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This case series aims to characterize the development of systemic lupus erythematosus (SLE) induced by anti-tumor necrosis factor α (anti-TNFα) therapy in patients with inflammatory rheumatic diseases, namely rheumatoid arthritis (RA), spondylarthritis (SpA), and psoriatic arthritis (PsA). Patients with a diagnosis of SLE induced by anti-TNFα therapy and registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα between 2001 and 2020 were included. Demographic, clinical, and laboratory data were obtained by consulting Reuma.pt. The diagnosis of SLE induced by anti-TNFα was considered if there was a temporal relationship between the onset of anti-TNFα therapy and manifestations (clinical and immunological) in accordance with the American College of Rheumatology/European League Against Rheumatism criteria (2019). A total of 607 patients with inflammatory rheumatic diseases and six cases of SLE induced by anti-TNF-α therapy were reviewed: two patients were affected by RA, three patients by SpA, and one by PsA. All these patients had articular and constitutional symptoms that improved after discontinuation of the anti-TNFα agent. After switching to a second anti-TNFα agent, there was no recurrence of SLE over time. The development of SLE secondary to anti-TNFα agents in inflammatory rheumatic patients is rare. In this case series, all patients had a mild disease that improved after therapy discontinuation without recurrence of the disease. SLE induced by anti-TNFα should be considered in the follow-up of RA, SpA, and PsA patients.

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient’s admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Behçet disease (BD) is a rare systemic vasculitis of unknown etiology, primarily characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Pathergy test positivity is a nonspecific inflammatory response of the skin to trauma and supports the diagnosis. Recently, new inducers of pathergy reactions have been identified, for example, the placement of dental braces and laser hair removal. Our clinical case highlights the importance of thinking about this potential pathergy inducer in BD patients, to improve their quality of life and avoid complications.

Rheumatic musculoskeletal diseases or RMD [rheumatoid arthritis (RA) and spondyloarthritis (SpA)] are systemic inflammatory diseases for which there are no biomarkers capable of predicting treatments with a higher likelihood of response in naive patients. In addition, the expiration of the anti-TNF blocking drugs’ patents has resulted in the availability of anti-TNF biosimilar drugs with the same efficacy and safety than originators but at significantly reduced prices. To guarantee a personalized therapeutic approach to RMD treatment, a board of rheumatologists and stakeholders from the Campania region, Italy, developed a clinically applicable arthritis therapeutic algorithm to guide rheumatologists (DATA project). The general methodology relied on a Delphi technique forecast to produce a set of statements that summarized the experts’ consensus. Selected clinical scenarios were discussed in light of the available evidence, and there were two rounds of voting on the therapeutic approaches. Separate discussions were held regarding rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The decision-making factors for each disease were clinical presentation, demographics, and comorbidities. In this paper, we describe a virtuous process between rheumatologists and healthcare system stakeholders that resulted in the development of a shared therapeutic algorithm for RMD patients naive to bDMARDs.

The primary objectives of the study were to evaluate the efficacy and safety of tofacitinib and baricitinib up to 24 months of follow-up in patients with rheumatoid arthritis (RA) treated in Southern Italy. Patients’ data, activity index, and clinimetric scores were collected at baseline (T0), six (T6), twelve (T12), and twenty-four (T24) months following treatment initiation. At six, twelve, and twenty-four months, adverse events and treatment cessation were also recorded. Sixty-eight patients (mean age: 62.2±10.9 years; mean RA duration: 15±9.6 years) were enrolled over a period of 12 weeks. At baseline, twenty-four patients (35.3%) were treated with tofacitinib, and forty-four patients (64.7%) were treated with baricitinib. The baseline mean disease activity was moderate as measured by DAS28- ESR (5.0±1.0), DAS 28 CRP (4.69±0.94), and SDAI (26.87±10.73) score. Before beginning JAKinhibs therapy, thirty-two patients (61.8%) were taking bDMARDs, while the remaining thirty-six (38.2%) were bDMARDs-naïve. The 24-month retention rate for JAKinhibs was 91.1%. Six months after beginning treatment with JAKinhibs, a statistically significant improvement was observed in all evaluated activity indices and clinimetric scores. Improvement was confirmed during the 12- and 24-month follow-up evaluations. The positive correlation between baseline-T6 SDAI delta and discontinuation of JAKinhibs (p=0.02) suggests that RA worsening in the first six months may be a predictor of therapy withdrawal. Patients with RA responded favorably to tofacitinib and baricitinib in this prospective, real-world study from a single center in Southern Italy. Efficacy was observed despite an underlying persistent and treatment-resistant disease.

