Myelitis transverse in Sjögren's syndrome and systemic lupus erythematosus: presentation of 3 cases.

Transverse myelitis is a rare focal inflammation of the spinal cord. Multiple etiologies have been identified including autoimmune diseases, mainly systemic lupus erythematosus and Sjögren' syndrome. It can occur in an acute or subacute clinical onset, with the acute presentation having a worse prognosis. An early diagnosis and intensive treatment are important features recommended in these patients. We present three cases with transverse myelitis associated with autoimmune diseases. We discuss different clinical manifestations, association with autoantobodies, radiologic findings, and therapeutic and prognostic issues.

Genetically determined Amerindian ancestry correlates with increased frequency of risk alleles for systemic lupus erythematosus.

OBJECTIVE: To assess whether genetically determined Amerindian ancestry predicts increased presence of risk alleles of known susceptibility genes for systemic lupus erythematosus (SLE). METHODS: Single-nucleotide polymorphisms (SNPs) within 16 confirmed genetic susceptibility loci for SLE were genotyped in a set of 804 Mestizo lupus patients and 667 Mestizo healthy controls. In addition, 347 admixture informative markers were genotyped. Individual ancestry proportions were determined using STRUCTURE. Association analysis was performed using PLINK, and correlation between ancestry and the presence of risk alleles was analyzed using linear regression. RESULTS: A meta-analysis of the genetic association of the 16 SNPs across populations showed that TNFSF4, STAT4, ITGAM, and IRF5 were associated with lupus in a Hispanic Mestizo cohort enriched for European and Amerindian ancestry. In addition, 2 SNPs within the major histocompatibility complex region, previously shown to be associated in a genome-wide association study in Europeans, were also associated in Mestizos. Using linear regression, we predicted an average increase of 2.34 risk alleles when comparing an SLE patient with 100% Amerindian ancestry versus an SLE patient with 0% Amerindian ancestry (P < 0.0001). SLE patients with 43% more Amerindian ancestry were predicted to carry 1 additional risk allele. CONCLUSION: Our results demonstrate that Amerindian ancestry is associated with an increased number of risk alleles for SLE.

Prescription rheumatology practices among Mexican specialists.

BACKGROUND: We undertook this study to describe prescription practices and the degree of disease control in a large sample of patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) treated by rheumatologists in Mexico. METHODS: Board-certified Mexican rheumatologists across the country were asked to assess consecutive RA and AS patients; 1208 patients completed a self-administered questionnaire with information on demographics, disease duration, co-morbidity, treatment, pain, disability and a validated Spanish version of instruments to measure physical function and quality of life. RESULTS: Of the 1096 RA patients, 88.1% were treated with nonsteroidal anti-inflammatory drugs (NSAIDs), 1020 (93.3%) with disease-modifying anti-rheumatic drugs (DMARDs), 365 (33.4%) with steroids, and 70 (6.4%) with biological agents. Their mean Health Assessment Questionnaire Disability Index (HAQ-Di) score was 1.21+/-0.80, Disease Activity Index, 28 joint count (DAS 28) 3.9+/-1.29, and Rheumatoid Arthritis Disease Activity Index (RADAI), 3.94+/-2.01. Regarding the 112 AS patients, 110 (98.2%) received NSAIDs, 90 (80.4%) were on DMARDs, 11 (9.8%) took steroids, and 11 (9.8%) received biological agents, their functional status shown as Bath Ankylosing Spondylitis Functional Index (BASFI) score of 4.4+/-2.5. Among the 1110 DMARD users, only 64 received one drug, and a great proportion used two or more DMARDs; 81 subjects (16.2%) were on biological agents, in any combination. RA patients more commonly used methotrexate, 791 (72%) cases, and hydroxychloroquine. Taking into account their diagnosis, the combination most prescribed was NSAIDs plus DMARDs in 660 subjects (54.7%). CONCLUSIONS: DMARDs in combination with other drug are the most frequently prescribed therapeutic scheme for RA and AS patients. These schemes used for both conditions by Mexican rheumatologists are in line with current international recommendations.

Costs of the standard rheumatology care in active rheumatoid arthritis patients seen in a tertiary care center in Mexico City.

