Our study seeks to determine the effectiveness of an algorithm when used by primary care physicians for the diagnosis of cases of joint pain patients. A randomized clinical experiment was carried out. Primary care physicians from five cities in Colombia developed a series of clinical cases, which were presented to them through a website on their personal cell phones. Half of the doctors developed the cases using the diagnostic algorithm, and the other half developed the cases without the use of the algorithm. Main measures were proportion of correct diagnosis, number, type of laboratory and diagnostic images requested for the diagnostic approach of clinical cases. Two hundred and twenty-four primary care physicians participated. The overall proportion of cases correctly diagnosed was 37.3% higher in the intervention group; we found a greater difference in cases of spondyloarthritis (60.8%), followed by systemic lupus erythematosus with joint involvement (32.2%), rheumatoid arthritis (30.3%) and osteoarthritis (25.9%). The average number of tests requested to develop clinical cases was lower in the intervention group than in the control group, both globally and for each of the four diseases, with statistically significant differences for each of the comparisons. The diagnostic algorithm proved to be an effective tool when used by primary care physicians; the proportion of correct diagnoses increased, and the number of tests requested in the development of the cases decreased.

A substantial amount of people with a rheu-matic disease perceive invalidation consisting of lack of understanding and discounting (negative social responses). To get insight into the potential buffering role of self-effi-cacy and pain acceptance against invalidation, this cross-sectional study examined associations between these vari-ables. Spanish speaking people (N = 1153, 91% female, mean age 45 ± 11 years) with one or multiple rheumatic diseases completed online the Illness Invalidation Inven-tory, the Chronic Pain Acceptance Questionnaire, and the Chronic Disease Self-Efficacy Scale. Higher self-efficacy (t = − 4.80, p = < 0.001) and pain acceptance (t = − 7.99, p = < 0.001) were additively associated with discounting. Higher self-efficacy (t = − 5.41, p = < 0.001) and pain acceptance (t = − 5.71, p = < 0.001) were also additively associated with lack of understanding. The combined occurrence of high self-efficacy and high acceptance was associated most clearly with lower lack of understanding (interaction: t = − 2.12, p = 0.034). The findings suggest the usefulness of examining whether interventions aimed at increasing self-efficacy and pain acceptance can help people with rheumatic diseases for whom invalidation is a consider-able burden.

Juvenile systemic sclerosis (JSSc) is a rare disorder with paucity of information on its treatment and longterm outcome. Herein, we are sharing our experience with this rare entity. Case records of children, diagnosed to have systemic sclerosis attending Pediatric Rheumatology Clinic at All India Institute of Medical Sciences, New Delhi from January 1998 to June 2016 were reviewed. The demographic, clinical, laboratory, treatment and outcome details were recorded. Disease outcome was classified arbitrarily as controlled, partly controlled or non-responsive/progressive based on: (A) ability to perform activities of daily life (ADL) and (B) presence or absence of musculoskeletal symptoms, skin changes (ulceration/progressive digital pitting/gangrene), and visceral organ involvement (dyspahgia, cardiopulmonary symptoms). Controlled: ability to perform ADL and absence of B features for at least 6 months. Partly controlled: inability to perform ADL or any of the B features. Non-responsive/progressive disease: presence of both A and any of B features. Thirty-two children (21, girls) diagnosed as systemic sclerosis for whom follow-up of more than 6 months was available were included for this retrospective analysis. Mean (SD) age at presentation was 112.79 (30.05) months, while the median (IQR) delay in diagnosis was 28.5 (9-47.25) months. Of the 32 children 17 (53.12%) had diffuse systemic sclerosis (dSSc), 5 (15.62%) had limited systemic sclerosis (lSSc) and 10 (31.25%) had sclerosis with overlap syndrome. The common clinical features apart from sclerosis/induration proximal to metacarpophalangeal joint were Raynauds phenomenon (n = 22, 68.7%), skin rash (n = 20, 62%), arthritis or arthralgia (n = 16, 50%), and muscular weakness (n = 10, 31.2%). Among those for whom data regarding investigations were available; ANA was positive in 50% (12/24), whereas Anti Scl70 was positive in one out three cases. Treatment regimen included naproxen, methotrexate, calcium channel blockers with or without steroids. HCQ was added in children with skin rash or in children with partial control. Median (IQR) follow-up period was 19.75 (12-31.75) months. With the above treatment protocol, 19 (59.3%) children achieved disease control on treatment, 8 (26.6%) had partial control while 5 (16.6%) showed no response or progressive disease. Esophageal dysmotility and intertitial lung disease (ILD) were documented in three children each. Complication (cataract and herpes zoster) related to immunosuppressive therapy were observed in two children. There was no mortality during the study period. Juvenile Sclerosis though rare is associated with significant morbidities and lacks a curative treatment but a reasonable quality of life to perform daily activities can be achieved using methotrexate and steroid-based immuosuppressive therapy.

This study investigated as to how social support influences health among people with rheumatoid arthritis (RA). We refer to the stress-buffering hypothesis of social support which suggests that the negative consequences of stressors on health outcomes can be buffered by social support. In this study, pain represents a stressor and depressive symptoms represent negative health outcomes. It was hypothesized that higher levels of social support should attenuate the association between pain and depression in RA. A cross-sectional study was conducted in 361 patients with RA. They completed questionnaires on social support, depression and perceived pain. Linear regression analysis was applied, with pain as the main explanatory variable, depression as a dependent variable, and an interaction term "social support × pain". Both pain and social support showed significant associations with depression, with more severe pain and lower social support going along with a higher depression score. However, the interaction term "social support × pain" was not significant, indicating that social support did not attenuate the association between pain and depression. Social support was inversely associated with the experience of depressive symptoms among people suffering from RA. However, it had no buffering effect in attenuating the postulated association between the stressor "pain" and the negative health outcomes assessed as depressive symptoms. The stress-buffering hypothesis of social support was not supported by data from this study among people suffering from RA.