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.

Objective: To evaluate efficacy of methotrexate treatment in peripheral arthritis of ulcerative colitis. Methods: We studied 18 patients (10/8 M/F; mean age: 38.90 yrs; range: 21-65 yrs), with peripheral arthritis (14 with polyarticular, 4 with oligoarticular subset) associate ulcerative colitis. Methotrexate 20 mg/week was administered in our patients, who were already receiving mesalazina for inflammatory bowel disease. At baseline, after 3 (T1), 6 (T2) and 12 months (T3) serological parameters (ESR and CRP), functional status (HAQ) and disease activity (VAS, GH, Ritchie articular index) were evaluated. Results: During the therapy a significant improvement was observed in disease activity, functional status and serological parameters since T1. ESR and CRP did not change at T2 and T3. Instead VAS, GH, Ritchie articular index and HAQ had a significant and gradual improvement from T1 to T3. Conclusion: Methotrexate treatment was efficacious in the treatment of peripheral arthritis associate ulcerative colitis. This drug induced improvement in disease activity, functional status and serological parameters after 3 months of therapy.

The first cases of atresia or web in the pyloric and prepyloric regions were described in the literature since 1937. To date, only one case of atresia at the junction between the fundus and the body of the stomach has been reported. We want to describe a complex case with incomplete atresia between fundus and gastric body, with left lateral diaphragmatic hernia, treated in several stages by endoscopic, open surgery and minimally invasive surgery

The first cases of atresia or web in the pyloric and prepyloric regions were described in the literature since 1937. To date, only one case of atresia at the junction between the fundus and the body of the stomach has been reported. We want to describe a complex case with incomplete atresia between fundus and gastric body, with left lateral diaphragmatic hernia, treated in several stages by endoscopic, open surgery and minimally invasive surgery

Purpose: Recursive partitioning analysis (RPA) is a prognostic index capable of predicting survival in patients with brain metastases. Histology of the primary tumour has only recently been introduced among the factors that could potentially affect the prognosis of these patients. The main purpose of this study was to analyse the impact of RPA in correlation with histology of the primary tumour in patients with brain metastases treated with hypofractionated radiotherapy., Materials and Methods: A total of 382 patients were treated at the Department of Radiotherapy of Brescia University, and RPA classes were retrospectively assigned to all patients. Univariate and multivariate analyses were then performed to verify the role of the single prognostic variables, for the entire group and for each prognostic class, as well as in correlation with histology of the primary tumour., Results: Most patients were classified as RPA prognostic class 2 (48%). The majority of patients was treated with a total dose of 30 Gy delivered in ten fractions, whereas the dose of 20 Gy in four or five fractions was primarily used in patients classified as RPA class 3. At univariate analysis, the main variable correlating with overall survival (OS) was RPA class (p=0.000). Uni- and multivariate analysis performed on RPA class 1 patients only confirmed the role of general performance status, number of metastases and total radiotherapy dose for predicting OS. In the group with the worst prognosis (RPA class 3), none of the variables had a statistically significant role in improving OS. Tumour histology and radiotherapy dose influence OS, even in RPA class 1 and 2 patients., Conclusions: This analysis confirms that RPA prognostic class is the factor that most predicts survival. Primary tumour histology helps determine prognosis, especially in RPA prognostic classes 1 and 2. As regards RPA class 3, no factor influences survival prognosis.

