Cardiovascular Disease Risk Associated to Chronic Inflammatory Rheumatic Diseases in Patients Seen in Rheumatology Unit in Yaounde, Cameroon

Introduction: Even though there is a huge burden of both chronic inflammatory rheumatic diseases (CIRD) and cardiovascular diseases in Sub-Saharan Africa, no published study from this region has yet addressed the issue of cardiovascular diseases in a group including different CIRD to the best of our knowledge. Objective: We conducted this research with the aim to explore the association between CIRD and cardiovascular risk in a Cameroonian population based on the World Health Organization (WHO) and International Society for Hypertension (ISH) risk charts. Methods: This cross-sectional study included CIRD patients, followed at the rheumatology unit of the Yaounde Central Hospital, and, who were matched to non-CIRD subjects for sex, age and race. Cardiovascular risk factors were studied and subsequently the cardiovascular risk was estimated using the WHO/ISH risk charts. Analyses were performed in Epi-info and SPSS software and results were considered statistically significant for a p-value less than 0.05. Results: In total, 109 CIRD patients and 111 non-CIRD subjects were included. Their respective mean ages were 44.4 ± 15.2 years and 44.2 ± 15.1 years. Odds ratio 2.09, 95% confidence interval (CI) (1.07 - 4.08);high BMI OR 1.89, 95% CI (1.1 - 3.24);diabetes mellitus (p = 0.03) and physical inactivity (p < 0.001) were all markedly found in CIRD patients compared with controls. Ten (9.2%) CIRD patients had a past history of atherosclerotic cardiovascular events compared with no control (p < 0.001). The cardiovascular risk estimated with the WHO/ISH risk charts was low in 43 (79.6%) patients with CIRD versus 52 (88.1%) non-CIRD subjects. Conclusions: CIRD were associated with hypertension, excess overall adiposity, diabetes mellitus, and physical inactivity. A substantially increased proportion of CIRD patients with a past history of atherosclerotic cardiovascular events were noted. But the WHO/ISH risk charts broadly found a similar and globally decremented cardiovascular risk in both study groups, highlighting the need to pursue research for definite conclusions on their reliability.

Fibromyalgia Being Strongly Associated with Manual Labor Among Male Patients Attending Rheumatology Clinic

Introduction: Fibromyalgia is a common chronic pain syndrome, associated with different risk factors, including trauma. Many patients with the current or past history of manual labor attend our rheumatology clinic/s. Should manual labor be considered a risk factor for the development of fibromyalgia? Patients and Methods: A prospective study, where all male patients seen at the rheumatology clinic/s with the diagnosis of fibromyalgia were asked about their present and past type of job/s. Manual job was defined as a job where the participant had a strenuous physical activity of more than 2 hours during the working day. A similar number of Ethnic- and age-matched female patients from the same clinic/s were recruited as a control group. Results: 69 and 40 Arab and Jewish male participants were recruited, respectively. 54% of the Arab male patients and 20% of the Jewish male patients were considered manual laborers. Construction and renovation accounted for 46% of the type of jobs practiced by Arab patients. Only 4% of Arab female patients were considered manual laborers. Conclusion: Manual labor seems to be a risk factor for the development of fibromyalgia among male laborers.

Quality of Life of Patients with Knee Osteoarthritis with Questionnaire OAKHQOL (OsteoArthritis of Knee Hip Quality of Life) in Rheumatology Consultation in Burkina Faso (West Africa)

Objective: To study the quality of life of patients with knee OA with the questionnaire OAKHQOL (OsteoArthritis of Knee Hip Quality Of Life). Patients and Methods: This was a cross-sectional study over a period of six months, in patients with symptomatic knee osteoarthritis. All patients met the clinical and radiological criteria of the ACR. The OAKHQOL questionnaire was used to investigate the quality of life of patients. Results: One hundred and six patients were included. There were 94 (88.7%) women and 12 (11.3%) men with a sex ratio of 0.12. The average age of patients was 55 ± 10.4 years. The average pain intensity was 55.1 ± 22.4. The majority of patients (69.8%) had stage 3 of Kellgren and Lawrence classification. The dimension “pain” had the lowest normalized score (60.6). There was a significant correlation between the age range of 30 to 40 years and declining mental health (49.5) . The patients with over 60 years of age had a decrease in pain tolerance and reduced social activities. Lequesne score was associated with severe all dimensions except “social support” of the patient. Conclusion: The knee has an impact on quality of life of patients followed in rheumatology by OAKHQOL questionnaire.