OBJECTIVE: To assess the costs of standard care in patients with active rheumatoid arthritis (RA) seen in a tertiary care center in México City in the context of a clinical trial. To analyze the relationship between costs and utility units obtained by the patients in this scenario. PATIENTS AND METHODS: This economic evaluation was performed during a clinical trial with a 48-week followup in a tertiary care center in México City. The trial compared the efficacy of omega-3 fatty acids versus placebo in patients with active RA who also received standard rheumatology care. The costs of medical consultations, complementary tests and drugs were assessed. Other direct costs were also measured. Hypothetical scenarios with fewer medical consultations and complementary tests than those in the clinical trial were also analyzed. Utilities were assessed by the Health Utility Index. A cost-utility ratio was calculated using the baseline utilities score as comparator. A descriptive statistical analysis was performed. RESULTS: Ninety RA patients (83 women [92%], age [X ± SD] 43.2 ± 14.2 years with disease duration of 3.3 ± 4.6 years) were included. Data from 88 patients were analyzed. The total direct costs were 152,704.11 US$ 2005 divided into medical attention (78,386.43 US$ 2005, 51.33%), drugs (39,339.5 US$ 2005, 25.76%) and other direct costs (34,978.18 US$ 2005. 22.91%). In scenarios with fewer medical consultations and complementary tests than those in the clinical trial, the total direct costs ranged from 39,507.4 to 103,880.6 US$ 2005. Patients improved by a mean of 0.18 utility units on a 0-1 scale equivalent to 0.18 quality adjusted lifeyears (QALYs). The cost-utility ratios ranged from 2,494.1 to 9,640.38 US$ 2005 per QALY in the scenarios analyzed. CONCLUSIONS: The direct costs of the standard care of RA in the scenarios analyzed are substantial in the social and economic context of Mexico. The cost per gained QALY is high.

El apoyo social asistencial en pacientes reumáticos: impacto de la intervención en México / Institutional social case work in rheumatic patients: impact of the intervention in Mexico

La afección biopsicosocial del paciente reumático puede ser tan grave que requiere de apoyo social asistencial (ASA). Objetivo: Conocer las repercuciones del ASA en pacientes reumáticos de un centro de tercer nivel. Diseño: Estudio descriptivo y transversal. Material y Métodos: Se estudiaron 84 pacientes referidos por reumatólogos para ASA de mayo de 1990 a agosto de 1993. Descripción del ASA: Se aplicó un estudio socioeconómico que evalúa datos generales, ingresos, condiciones de vivienda, de alimentación, relaciones familiares, actitud del paciente, costo del tratamiento, acceso a servicios de salud, incapacidad física y depresión. Se realizó un diagnóstico y en conjunto con el paciente se elaboró un plan de apoyo social. La entrevista tuvo una duración promedio de 30 minutos. Análisis: Se utilizó estadística descriptiva, X², t de Student y análisis multivariado para evaluar las características de aquellos con una respuesta adecuada. Reultados: De los 84 pacientes, 92 por ciento eran de clase socioeconómica baja; 38 por ciento tenían primaria incompleta; 87 por ciento se encontraban incapacitados parcialmente y el 43 por ciento mostró una mala actitud ante el problema. Un 63 por ciento requirió de apoyo económico cuyo costo promedio fue de N$ 4,894. El 65 por ciento resolvió su problema y en el análisis discriminante los factores que predecían éxito del programa de ASA fueron actitud, costo, incapacidad, residencia en el DF, condiciones de alimentación y vivienda, edad menor de 40 años y relaciones familiares adecuadas. Conclusiones: Es importante realizar una buena selección de candidatos para recibir ASA y lograr los mejores resultados. El procedimiento puede causar dependencia hacia el prestador del ASA

La calidad de la atención médica en el Servicio de Reumatología de un centro de tercer nivel vista a través de la satisfacción del paciente

La satisfacción del paciente con la atención médica recibida se debe considerar cuando se evalúa calidad de la atención. Objetivos: a) primario: conocer el grado de satisfacción del paciente con los diversos elementos involucrados en la consulta externa de reumatología de un centro de tercer nivel y b) secundarios: evaluar su relación con las siguientes variables: diagnóstico, capacidad funcional, escolaridad, depresión, tipo de médico (residente vs médico de base) y nivel socio-económico y diseñar estrategias para corregir los problemas que se identifiquen y un programa de seguimiento y evaluación periódicos: Diseño: estudio descriptivo y transversal. Material y métodos: Se aplicó un cuestionario a 220 pacientes al salir de su consulta médica habitual a través de un entrevistador entrenado. El instrumento evaluaba los diversos elementos que a nuestro juicio deben medirse en los diferentes servicios de nuestro departamento, las preguntas se contestaban en su mayoría en escalas visuales análogas de 0-10. Análisis: Se utilizó estadística descriptiva entre grupos se realizó con estadística no paramétrica; se consideró significativo un valor de alfa de 0.05 bimarginal sin ajuste para comparaciones múltiples. resultados: Se encontró en general que el grado de satisfacción con la atención recibida es alto pero significativamente menor para el servicio de recepción (p < 0.05). Los pacientes de menor escolaridad se encontraban más deprimidos, más satisfechos y conocían con menor frecuencia el nombre del médico y su diagnóstico (p < 0.05). Conslusiones: La satisfacción del paciente puede utilizarse para mejorar la calidad de la atención médica; debe fomentarse su detección y atender sugerencias