More than 150.000 hip and knee arthroplasties are performed every year in Italy. More than 50% of the patients receive a polyethylene component (Ultra High Molecular Weight PolyEthylene, UHMWPE). Polyethylene abrasive wear induces over time in vivo a foreign-body response and consequently osteolysis, pain and need of implant revision. Furthermore, oxidative wear due to gamma-rays sterilization caused in the '90ies several and severe failures. To solve these problems, since then, the orthopaedics research has been addressed to: 1) develop new cross linked polyethylene with a higher molecular mass than UHMWPE and, consequently, a higher abrasive wear resistance; 2) avoid the oxidative wear induced by gamma-rays sterilization, by using other sterilization methods and by stabilizing UHMWPE by means of antioxidants such as Vitamin E. According to the most recent studies, performed on limited cohorts and mostly funded by manufacturers, cross linked polyethylene shows a better abrasive wear resistance if compared to the conventional polyethylene but no significant differences have been detected in the clinical outcomes. Clinical follow up of Vitamin E stabilized PE are not yet available. The organization of national arthroplasties registries, able to trace and characterize the implanted devices and based on the whole patients population, will facilitate the early detection of devices that show a performance inferior than the expected one. In Italy, the National Institute of Health has been entrusted by the Ministry of Health to organize the national arthroplasty registry.

Objective: To evaluate efficacy of methotrexate treatment in peripheral arthritis of ulcerative colitis., Methods: We studied 18 patients (10/8 M/F; mean age: 38.90 yrs; range: 21-65 yrs), with peripheral arthritis (14 with polyarticular, 4 with oligoarticular subset) associate ulcerative colitis. Methotrexate 20 mg/week was administered in our patients, who were already receiving mesalazina for inflammatory bowel disease. At baseline, after 3 (T1), 6 (T2) and 12 months (T3) serological parameters (ESR and CRP), functional status (HAQ) and disease activity (VAS, GH, Ritchie articular index) were evaluated., Results: During the therapy a significant improvement was observed in disease activity, functional status and serological parameters since T1. ESR and CRP did not change at T2 and T3. Instead VAS, GH, Ritchie articular index and HAQ had a significant and gradual improvement from T1 to T3., Conclusion: Methotrexate treatment was efficacious in the treatment of peripheral arthritis associate ulcerative colitis. This drug induced improvement in disease activity, functional status and serological parameters after 3 months of therapy.

Aim: It is well-know that hyperthyroidism is one of the key causes of secondary osteoporosis. High values of thyroid hormones increase the bone mineral turnover speed by promoting osteoclastic and osteoblastic activities. The aim of our study is to evaluate the increase of bone mineral density (BMD) in osteoporotic and hyperthyroid patients treated with only antithyroid drugs versus patients treated with antithyroid drugs and diphosphonates., Methods: Twenty-six elderly male patients, 65-75 years, were selected. In all these patients, thyroid function (FT3, FT4, TSH, Tg, AbTg, AbTPO) was evaluated at baseline and after 6 and 12 months from the start of medical treatment; the following were evaluated: BMD, calcium serum, phosphorus serum, alkaline phosphatase, PTH and 24 hours urinary calcium, phosphorus and hydroxyprolin. Thirteen patients (group 1) were treated with antithyroid drugs (methimazole 5-20 mg/die/os) and diphosphonates (alendronate 10 mg/die/os). The control group of 13 patients (group 2) was treated with antithyroid drugs only., Results: After 6 months of treatment, the patients of group 1 showed a mean increase of 2.5% in lumbar spine BMD compared with a mean increase of 0.3% in group 2 (p<0.01). After 12 months, group 1 showed a mean increase of 6.2% in lumbar spine BMD, compared with a mean increase of 2% in group (p<0.001)., Conclusions: The combination of antithyroid and diphosphonates drugs appears to be more efficacious than antithyroid therapy alone for the treatment of osteoporosis in male hyperthyroid patients.