Autoimmunity as the comet tail of COVID-19 pandemic

Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection can give rise to different clinical manifestations that are directly related to viral tissue damage or indirectly induced by the antiviral immune response.Hyper-activation of the immune system in an attempt to eradicate the infection may trigger autoimmunity.Several immune-mediated disorders have been described in SARS-CoV-2-infected individuals.These include cutaneous rashes and vasculitis,autoimmune cytopenia,anti-phospholipid syndrome,central or peripheral neuropathy,myositis and myocarditis.On the other hand,rheumatic patients were reported to have similar coronavirus disease 2019(COVID-19)incidence,morbidity and mortality rates compared to general population.This opinion review will summarize the crucial immunologic steps which occur during SARSCoV-2-infection that may link autoimmunity to COVID-19 and provides an opportunity for further discussion regarding this association.

The Impact of Intramuscular Depot Betamethasone Injection (Diprospan) on Patients with Fibromyalgia and Normal C-Reactive Protein Levels

Introduction: Intramuscular depot betamethasone treatment had resulted in a significant improvement among fibromyalgia patients with elevated C-reactive protein (C-RP) levels. Here, we wanted to evaluate the same regimen of treatment among fibromyalgia patients with normal C-RP levels. These patients represent the overwhelming majority of fibromyalgia patients. Patients and Methods: Consecutive patients with fibromyalgia attending the outpatient rheumatology clinic, with normal C-RP level and negative serology, who had failed different medical treatment, were asked to participate in our study. All patients have qualified the American College of Rheumatology (ACR) criteria from 2010. After consent, patients had an intra-muscular injection of 14 mg depot betamethasone at the gluteal area. Just prior to the injection, 1 week and 1 month later, patients were interviewed by phone and asked to answer the Fibromyalgia Revised Questionnaire (FIQR). Wilcoxon’s signed ranked test was used to compare the results 1 week and 1 month following the injection, compared to the base line scores. Results: Seventeen (17) patients completed the study. Favorable effects were seen regarding 13 out of 19 parameters one week following the injection, including functional parameters, mood and anxiety, tenderness to touch and intolerance to noise and light. No significant favorable effect was seen 1 month following the injection except for one parameter: ability of walking for twenty minutes. Conclusions: IM depot betamethasone injection had very limited and transient favorable effects on fibromyalgia patients with normal C-RP levels. Such a treatment is not a recommended modality of routine treatment, among fibromyalgia patients with normal C-RP levels.

“FISH VERTEBRA” about 3 Sickle Cell Patients Followed at Laquintinie Hospital, Douala

Vertebral involvement in particular is common in sickle cell patients. We report 3 cases of “fish vertebra” fractures in sickle cell patients aged 16, 18, and 24 years old respectively at Laquintinie Hospital, Douala. When the vertebral fractures were diagnosed, the 3 patients had back pain and kyphosis deformities of the dorsal spine. Treatment with an infusion of biphosphonates (zoledronic acid at a dose of 0.5 mg·per·kg) was offered to all three patients. Two out of three patients received treatment with biphosphonates with a successful outcome. Profound vitamin D deficiency is associated with increased bone remodeling and a history of fractures. In sickle cell anemia, vertebral fractures may also result from bone fragility, which is often overlooked as aseptic osteonecrosis and osteomyelitis, which are very often suspected.

Prevalence and Factors Associated with Low Back Pain among Healthcare Workers in Two Hospitals in Yaoundé-Cameroon: A Cross-Sectional Study