Information on measurement properties of translated versions of the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index is still limited. This study investigated the internal consistency, test–retest reliability/agreement, construct validity, and floor and ceiling effects of Portuguese–Brazil WOMAC applied to civil servants at baseline of ELSA-Brasil Musculoskeletal cohort. Each measurement property was evaluated in the overall sample, in the subgroup reporting knee symptoms, and across different sociodemographic strata (except factorial analyses). Separate analyses were performed for pain, stiffness and function dimensions, considering the knee with the worst score (or right knee if same score in both knees). A total of 1740 participants were included (319 completed WOMAC on 2 occasions), mean age 56.0 (standard deviation = 8.9) years, 46.8% male, 42.1% had knee symptoms. In the overall sample, the range of results for WOMAC’s dimensions were: internal consistency = cronbach alpha 0.92–0.98; test–retest reliability = intraclass correlation coefficient 0.85–0.97; standard error of measurement (SEM) = 1.38–5.86; smallest detectable change (SDC) = 3.84–16.25; lowest possible score = 38.8%-61.1% (floor effect present); highest possible score = 0.2%-0.9% (ceiling effect absent). Construct validity was confirmed by hypothesis testing and factorial analysis. Results were similar in the symptomatic group, except for higher SEM and SDC, and the absence of floor effects in pain and function dimensions. Portuguese–Brazil WOMAC showed good overall quality in a nonclinical setting. Variability in measurement properties across different strata of the population should be taken into consideration for the design of future studies using WOMAC.

The study compares patient–physician discordance in global assessment in patients with osteoarthritis (OA) versus patients with rheumatoid arthritis (RA) seen in routine care. This is a cross-sectional study conducted at an academic rheumatology center at which all patients are asked to complete a Multi-Dimensional Health Assessment Questionnaire (MDHAQ), which includes a patient global assessment (PATGL). Rheumatologists are encouraged to complete a physician questionnaire, which includes a physician global assessment (DOCGL). Patients with either OA or RA were identified using ICD9 codes and classified as positive discordance (PATGL-DOCGL ≥ 2), negative discordance (PATGL-DOCGL≤ − 2), and concordance (absolute difference between the two assessments

Pain management is a cornerstone of osteoarthritis (OA) management. The aim of this review is to obtain current, literature-based estimates of the effect of common pharmacologic treatments on pain reduction in OA. A MEDLINE search (2006–2016) was conducted for randomized controlled trials studying acetaminophen, oral NSAIDs, topical NSAIDs, COX-2 inhibitors, and opioids in the treatment of OA pain. Drug effect on pain was estimated using relative change in pain, and expressed as percentage change. An overall effect for each drug category was obtained as a weighted average of study-specific effects, with weights based on each study’s sample size. Twenty-nine studies were included. The effect on pain was estimated in a total of 43 treatment arms (acetaminophen n = 6, oral NSAIDs n = 9, topical NSAIDs n = 8, COX-2 inhibitors n = 9, and opioids n = 11). Relative (%) changes in pain were found to be as follows: acetaminophen = 32.5, oral NSAIDs = 34.3, topical NSAIDs = 40.9, COX-2 inhibitors = 36.9, and opioids = 35.4. The effects of 5 major drug categories in the treatment of OA pain were reviewed with data extracted from 29 studies published from 2006 to 2016. Acetaminophen was found to have an RC value close to that of oral NSAIDs. The effects of oral NSAIDs, COX-2 inhibitors, and opioids in controlling pain were similar to what has been demonstrated in previous literature. Topical NSAIDs were found to have a greater RC than oral NSAIDs.

To explore the contribution of physical capacity in explaining variations in fatigue among people with rheumatoid arthritis (RA). This study included participants recruited for a physical activity intervention. Data were collected from the Swedish Rheumatology Quality Registers, from questionnaires on fatigue, activity limitation, perceived health, pain and anxiety/depression and from physical capacity tests (lower limb function, grip strength, and aerobic capacity). We used logistic regression to estimate the association between severe fatigue (≥ 50, visual analogue scale 0–100) and (A) independent variables related to disease and disease impact and (B) model A plus physical capacity tests. Pooled odds ratio tests compared model fit. Out of the 269 participants (mean age 60 years, mean disease activity score [DAS28] 2.8), severe fatigue was reported by 35%. The three variables which were statistically significantly associated with severe fatigue (p

This study evaluated the synergistic effects of ultrasound (US) and low-level laser therapy (LLLT) with or without therapeutic exercises (TE) in women with knee osteoarthritis. Forty-two Caucasian women with knee osteoarthritis were allocated into three groups: (1) the placebo group who did not perform TE, but the prototype without emitting light or ultrasonic waves was applied, (2) the US + LLLT group in which only the prototype was applied and (3) the TE + US + LLLT group that performed TE before the prototype was applied. However, 35 women completed the full clinical trial. Pressure pain thresholds (PPT) using an algometer and functional performance during the sit-to-stand test were carried out. The average PPT levels increased for US + LLLT (41 ± 9 to 54 ± 15 N, p