The Authors report a 10-years-old boy who was diagnosed as having upper esophageal stenosis. Biopsies of the stricture showed heterotopic gastric mucosa; endoscopic treatment was safe and effective.

Background: Oxidised UHMWPE due to gamma irradiation in air has a greater susceptibility to wear than non-oxidised UHMWPE (ethylene oxide, EtO)., Aim: To evaluate, the biological reaction of loose implants with oxidised and non-oxidised PE components., Materials and Methods: Ten loose PE cups sterilised by EtO (group 1) and 13 sterilised by gamma irradiation in air (group 2) were studied. PE wear and oxidation were related to biological reaction., Results: Group 1: PE cups had low wear score and no oxidation. In the oldest implants, a few PE particles and macrophages were observed in the interface membrane. Group 2: PE inserts had medium-to-high PE wear score and variable oxidation. In the interface membrane, the number and total area of PE particles were high and variable; giant cells were more numerous than macrophages., Conclusion: Junctional tissues around loose oxidised PE components contain more PE debris and giant cells than membranes around PE components that are not oxidised.

Fecal incontinence or soiling always endangers the personality development of a children. For very severe cases, the patient will be limited on his educational and professional training as well as on his sexal life. The outlook of severe cases, the chances of completing school, the choice of professional training and of sexual life in the future will be limited. A corrective procedure for anorectal incontinence depends on the exact investigation of all factors contributing to continence. The aim of this paper is to analyze the diagnostic aspects concerning continence in order to choose for each patient the most appropriate procedure for the treatment of all disturbance of stool control. A long term review of 312 patient with MAR, Myelomeningocele and severe stipsis with soiling was undertaken to determine the level of continence achieved. The choice between conservative measures and surgical procedures depends on clinical and manometric findings.

The case of a newborn with asymptomatic chylous ascites operated on because of voluminous inguino-scrotal hernia is reported and a review of the recent literature about aetiology, diagnosis and treatment of neonatal chylous ascites is made.

Two brothers of normal not consanguineous parents, with bilateral intrabdominal cryptorchidism, were admitted to our Institution. Both children had short stature, limb and hand malformations and craniofacial patterns of Robinow syndrome. During the orchidopexy, bilateral epididymal and vasal abnormalities were found in both of them. This anomaly associated with Robinow syndrome has never been reported before. These two cases provides the Authors with the opportunity of reviewing clinical features, genetics and radiological patterns of this rare syndrome.

The primary torsion of the omentum is a rare cause of acute abdomen. The clinic features may mimic closely acute appendicitis, with acute onset of right lower quadrant pain. The Authors, after reporting two cases recently observed, discuss the aetiopathogenetic aspects, point out the problems of diagnosis and finally suggest the most correct surgical approach.

Ovarian tumors in children are uncommon. We reviewed all cases of ovarian tumors treated at the Department of Pediatric Surgery of Vicenza Regional Hospital from 1979 to 1994. They include 6 cases of cystic teratoma and 1 gonadoblastoma; the malignant lesions included 1 immature teratoma, 1 dysgerminoma, 1 yolk-sac tumors and 1 patient with ovarian infiltration from malignant leukemia. Only the patient with leukemia died of progression of the disease. These data show that most ovarian masses are benign. Germ-cell tumors are the most common malignancy and epithelial cell tumors are less likely. Epithelial cyst and teratomas are the most common benign lesions. Although ultrasound was 100% accurate in the diagnosis of ovarian pathology, the ultrasonogram could not distinguish between benign and malignant lesions.