Background: Low back pain (LBP) is a very common health problem amongst the general population and a major cause of disability that affects work performance and well-being. Healthcare workers (HCWs) are especially at risk of developing LBP because of physical and emotional factors. Little is known about the burden of LBP in Cameroon. Objective: To determine the prevalence of low back pain and identify its associated factors among healthcare workers. Methods: A cross-sectional study using a self-administered questionnaire was conducted among healthcare workers in the Yaound Central Hospital and the Yaound University Teaching Hospital. The questionnaire collected data regarding recent, past year and lifetime occurrences of LBP, socio-demographics and work conditions. Data were analysed using IBM Statistical Package for Social Sciences (SPSS) version 26. Results: A total number of 268 HCWs participated in the study, including 197 (73.5%) females and 71 (26.5%) males. The mean age of the study participants was 40.60 8.38 years (extremes of 20 and 65 years). The lifetime, annual, and point prevalences of LBP among the participants were 67.5% (CI: 61.6 - 73.1), 61.5% (CI: 55.6 - 67.1) and 35.7% (CI: 29.7 - 41.5) respectively. Multivariate analysis confirmed a moderate stress level, a sedentary lifestyle, working in the medicine and specialities department, lifting heavy objects and bending to work as associated factors to LBP. Most sufferers had a minimal functional disability (65.7%) while 34.3% had a moderate to severe disability. Conclusions: Healthcare providers have a considerably high prevalence of low back pain. Factors associated with LBP found in this study were similar to those widely recognized in the literature. A substantial proportion of healthcare providers are suffering from functional disability associated with low back pain, affecting their social and work lives. There is a need for multilevel interventions to prevent and control low back pain in this highly vulnerable occupational group.

Clinical features and epidemiology of spondyloarthritides associated with inflammatory bowel disease

Inflammation of axial and/or peripheral joints is one of the most frequent extra-intestinal manifestations complicating the clinical course and therapeutic approach in inflammatory bowel diseases(IBD).The frequency of these complications seems to be similar for both diseases, Crohn's disease and ulcerative colitis.Arthritis associated with IBD belongs to the category of spondyloarthropathies.Axial involvement ranges from isolated inflammatory back pain to ankylosing spondylitis, whereas peripheral arthritis is noted in pauciarticular and in polyarticular disease.Asymptomatic radiological involvement of the sacroiliac joints is reported to occur in up to 50% of patients.Other musculoskeletal manifestations such as buttock pain, dactylitis, calcaneal enthesitis, and thoracic pain are frequently underdiagnosed and, consequently, are not treated appropriately.Several diagnostic approaches and criteria have been proposed over the past 40 years in an attempt to correctly classify and diagnose such manifestations.The correct recognition of spondylarthropathies needs an integrated multidisciplinary approach in order to identify common therapeutic strategies, especially in the era of the new biologic therapies.

Hepatitis C virus syndrome: A constellation of organ-and non-organ specific autoimmune disorders, B-cell nonHodgkin's lymphoma, and cancer

The clinical course of chronic hepatitis C virus(HCV)infection is characterized by possible development of both liver and extrahepatic disorders. The tropism of HCV for the lymphoid tissue is responsible for several immune-mediated disorders; a poly-oligoclonal B-lymphocyte expansion, commonly observed in a high proportion of patients with HCV infection, are responsible for the production of different autoantibodies and immune-complexes, such as mixed cryoglobulins. These serological alterations may characterize a variety of autoimmune or neoplastic diseases. Cryoglobulinemic vasculitis due to small-vessel deposition of circulating mixed cryoglobulins is the prototype of HCV-driven immune-mediated and lymphoproliferative disorders; interestingly, in some cases the disease may evolve to frank malignant lymphoma. In addition, HCV shows an oncogenic potential as suggested by several clinicoepidemiological and laboratory studies; in addition to hepatocellular carcinoma that represents the most frequent HCV-related malignancy, a causative role of HCV has been largely demonstrated in a significant percentage of patients with isolated B-cells nonHodgkin's lymphomas. The same virus may be also involved in the pathogenesis of papillary thyroid cancer, a rare neoplastic condition that may complicate HCVrelated thyroid involvement. Patients with HCV infection are frequently asymptomatic or may develop only hepatic alteration, while a limited but clinically relevant number can develop one or more autoimmune and/or neoplastic disorders. Given the large variability of their prevalence among patients' populations from different countries, it is possible to hypothesize a potential role of other co-factors, i.e., genetic and/or environmental, in the pathogenesis of HCV-related extra-hepatic diseases.