The aim of this study was to develop and to validate a Bengali version of the Western Ontario and McMaster Osteoarthritis (WOMAC®) index in Bangladesh. The WOMAC® was translated into the local language of Bangladesh (Bengali) and adapted in the local sociocultural context, following the standard guidelines by Beaton et al. Content validity of the preliminary Bengali version was assessed by using the index of content validity (ICV) and floor and ceiling effects. Patients were assessed at the Department of Rheumatology of Bangabandhu Sheikh Mujib Medical University and were diagnosed to have knee OA by American College of Rheumatology criteria and recruited according to the requirements of the validation study. Convergent and divergent validity were measured by comparing with Health Assessment Questionnaire (HAQ) and the Short Form-36 (SF-36), and internal consistency was assessed using Cronbach’s alpha coefficient. The questionnaire was readministered to 40 patients within a week for assessing reliability by using intra-class correlation coefficient (ICC) and Spearman’s rank correlation coefficient. In addition, factor analysis of Bengali WOMAC® questionnaire was performed to examine the number of factors influencing a common set of items. A Bengali version was developed with changes in three items to suit local practices. The ICV of the content validity was 1 for all items. The Bengali WOMAC® had similar construct validity when compared to the HAQ (ρ 0.74, n = 70) and SF-36 bodily pain and physical functioning. It had dissimilar construct validity to SF-36 mental health domain except WOMAC® pain. Factor analysis revealed five factors with eigenvalues of more than 1.0. Cronbach’s alpha and ICC exceeded 0.7 in all domains. In the test–retest reliability testing, Spearman’s ρ for all items exceeded 0.4 (n = 40). This study has demonstrated that the Bengali version of WOMAC® is a valid tool for assessing quality of life of patients with knee osteoarthritis in Bangladesh and is reliable.

There are no standardized bedside assessments for subtyping patients with osteoarthritis (OA) based on pain mechanisms. Thus, we developed a bedside sensory testing kit (BSTK) to classify OA patients based on sensory profiles potentially indicative of pain mechanism. After usability and informal reliability testing (n = 22), the kit was tested in a formal reliability study (n = 20). Patients completed questionnaires and sensory testing: pressure algometry to detect hyperalgesia; repeat algometry after heterotopic noxious conditioning stimulation to measure diffuse noxious inhibitory control (DNIC); light touch using Von Frey filaments; and cold allodynia using a brass rod. The procedure was brief and well tolerated. Algometry and filament testing were highly reliable [intra-class correlation coefficients (ICCs) 0.71-0.91]; DNIC was acceptably reliable (ICCs 0.53-0.91); brass rod reliability was inconclusive. Patients were classified empirically into four groups: "All abnormal findings" (primary and secondary hyperalgesia and dysfunctional DNIC); "all normal findings"; and two intermediate groups. The "all abnormal findings" group had more neuropathic pain symptoms, and lower WOMAC total, stiffness, and activity scores than the "all normal findings" group. Simple BSTK procedures, consolidated in a kit, reliably classified OA patients into subgroups based on sensory profile, suggesting that OA patients differ in underlying pain mechanisms. Further research is needed to confirm these subgroups and determine their validity in predicting response to treatment.

The goal of our study was to evaluate the associations between various definitions of radiographic hand osteoarthritis (OA) and self-reported hand pain. We conducted a cross-sectional study with 3604 participants from the Osteoarthritis Initiative (OAI). Posteroanterior radiographs of the dominant hand were read using a modified Kellgren–Lawrence (KL) scale. For our primary analysis, hand OA at person level was defined as two or more finger joints with KL grade 2 or higher. In addition, for the purpose of exploratory analyses, we explored more conservative definitions of hand OA as well as different sum scores and digit- and row-based scores. The majority of definitions of radiographic hand OA were statistically significantly associated with self-reported hand pain. In our main analysis, persons with two or more finger joints with KL grade > 2 were approximately two times more likely to self-report hand pain than persons without radiographic hand OA. Increasing KL grades and increasing number of joints affected lead to stronger associations. Almost all definitions of hand OA were related to pain. Individuals with more severely affected joints or with higher number of affected joints are more likely to report hand pain than their peers. Specifically, individuals with hand joints with KL 3 or 4 have the greatest likelihood of hand pain.

Establishing prevention and therapeutic strategies for osteoarthritis (OA) is necessary to minimize functional disability and the impact of the disease on society. The aim of this study was to determine the effects of an exercise therapy protocol on inflammatory markers, perception of pain, and physical performance in individuals with OA of the knee. The protocol consisted of flexibility training and muscle strengthening over 12 weeks with three 80-min sessions per week. Peripheral blood was collected to determine serum levels of interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and soluble forms of the TNF-α receptor (sTNFR1 and sTNFR2). A clinical assessment of the musculoskeletal system and Western Ontario and McMaster Universities (WOMAC) questionnaire were applied to evaluate the specific symptoms of knee OA. Pain intensity was evaluated using a visual analog scale (VAS). All measurements were taken before and after the intervention. Twenty-two individuals (mean age 58.8 ± 6.4 years) completed the protocol. A decrease in the perception of pain was evident on VAS (p < 0.001) and pain subscale of the WOMAC (p < 0.001). In addition, there was a reduction in serum levels of IL-6 (p < 0.001). However, changes in the levels of the TNF-α and its soluble receptors were not statistically significant. Physical function subscale score and the WOMAC global score improved significantly (p < 0.001). The training also promoted an increase in the progression load for all muscles groups analyzed (p < 0.001). Our data suggest that the exercise therapy protocol could be a strategy for reducing IL-6 levels, managing pain, and improving function in individuals with OA of the knee. However, more studies are necessary to investigate the issue.