Testis tumors in children occur infrequently and exibit differences in their histopathology, clinical behaviour and therapy from their adult counterparts. From 1979 to 1994, 17 children and adolescent with testicular tumors were treated at the Pediatric Surgical Department of Vicenza Regional Hospital. Paratesticular rabdomiosarcoma were present in 3 cases, 4 patients had embrional carcinoma, 1 Sertoli cell tumor, 2 Leydig cell gonadal stromal tumor, and leukemic infiltrates of the testis were clinically evident in 7 patients. We report our clinical series and discuss in relation to clinical characteristic, histopathology and therapy and conclude that the improved survival during the past decade is attributable to better diagnostic imaging thecniques, the availability of serum tumor markers to monitor disease activity and more effective chemotherapy.

A case of nodular fasciitis occurring in a 14-year-old girl is described and the clinical-pathological profile and the diagnostic problems are analyzed. The Authors believe this report useful to be reported for the relative rarity of the disease, especially in children, the very great dimension and the unusual retroperitoneal localization.

Important considerations in evaluating newborn urine examinations by dip-stick method are: ease of performance, the volume of the specimen required for test, the time required to perform the test and the cost. In considering the dip-stick test for the early diagnosis of Urinary Tract Infections (U.T.I.), it has never been tested with later follow-up to evaluate its sensitivity and specificity, also in regard to reduce the risk of further complications for urinary tract and kidney.

The authors analyze the biomechanical effectiveness of pelvic osteotomy according to the Chiari method. This type of operation reduces joint loading and increases the joint support surface. The authors examined 18 patients aged an average of 31 years. This series shows that the effectiveness of pelvic osteotomy according to the Chiari method is particularly observed in cases in which joint morphology is best preserved.

Previous studies reported that norepinephrine (NE) induces contraction of the calf isolated coronary arteries after beta-adrenergic blockade with propranolol (PR), and that the effect disappeared after phentolamine. An higher Ca++ concentration increased the response of preparation to NE, whereas the reduction of the concentration reduced the response. In isolated coronary arteries the baseline tone and contractile response to NE after PR were studied as influenced by DA and nicardipine (NI). NI always induced vessel relaxation and DA induced a contraction followed by relaxation. The NE contraction was not abolished in calcium-free medium but in presence of DA and was reduced by NI in the medium containing Ca++. We conclude that NE induces contractions by facilitating the influx of the extracellular Ca++ and by promoting the liberation of intracellular bound Ca++.

The authors describe embryology and anatomy of synovial plica of the knee joint. They propose a clinic and pathogenic classification and after examining the diagnostic problem of plica syndrome, analyze their long-term results after surgical treatment.

The authors, after referring the various pathogenetic hypotheses for Paget's disease (till the latest hypothesis of infection by slow-action virus) report their follow-up of forty-five patients with Paget's disease of bone; then explain their diagnostic method, and record complications stressing the sarcomatous degeneration. Finally they give details on their therapeutic treatment emphasizing the need of hematochemical and radiographic periodical controls in order to optimize the treatment case by case.

The NRC (National Research Council) task force on head and neck cancer issued this document to help clinicians involved in diagnosing and treating precancerous oral diseases. Chapter 1 includes definition, epidemiology, risk factors (alcohol, smoking, poor oral hygiene), WHO classification, clinical picture of leukoplakias, erythroplasia, lichen planus, as well as their natural history. Chapter 2 points out the clinical signs to be looked for in order to make a proper diagnosis and discusses biopsy techniques. Chapter 3 deals with therapeutic procedures (surgical technique and medical treatment), while Chapter 4 concerns follow-up according to the clinical and histological diagnosis. Finally, some statistical forms are enclosed: Form 1 consists of information regarding educational qualifications, occupation, alcohol consumption, smoking and dietary habits; Form 2 consists of information about previous diseases and the history of the present disease; Form 3 records the signs and symptoms observed for the precancerous lesion; Form 4 records treatment modalities; Form 5 records patient follow-up.