Osteoporosis Treatment:When to Discontinue and When to Re-start

A number of effective therapies for the treatment of osteoporosis have become available in recent years. However, uncertainty exists regarding their long-term use and effectiveness. Bisphosphonate treatment, unlike hormone replacement, denosumab or teriparatide, is associated with benefits extended even after treatment discontinuation. The extended benefits are most apparent for alendronate （ALN） and zoledronate （ZOL）. A drug holiday might be considered in patients compliant with treatment, and who have had a response fractures the decision to consider a drug holiday should treatment. at low-moderate risk and who have been fully to treatment. In patients at low-moderate risk of be balanced also with the safety profile of each

Hepatitis C virus-related lymphoproliferative disorders:An overview

Hepatitis C virus （HCV） is a global health problem affecting 3% of the world＇s population （about 180 million） and a cause of both hepatic and extrahepatic diseases. B-cell lymphoproUferative disorders, whose prototype is mixed cryoglobulinemia, represent the most closely related as well as the most investigated HCV- related extrahepatic disorder. The association between extrahepatic （lymphoma） as well as hepatic malignancies （hepatocellular carcinoma） has justified the inclusion of HCV among human cancer viruses. HCV-associated manifestations also include porphyria cutanea tarda, lichen planus, nephropathies, thyreopathies, sicca syndrome, idiopathic pulmonary fibrosis, diabetes, chronic polyarthritis, sexual dysfunctions, cardiopathy/ atherosclerosis, and psychopathological disorders. A pathogenetic link between HCV virus and some lymphoproliferative disorders was confirmed by their responsiveness to antiviral therapy, which is now considered the first choice treatment. The aim of the present paper is to provide an overview of extrahepatic manifestations of HCV infection with particular attention to B-cell lymphoproliferative disorders. Available pathogenetic hypotheses and suggestions about the most appropriate, currently available, therapeutic approaches will also be discussed.

Utility of arthroscopic guided synovial biopsy in understanding synovial tissue pathology in health and disease states

The synovium is the soft tissue lining diarthrodial joints, tendon sheaths and bursae and is composed of intimal and subintimal layers. The intimal layer is composed of type A cells(macrophages) and type B cells(fibroblasts); in health, the subintima has few inflammatory cells. The synovium performs several homeostatic functions and is the primary target in several inflammatory arthritides. Inflammatory states are characterised by thickening of the synovial lining, macrophage recruitment and fibroblast proliferation, and an influx of inflammatory cells including lymphocytes, monocytes and plasma cells. Of the various methods employed to perform synovial biopsies arthroscopic techniques are considered the "gold standard", and have an established safety record. Synovial biopsy has been of critical importance in understanding disease pathogenesis and has provided insight into mechanisms of action of targeted therapies by way of direct evidence about eventsin the synovial tissue in various arthritides. It has been very useful as a research tool for proof of concept studies to assess efficacy and mechanisms of new therapies, provide tissue for in vitro studies, proteomics and microarrays and allow evaluation for biomarkers that may help predict response to therapy and identify new targets for drug development. It also has diagnostic value in the evaluation of neoplastic or granulomatous disease or infection when synovial fluid analysis is noncontributory.

An overlap syndrome involving autoimmune hepatitis and systemic lupus erythematosus in childhood

We report a 12 years old female patient with an overlap syndrome involving autoimmune hepatitis （AIH） and systemic lupus erythematosus （SLE）. The patient presented with jaundice, hepatosplenomegaly, malaise, polyarthralgia, arthritis and butterfly rash on the face. Laboratory tests revealed severe liver dysfunction, Coombs positive hemolytic anemia and a positive ANA/ anti-dsDNA test. Renal biopsy showed class IIA kidney disease, while liver biopsy showed chronic hepatitis with severe inflammatory activity. The patient satisfied the international criteria for both SLE and AIH. Clinical symptoms and laboratory findings of SLE improved with high dose treatment with corticosteroids and azathioprine, however, remission of the liver disease could not be achieved. Repeat biopsy of the liver after three years of therapy revealed ongoing chronic hepatitis with high level of inflammatory activity. The present case indicates that children with liver dysfunction and SLE should be investigated for AIH. There is much diagnostic and therapeutic dilemma in patients with AIH-SLE overlap syndrome.

Combined therapeutic approach:Inflammatory bowel diseases and peripheral or axial arthritis

Inflammatory bowel diseases(IBDs), particularly Crohn's disease(CD) and ulcerative colitis(UC), are associated with a variety of extra-intestinal manifestations(EIMs).About 36% of IBD patients have at least one EIM, which most frequently affect the joints, skin, eyes and the biliary tract.The EIMs associated with IBD have a negative impact on patients with UC and CD, and the resolution of most of them parallels that of the active IBD in terms of timing and required therapy;however, the clinical course of EIMs such as axial arthritis, pyoderma gangrenosum, uveitis, and primary sclerosing cholangitis is independent of IBD activity.The peripheral and axial arthritis associated with IBD have traditionally been treated with simple analgesics, non-steroidal anti-inflammatory drugs, steroids, sulfasalazine, methotrexate, local steroid injections and physiotherapy, but the introduction of biological response modifi ers such as tumor necrosis factor-α blockers, has led to further improvements.