Although greater trochanter pain syndrome (GTPS) is a prevalent cause of musculoskeletal pain in the general population, there is lack of imaging studies searching for differential features of inflammatory enthesitis in GTPS. We analyzed the features of GTPS using sonography and magnetic resonance imaging (MRI) to identify useful differential signs between spondyloarthritis (SpA) and other inflammatory or non-inflammatory musculoskeletal diseases. All patients with unilateral GTPS attended by our Arthritis Unit between February 2011 and March 2012 were included. Patients were classified as having SpA or mechanical (without inflammatory musculoskeletal disease) GTPS. Rheumatoid arthritis (RA) patients were also included as inflammatory controls. Ultrasound scans of the painful and contralateral, asymptomatic, greater trochanter were made. We assessed the gluteus medius and gluteus minimus tendons for signs suggestive of tendinopathy. Random MRI of the same regions was made in a subgroup of patients to validate the ultrasound findings. A total of 107 patients with unilateral GTPS were included, of whom 96 were female, with a mean age of 61.6 years: 34 had SpA, 48 had non-inflammatory musculoskeletal disease, and 25 had RA. No specific sonographic features for SpA were found. Pathological findings were more frequent in patients without musculoskeletal inflammatory disease (mainly bursitis and erosions). A large number of alterations were found in the asymptomatic side (around 40 % had cortical irregularities and 20 % bursa effusion). Signs of enthesopathy were more prevalent in the gluteus minimus tendon, regardless of the diagnosis (54.2 % had erosions, 39.3 % bursitis, 38.3 % calcifications and 37.4 % tendinosis). No patient had power Doppler signal. Age was the main factor in the appearance of tendinopathy. MRI confirmed the changes detected by ultrasound in all 40 patients evaluated. GTPS in patients with SpA has similar sonographic findings to those observed in patients with RA and patients without musculoskeletal inflammatory disease. Neither sonography nor MRI was clinically useful in classifying GTPS as a manifestation of SpA.

Celiac disease (CD) is an autoimmune systemic disease characterized by not only gastrointestinal but also extraintestinal manifestations. The aim of our study was to do a serological screening for CD, by IgA endomysial antibodies (EmA), in patients with unexplained articular manifestations. Two hundred and eleven patients suffering from arthritis or arthralgia without evident cause were studied. EmA were determined by indirect immunofluorescence on human umbilical cord. Two thousand and five hundred blood donors served as control group. Out of 211 patients, 5 had EmA (2.37 %). The frequency of EmA in our patients was significantly higher than in the control group (2.37 vs. 0.28 %, p < 0.01). All patients with positive EmA were female. EmA were significantly more frequent in female patients than in female healthy subjects (3 vs. 0.4 %, p < 0.01). Medical records revealed: diarrhea (one patient), short size (one patient), anemia (three patients), weight loss (two patients) spontaneous abortion (three patients), secondary amenorrhea (one patient), early menopause (one patient) and early baby death (one patient). Biochemical analysis showed decreased level of calcium (one patient), vitamin D (one patient) and cholesterol (one patient). Unexplained liver cytolysis was observed in two patients. Radiological examination showed demineralization of two hands in one patient. Bone osteodensitometry done in one patient out of five revealed lumbar osteopenia. The articular manifestations of the five patients did not respond to corticosteroid treatment. CD must be considered among the differential diagnosis in a patient with arthritis or arthralgia.

Evidence supports early use of non-biologic DMARDs to prevent irreversible damage in inflammatory arthritides, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), and possibly ankylosing spondylitis (AS). However, there is a paucity of data exploring their effects on pain as a primary outcome in these conditions. This systematic literature review investigated the effect of non-biologic DMARDs on pain levels in IA and examined whether disease duration impacted efficacy. We searched Medline, Embase, Cochrane Central, and Cochrane Database of Systematic Reviews, abstracts from the 2008 to 2010 American College of Rheumatology annual congresses, and citation lists of retrieved publications. Only randomized, double-blind controlled trials were analyzed. Quality was assessed with the Risk of Bias tool. Descriptive statistics were used in meta-analysis. 9,860 articles were identified, with 33 eligible for inclusion: 8 in AS, 6 in PsA, 9 in early RA (ERA), and 10 in established RA. In ERA and established RA, all studies of DMARDs (monotherapy and combination therapies) consistently revealed statistically significant reductions in pain except three oral gold studies. In AS, sulfasalazine studies showed significant pain reduction, whereas use of other DMARDs did not. In PsA, 5 of 6 studies reported VAS-pain improvement. From the studies included, we were unable to assess the influence of disease duration on pain outcomes in these rheumatic conditions. DMARDs improve pain in early and established RA. Sulfasalazine may improve pain in AS and PsA. Further study is needed to assess the relationship between disease duration and DMARD efficacy in reducing pain in these conditions.

To investigate (1) the amount of self-reported time spent sedentary among a large cohort of persons with rheumatoid arthritis (RA), and (2) the contribution of sedentary time to explain perceived health and activity limitation in RA beyond that of previously known correlates. This cross-sectional study used data from a postal questionnaire and the Swedish Rheumatology Quality registers (SRQ). The International Physical Activity Questionnaire was used to assess sedentary time (sitting) and moderate, vigorous and walking activity (MVPA). Sociodemographics, pain, fatigue, fear-avoidance beliefs, anxiety/depression, disease duration, MVPA and sedentary time were included in multiple regression models with perceived health (Visual Analogue Scale 0-100) and activity limitation (Stanford Health Assessment Questionnaire) as dependent variables. Results: In all 3152 (59%) of 5391 persons identified as eligible from the SRQ, responded to the questionnaire. 2819 individuals with complete data on all study variables were analysed. Mean time (SD) spent sedentary was 257 (213) minutes per day. Sedentary time did not contribute significantly to explain perceived health and only minimally to explain activity limitation. Instead, variation was mainly explained by pain; for perceived health (Beta = 0.780, p < 0.001) and for activity limitation (Beta = 0.445, p < 0.001).The results indicate a non-significant role of sedentary time and a need for increased focus on pain in the management of RA. Future studies should use prospective designs and objective assessment methods to further investigate the associations between sedentary time and health outcomes in persons with RA. De 2 första författarna delar förstaförfattarskapet.

Anti-cyclic citrullinated peptide antibody (anti-CCP) is a specific marker for the diagnosis of rheumatoid arthritis. However, this antibody can be detected in other rheumatic diseases and even in healthy people. This study aims to determine the prevalence and the clinical significance of anti-CCP in patients with primary Sjogren syndrome (pSS). We analyzed the clinical and laboratory data of 95 patients with pSS by retrospective review of their medical records. Anti-CCP was measured by ELISA kit. Anti-CCP, rheumatoid factor (RF), anti-nuclear antibody, anti-Ro and anti-La antibodies, and clinical data were investigated. We analyzed clinical and serologic characteristics of anti-CCP-positive patients. Twenty-one patients (22.1%) had positive anti-CCP (mean titer 61.6 ± 15.6 U/ml) and 40 patients (42.1%) had positive RF (mean titer 98.8 ± 22.7 IU/ml). Seventy-nine patients (83.1%) had arthralgia, and 31 patients (32.6%) had non-erosive arthritis on physical examination and radiologic images. Anti-CCP-positive patients had more frequently positive RF (71.4% vs. 41.8%, P = 0.01) and anti-Ro antibody (85.7% vs. 60.8%, P = 0.03). Anti-CCP-positive patients had non-erosive arthritis more frequently than anti-CCP-negative patients (76.1% vs. 21.6%, P < 0.01). The prevalence of anti-CCP was 22.1% in pSS, and anti-CCP was associated with non-erosive arthritis, and positivity of RF and anti-Ro antibody.

The aim of this study was to assess the efficacy and safety of intra-articular sodium morrhuate injections in the treatment of recurrent knee joint effusions. Ninety-eight knees of 92 patients (f = 59, m = 33) with knee arthritis of heterogeneous etiology were treated with chemical synovectomy (CSO). Of those, 39 patients suffered from rheumatoid arthritis (RA). The mean follow-up was 29.8 months. Clinical outcome was evaluated by analyzing subjective patient satisfaction, activity level, pain severity on the basis of the Visual Analogue Pain Scale (VAS), Lysholm and Gillquist score, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Fifty-seven percent of all patients and 67% of patients diagnosed with RA were satisfied with CSO. No significant effects on patient satisfaction by CSO were noted in patients older than 40 years. Overall, VAS, Lysholm and Gillquist score, and KOOS improved significantly at final review. The intra-articular application of sodium morrhuate is an effective and safe measure in the treatment of recurrent symptomatic knee joint effusions in young patients suffering from recurrent knee joint effusions.

Adult-onset Still's disease (AOSD) is a complicated multi-systemic inflammatory disease, the main features of which are high spiking fever, evanescent rash, polyarthralgia, lymphadenopathy, hepatosplenomegaly and leukocytosis. The pathogenesis and etiology of AOSD are still unknown. We report a case of atypical AOSD presenting with only arthralgia, fever, lymphadenopathy, slightly elevated serum C-reactive protein and ferritin levels and a slightly elevated erythrocyte sedimentation rate; these signs and symptoms did not fulfill the proposed diagnostic criteria of both Cush and Yamaguchi. After exclusion of other likely diagnoses, a diagnosis of atypical AOSD was made, and a low dose of corticosteroids was effective in resolving all of the patient's symptoms. More clinical practice and research are needed to determine pathogenesis and etiology of AOSD and to amend the diagnostic criteria to include such atypical cases.

The local tolerability of lornoxicam (Xefo®) after single and repeated intraarticular administration was assessed in the rabbit and compared to established standard therapies (hyaluronic acid—Synvisc® and the glucocorticoid triamcinolone—Triam®), and the results are discussed in the context of the literature. Two local tolerance studies were performed using five male rabbits per group. Lornoxicam and competitor products were administered into the right knee joint in a volume of 500 μL. The contralateral left knee joint of the same animal was used as the control and was injected with water for injection. Three out of five animals were killed 72 h after the last administration, whereas the remaining two animals were subjected to a 2- or 6-week recovery period in the first and the second study, respectively. Findings revealed adaptive changes related to the mechanical irritation of the injection and to adaptive responses of the synoviocytes, but no signs of toxicity to bone or chondrotoxicity. Toxicokinetic analysis showed a fast and almost complete absorption of lornoxicam from the joints into the systemic circulation. As a conclusion, repeated intraarticular administration of lornoxicam was well tolerated in rabbits.