Beyond the joint: Subclinical atherosclerosis in rheumatoid arthritis

Rheumatoid arthritis is a chronic autoimmune inflammatory disease associated with increased cardiovascular risk and higher mortality in respect to general population.Beyond joint disease,inflammation is the major determinant of accelerated atherosclerosis observed in rheumatoid arthritis.We review the relationship between inflammation,atherosclerosis and cardiovascular risk in rheumatoid arthritis,focusing on the assessment of subclinical atherosclerosis by functional and morphological methods.These tools include flow mediated dilatation,carotid intima-media thickness,ankle/brachial index,coronary calcium content,pulse wave analysis and serum biomarker of subclinical atherosclerosis.

High circulating N-terminal pro-brain natriuretic peptide and tumor necrosis factor-α in mixed cryoglobulinemia

AIM: To evaluate serum levels of N-terminal pro-brain natriuretic peptide (NTproBNP) and tumor necrosis factor α (TNF-α) in a large series of patients with hepatitis C associated with mixed cryoglobulinemia (MC+HCV).METHODS: Serum NTproBNP and TNF-α levels were assayed in 50 patients with MC+HCV, and in 50 sex- and age-matched controls. RESULTS: Cryoglobulinemic patients showed signifi cantly higher mean NTproBNP and TNF-α levels than controls (P < 0.001; Mann-Whitney U test). By defining high NTproBNP level as a value higher than 125 pg/mL (the single cut-off point for outpatients under 75 years of age), 30% of MC+HCV and 6% of controls had high NTproBNP (χ2, P < 0.01). With a cut-off point of 300 pg/mL (used to rule out heart failure (HF) in patients under 75 years of age), 8% of MC+HCV and 0 controls had high NTproBNP (χ2, P < 0.04). With a cut-off point of 900 pg/mL (used for ruling in HF in patients aged 50-75 years; such as thepatients of our study), 6% of MC+HCV and 0 controls had high NTproBNP (χ2, P = 0.08).CONCLUSION: The study demonstrates high levels of circulating NTproBNP and TNF-α in MC+HCV patients. The increase of NTproBNP may indicate the presence of a subclinical cardiac dysfunction.

Takayasu's arteritis following Crohn's disease in a young woman:Any evidence for a common pathogenesis?

Takayasu's arteritis and Crohn's disease are chronic in-flammatory diseases of uncertain aetiology. They rarely occur together, with only twenty nine cases of co-ex-istent Takayasu's arteritis and Crohn's disease reported in the literature. In 88% of these cases, Takayasu's arteritis was diagnosed simultaneously or following a diagnosis of Crohn's disease. We present a case of a young Caucasian medical student, incidentally found to have bilateral carotid bruits on auscultation by a colleague. Magnetic resonance angiography revealed stenoses of the common carotid arteries with estab-lished collaterals, and a diagnosis of Type 1 Takayasu's arteritis was made. An 18F-fluorodeoxyglucose positron emission tomography scan revealed no active disease. Nine months later, she presented with a short history of abdominal pain, vomiting and abdominal disten-sion. Barium follow-through and computer tomography revealed a terminal ileal stricture and proximal small bowel dilation. An extended right hemicoloectomy was performed and histopathology supported a diagnosis of Crohn's disease. This case report is presented with a particular focus on the temporal relationship between these two disease processes and explores whether their concurrence is more than just co-incidence.