This study aims to evaluate the frequency of fatigue in Moroccan patients with ankylosing spondylitis (AS), and its relationships with disease-specific variables, psychological status, and sleep disturbance. A cross-sectional study included patients fulfilled the modified New York classification criteria for ankylosing spondylitis. To assess fatigue, the first item of Bath ankylosing spondylitis disease activity index (BASDAI) and the multidimensional assessment of fatigue (MAF) was used. The evaluation included the activity of the disease (BASDAI), global well-being (Bath ankylosing spondylitis global index), functional status (Bath ankylosing spondylitis functional index), metrologic measurements (Bath ankylosing spondylitis metrological index), and visual analog scale of axial or joint pain. The erythrocyte sedimentation rate and C-reactive protein were measured. To assess psychological status, the hospital anxiety and depression scale (HADS) was used. Sleep disturbance was assessed by the fourth item of Hamilton anxiety scale. One hundred and ten patients were included, of average age 38.0 years ± 12.6. In our data, 66.4% experienced severe fatigue (BASDAI fatigue ≥ 5). The mean total score of MAF was 26 ± 12.77. The disease-specific variables contributed significantly with both BASDAI fatigue and MAF as dependent variables, accounting for 71.3 and 65.6% of the variance, respectively. The contribution of the depression, anxiety, and sleep disturbance were 24.9, 18.4 and 15.4%, respectively. This study state the importance of fatigue in AS patients. Even though disease activity was the most powerful predictor of fatigue, the effects of psychogenic factors and sleep disturbance, should be taken into consideration in the management of AS.

Adult-onset Still's disease is a rare systemic inflammatory disease of unknown aetiology characterised by typical symptoms including daily high spiking fever, evanescent salmon-pink rash, sore throat, arthritis/arthralgias and polyserositis. The laboratory findings usually show neutrophilic leucocytosis, seronegativity and raised serum transaminases. We describe six typical cases. All of them had serum ferritin above 5,000 µg/L. Although there are few theories about the origin of the high ferritin level, an extremely high serum ferritin above 5,000 µg/L should be the main diagnostic tool of adult-onset Still's disease.

To determine whether the first presenting symptoms, the main problem that the disease is causing to patients, and the employment status at presentation of patients with early spondyloarthritis (SpA) in a multicultural/multiracial patient cohort are different between gender, race, and disease subgroups of the SpA spectrum (ankylosing spondylitis, enteropathic arthritis, psoriatic arthritis, or undifferentiated arthritis). All patients above the age of 16 years, with disease duration of less than 3 years since symptom onset, seen in clinic between 2004 and 2008 with spondyloarthritis (SpAs) were assessed regarding their first presenting symptom, the main problem caused by the disease, and their employment status. In addition, clinical parameters such as the degree of disease activity (measured by BASDAI, ESR, and CRP), functional ability (measured by BASFI), night pain, sleep disturbance, well-being over past week, and over past 6 months prior to assessment (measured by a 10 cm VAS; 0 = good health, 10 = worst possible) were obtained. Statistical analysis with Pearson's χ(2) test compared and correlated two groups, and one-way analysis of variance (ANOVA) was used when more than two groups were compared and correlated. A total of 96 patients [(male:female = 33:63; (34.4:65.6%), (mean age 43.8 ± (SD) 13.9)] with early SpA were assessed. They were of multiethnic background representing Caucasians (n = 52; 54.2%), Asians (n = 33; 34.4%), and Africans (n = 10; 10.4%) mixed race (n = 1; 1%). The disease spectrum consisted of ankylosing spondylitis (AS) (n = 12; 12.7%), enteropathic arthritis or SpA associated with inflammatory bowel disease (IBD) (n = 9; 9.4%), psoriatic arthritis (PsA) (n = 47; 49%), undifferentiated spondyloarthritis (USpA) (n = 27; 28.2%), reactive arthritis (n = 1;1%), and juvenile SpA (n = 1;1%). Back pain stated as the first presenting symptom by 45 patients (46.8%) (followed by knee pain) and joint pains as the main problem by 49 patients (51.7%), while 47 patients of 93 who replied on the employment section (50.5%) were working. The total group had BASDAI score of 5.91 (±2.1), ESR of 19.65 (±19.4) mmHg/h, CRP of 8.10 (±9.2) mmol/L, BASFI score of 4.51 (±2.57), night pain of 5.26 (±3.2), sleep disturbance of 5.24 (±3.03) well-being over past week of 5.9 (±2.7), and well-being over past 6 months of 6.4 (±2.5). Most patients had PsA at presentation. Comparisons between genders showed significantly more women to have knee pain as first presenting symptom than men. No differences between races found in the first presenting symptom, main problem caused to patients by disease, and employment, but Africans have significantly more sleep disturbance than other races. Comparisons between disease subgroups showed patients with AS to have significantly more back pain and hip pain as first presenting symptom and patients with IBD to have more joint pain as main problem caused by the disease.

Anterior cruciate ligament (ACL) tears are known to be a risk factor for incident knee osteoarthritis (OA). At the present time, it is unknown whether an incidental ACL tear in those with established knee OA alters the pattern of synovial joint damage. Therefore, our aim was to assess whether ACL tears in persons with knee OA are associated with specific patterns of cartilage loss, meniscal degeneration, and bone marrow lesion (BML) location. We included 160 participants from the progression subcohort of the Osteoarthritis Initiative (OAI) Study, an ongoing 4-year, multicenter study, focusing on knee OA. Regional cartilage morphometry measures including cartilage volume (mm(3)), denuded area, normalized cartilage volume, bone surface area, as well as location of meniscal pathology and BMLs in index knees on the same side were compared between those with and without ACL tears. Of the 160 subjects (51% women, age 62.1 (±9.9), BMI 30.3 (±4.7) kg/m(2)), 14.4% had an ACL tear. After adjusting for age, BMI and gender participants with ACL tears had significantly greater cartilage volume in the posterior lateral femur (P = 0.04) and the central medial tibia (0.001) compared to those without ACL tears. Normalized cartilage volume was not different between those with and without ACL tears. In addition, individuals with ACL tears had significantly larger bone surface areas in the medial tibia (P = 0,006), the central medial tibia (P = 0.008), the posterior lateral femur (P = 0.004), and the posterior medial femur (P = 0.04). Furthermore, participants with ACL tears showed significantly more meniscal derangement in the lateral posterior horn (P = 0.019) and significantly more BMLs in the lateral femur (P = 0.0025). We found clear evidence of predominant lateral tibiofemoral involvement, with OA-associated findings on MRI, including increased denuded area and bone surface area, BMLs, and meniscal derangement in knees of individuals with ACL tears compared to those without.

Mud-bath therapy plays a primary role in the treatment and prevention of osteoarthritis that has been recognised since antiquity. Numerous studies have demonstrated its clinical benefits and its effects on inflammatory mediators (interleukins), the immune system, cenesthesic factors (endorphins), and the diencephalic–pituitary–adrenal axis. This study was conducted to assess the efficacy of mud-bath therapy with mineral water from the Sillene Spring at Italy’s Chianciano Spa in patients with osteoarthritis of the knee. Patients (n = 61) were divided into two groups. Group A underwent three cycles of mud-based spa therapy over a year’s time, whereas group B did not. Clinical conditions, visual analogue scale pain ratings, and Lequesne indexes of the two groups were compared. We also compared these same parameters in the patients of the two groups that were following the therapy with drugs and in the patients of the group A before and after spa treatment. The percentage of patients with no symptoms or mild symptoms was higher in group A than in group B. Within group A, this percentage was higher after treatment than before spa therapy. Even in the comparison between the patients of the two groups that were following the therapy with drug, the results was that in group A the percentage of patients with no symptoms or mild symptoms was higher than in group B. Statistical analyses based on various tests revealed that almost all these differences were highly significant. No adverse effects were observed in any of the patients in group A. In conclusion, the mud-bath therapy performed at Chianciano Spa with Sillene Spring water remarkably improved the clinical conditions of patients with knee arthritis and significantly reduces the frequency and severity of symptoms and the disability they cause.

A 62-year-old man presented with a 2-month history of increasing pain in the left hip. Magnetic resonance imaging (MRI) showed bone marrow edema (BME) of the left femur, dual energy X-ray absorptiometry (DXA) showed osteopenia at the same level, whereas pelvis X-rays failed to show any objective findings. After ruling out other possible causes of BME such as aseptic osteonecrosis, infectious arthritis, primary or metastatic malignancy, tuberculosis, osteomyelitis, rheumatoid arthritis, and seronegative spondyloarthropathies, a diagnosis of transient osteoporosis of the hip (TOH) was made, and treatment with teriparatide at a daily dose of 20 μg was started and continued for 4 weeks. Disappearance of the symptoms and normalization of MRI were obtained.

Osteoid osteoma and osteoblastoma are benign bone tumors that occur most often in adolescents and predominantly in males. Typical clinical symptoms, such as reduced range of motion of adjacent joints, nocturnal bone pain and relief of pain using non-steroidal anti-inflammatory drug therapy especially in osteoid osteoma may lead to the correct diagnosis. However, these symptoms are not always apparent and specific. In radiographic examinations, the initial changes are often uncharacteristic causing further delay in diagnosis. Magnetic resonance imaging is increasingly used for screening, but early findings in the course of disease might not lead to the definite diagnosis. Both entities (especially osteoid osteoma) occur frequently in the area of the hip. To demonstrate pitfalls in the diagnostic pathway of hip pain caused by benign bone tumors, we present two cases with osteoid osteoma and one with osteoblastoma.

The aim of this study was to investigate the performance of minor salivary gland biopsy (MSGB), serological and clinical data in diagnosis of primary Sjogren’s syndrome (pSS). Retrospective review of 216 patients who underwent minor labial salivary gland biopsy in last 5 years was performed. Results of the patients with diagnosis of pSS were compared with the patients failing to fill the classification criteria of pSS. Two groups did not differ significantly in terms of clinical symptoms and signs except presence of Raynaud’s phenomenon. Specificity and positive likelihood ratio of clinical signs in diagnosis of pSS were quiet low. A total of 78.7% of pSS patients had a focus score ≥1 (Chiscolm’s score III/IV) while all of the non-SS patients had a focus score

To study the prevalence, and clinical and laboratory manifestations of male lupus, and compare these findings with their age-matched female lupus in Thai patients. The medical records of patients with diagnosed Systemic lupus erythematosus (SLE) were reviewed. The clinical and laboratory manifestations were determined. There were 37 males in 508 patients with SLE (7.3%). There was no difference in mean +/- SD age and disease duration between male patients and their 74 female age-matched controls. When compared with females, male lupus patients had a significantly lower prevalence of alopecia (13.6 vs. 44.6%, P = 0.001), arthralgia (2.7 vs. 17.6%, P = 0.032), Raynaud's phenomenon (0.0 vs. 12.2%, P = 0.027), and psychosis (0.0 vs. 13.5%, P = 0.029), but they had a significantly higher prevalence of thrombocytopenia (32.4 vs. 12.2%, P = 0.019) and renal insufficiency (40.5 vs. 16.4%, P = 0.006). Our study showed several existing sex-related differences in the clinical manifestations in Thai SLE patients.