TNF-α inhibitors and tocilizumab do not influence hepatic steatosis in patients with rheumatoid arthritis

AIM: To investigate the influence, if any, of tumor necrosis factor(TNF)-α inihibitors and Tocilizumab, on hepatic steatosis(HS) in rheumatoid arthritis(RA) patients in the light of the known role of TNF-α and interleukin-6, which are key-cytokines in the pathogenesis of RA, in inducing HS in general population.METHODS: We retrospectively reviewed the clinical charts of 36 RA patients, out of whom 12 had been treated with Methotrexate(MTX), 12 with TNF inhibitors ± MTX and 12 with Tocilizumab ± MTX. The 3 subgroups of patients matched each other for sex, age, body mass index, metabolic syndrome(MS) and other risk factors for atherosclerosis. At baseline and after 12 mo each patient underwent an abdominal ultrasonog-raphy for the assessment of presence of HS and the evaluation of its grade.RESULTS: No difference was detected either in the prevalence of HS or in that of its distinct grades between the 3 groups of patients at baseline. After 12 mo, the HS grade unchanged in 20 patients(7 subjects treated with MTX, 7 with TNF-α inhibitors ± MTX and 6 Tocilizumab ± MTX); increased in 12 patients(4 subjects treated with MTX, 4 TNF-α blockers ± MTX and 4 Tocilizumab ± MTX); decreased in 4(1 treated with MTX, 1 with anti-TNF-α + MTX and 2 with TCZ ± MTX(P = 0.75). No correlation was found between getting remission or low disease activity and the course of either MS or HS.CONCLUSION: We failed to detect any influence of MTX ± TNF-α inhibitors or Tocilizumab in reducing MS and HS. A prospective study is needed to clarify the topic.

Increased IgG Rheumatoid Factor-Positivity in the Asian Rheumatoid Arthritis Patients Irrespective of Ethnicity

Aim of Work: Initial observations implied IgG rheumatoid factor (RF) to be common among Malaysian rheumatoid arthritis (RA) patients. We tested this hypothesis and used a multiethnic RA cohort (Malays, Chinese and Indians) to investigate whether the IgG RF predominance might be genetically or environmentally determined. Patients and Methods: 556 serum samples comprising 171 patients classified as RA according to the 1987 ACR criteria, 60 patients with other rheumatic diseases and 325 non-rheumatic controls were tested for IgG RF, IgM RF and anti-CCP by ELISA. The findings were then tested in a larger RA case-control cohort (n = 1844). Results: IgG RF predominated over IgM RF in all the investigated ethnic groups. The sensitivity, specificity, and diagnostic accuracy of IgG RF (55.6%, 91.2% and 80.2%, respectively) were superior compared to IgM RF, but comparable to anti-CCP. IgG RF was however, also increased in the Malaysian controls, but the IgG RF superiority over IgM RF was still apparent after cutoff adjustment according to the 1987 ACR criteria. Autoantibody levels did not differ between the three ethnic groups. The Receiver Operating Characteristics (ROC) curves showed larger areas under the curves for IgG RF (0.826) and for anti-CCP (0.867) than for IgM RF (0.737). Review of the literature showed consistently higher sensitivity for IgG RF in studies of Asian RA patients as compared to Caucasian and African-American studies. Conclusion: Increased frequency of IgG RF-positive in RA populations with different genetic background living in Malaysia argues for an environmental factor selectively amplifying the IgG RF response.

来氟米特可改善银屑病性关节炎患者的银屑病病情:一项对TOPAS研究资料的深入分析

Background: Leflunomide has shown promise in the treatment of psoriasis. Objective: To provide an in-depth analysis of the effect of leflunomide on psoriasis in patients with psoriatic arthritis (PsA). Methods: 190 patients with plaque psoriasis (at least 3% skin involvement) and active PsA were randomized to double-blind treatment with leflunomide (100 mg/day loading dose for 3 days followed by 20 mg/day orally) or placebo for 24 weeks. Results: As previously reported, leflunomide resulted in a significantly higher Psoriatic Arthritis Response Criteria response rate than placebo (58.9 vs. 29.7% ; p < 0.0001). Significant differences in favor of leflunomide were also observed in the Psoriasis Area and Severity Index (PASI 50 in 30.4% of patients vs. 18.9% for placebo; p = 0.05), target lesion response (46.4 vs. 25.3% ; p = 0.0048), combined skin and joint response (27.2 vs. 8.9% ; p < 0.0001), Dermatology Life Quality Index (improvement of 1.9 points vs. 0.2; p = 0.0173) and certain SF-36 subdomains. Dermatological responses were observed at the earliest examination (4 weeks) and increased throughout the 24-week study. Conclusion: Once-daily oral leflunomide is an effective and convenient treatment for PsA and plaque psoriasis.