The main objective of this cross-sectional observational study was to investigate the relationship between clinical, ultrasonographic (US) and radiographic elbow features in patients with inflammatory joint diseases (IJD). The secondary objective was to evaluate the association between regional clinical elbow diagnoses and imaging findings. Consecutive patients with IJD attending follow-up visits were assessed for elbow pain and standardized elbow examination. Seven regional clinical diagnoses were defined. Digital elbow radiographs were read for 9 abnormalities. A standardized elbow grayscale (GS) and power Doppler (PD) scan recorded 13 defined abnormalities. Analysis encompassed 361 clinical, 361 US and 340 radiographic elbow assessments from 181 patients. US and clinical assessments showed an overall higher agreement than radiographic and clinical assessments (68.8 vs 59.1%, p = 0.001). When structural US abnormalities were compared with radiographic findings, agreement was slightly higher than when comparing all US abnormalities with radiographic findings (77.3%, k 0.533 and 73.5%, k 0.492). Enthesophytes, the most common abnormalities, were not associated with clinical findings. Subclinical US-synovitis and US-enthesopathy were found, respectively, in 17.3 and 14.1% of the clinically normal elbows. Clinical elbow arthritis prevalence and bias-adjusted kappa (PABAK) agreement was good for radiographic fat pad sign, PD-synovitis and GS-synovitis. Clinical elbow enthesopathy PABAK agreement was moderate for GS-enthesopathy and radiographic calcifications. US showed acceptable agreement with clinical and radiographic assessments for detecting elbow inflammatory and structural abnormalities in patients with IJD. Because US detected more abnormalities than radiography and has the capability to detect more subclinical abnormalities, US may be potentially used as a first-line elbow diagnostic tool in this clinical setting.

Ehlers-Danlos syndromes (EDS) are a heterogeneous group of hereditary connective tissue disorders characterized by joint hypermobility, widespread musculoskeletal pain and tissue fragility. Psychiatric disorders and psychosocial impairment are common, yet poorly characterized, findings in EDS patients. We investigated the frequency and types of psychiatric disorders and their relationship to systemic manifestations in a cohort of 106 classic and hypermobility type EDS patients. In this retrospective study, extensive medical chart review was performed for patients referred at two genetics clinics who were diagnosed with EDS. Statistical analysis was undertaken to determine the frequency of psychiatric disorders and association with systemic findings. Psychiatric disorders were found in 42.5% of the EDS cohort, with 22.7% of patients affected with 2 or more psychiatric diagnoses. Anxiety and depression were most commonly reported, with frequencies of 23.6 and 25.5%, respectively. A variety of other psychiatric diagnoses were also identified. Abdominal pain [odds ratio (OR) 7.38], neuropathic pain (OR 4.07), migraines (OR 5.21), joint pain (OR 2.85) and fatigue (OR 5.55) were significantly associated with the presence of a psychiatric disorder. The presence of any pain symptom was significantly associated with having a psychiatric disorder (OR 9.68). Muscle pain (OR 2.79), abdominal pain (OR 5.78), neuropathic pain (OR 3.91), migraines (OR 2.63) and fatigue (OR 3.78) were significantly associated with having an anxiety or mood disorder. Joint hypermobility and the classic dermatological features of EDS showed no significant association with having a psychiatric disorder. Our findings demonstrate a high frequency of psychiatric disorders and an association with pain symptoms in EDS.

The aim of this study was to determine the prevalence of joint pain and arthritis in renal transplant recipients and to investigate relationships with various laboratory and clinical parameters. Eighty-two patients who underwent renal transplantation (RT) had joint examinations and reportedv by questionnaire on levels of joint pain and arthritis. Each individual was then followed by the rheumatology department for 1 year, with joint examination and laboratory tests every 3 months. Thirty-one of 82 patients (37.8%) complained of joint pain before RT, of whom seven reported pain continuing after the operation. Seventeen of the 82 (20.7%) began to suffer joint pain after RT. Six (7.3%) and three (3.7%) of the 82 patients, respectively, developed arthritis before and after transplantation. The study showed that joint pain is common before and after RT. In renal transplant recipients, joint pain significantly correlated with serum cyclosporine levels higher than 200 ng/ml.

The purpose of the study was to report on the safety and feasibility of the application of maximal physical tests in a heterogeneous cohort of rheumatic patients. This is a 5-year retrospective descriptive report on the incidence of events associated with maximal physical testing from 536 patients, totalizing 5,910 tests. Tests were classified as cardiopulmonary, muscle strength, and physical functioning tests. Any adverse events during the tests and limiting factors incurring in tests cancellation were reported. Eighteen out of 641 cardiopulmonary exercise tests had an adverse occurrence, with cardiac disturbance (1.4% of total tests) being the most prevalent. Moreover, 14 out of 641 tests were not feasible. Out of 3,478 tests comprising leg press, bench press, knee extension, and handgrip tests, 15 tests had an adverse event. The most common occurrence was joint pain (0.4% of total tests), which was also the most frequent factor precluding testing (0.5% of total tests). Forty-five out of 3,478 (1.3%) of the tests were not feasible. There was a very low incidence of events (0.2%) during the physical functioning tests. Joint pain was the only adverse event during the tests, whereas physical limitations were the most important barriers for the execution of the tests (1.1% of total tests). The incidence of limiting events in this test was 1.6% (n = 29). This report brings new data on the safety and feasibility of maximal physical testing in rheumatic patients. The physical tests described in this study may be applied for testing rheumatic patients both in research and clinical setting.