Consensus statement on a framework for the management of comorbidity and extra-articular manifestations in rheumatoid arthritis.

The objective of the study was to develop evidence-based and practical recommendations for the detection and management of comorbidity in patients with rheumatoid arthritis (RA) in daily practice. We used a modified RAND/UCLA methodology and systematic review (SR). The process map and specific recommendations, based on the SR, were established in discussion groups. A two round Delphi survey permitted (1) to prioritize the recommendations, (2) to refine them, and (3) to evaluate their agreement by a large group of users. The recommendations cover: (1) which comorbidities should be investigated in clinical practice at the first and following visits (including treatments, risk factors and patient's features that might interfere with RA management); (2) how and when should comorbidities and risk factors be investigated; (3) how to manage specific comorbidities, related or non-related to RA, including major adverse events of RA treatment, and to promote health (general and musculoskeletal health); and (4) specific recommendations to assure an integral care approach for RA patients with any comorbidity, such as health care models for chronic inflammatory patients, early arthritis units, relationships with primary care, specialized nursing care, and self-management. These recommendations are intended to guide rheumatologists, patients, and other stakeholders, on the early diagnosis and management of comorbidity in RA, in order to improve disease outcomes.

Anakinra induces complete remission of nephrotic syndrome in a patient with familial mediterranean fever and amyloidosis.

Renal amyloidosis is one of the most severe complications of familial Mediterranean fever (FMF). Colchicine has reduced the incidence of this complication, which now only appears in untreated, under-treated and resistant patients, but it is usually ineffective in patients with advanced amyloidosis. Here we report a patient with FMF and biopsy-proven amyloidosis who presented with nephrotic syndrome despite colchicine treatment. Anakinra (an interleukin-1ß inhibitor) was started and a dramatic complete remission of nephrotic syndrome was observed in the following months. Anakinra can be an effective treatment for FMF patients with severe secondary amyloidosis.

Good response to surgical treatment and mycophenolate in woman with inflammatory pseudotunor secondary to ANCA positive vasculitis.

We present the case of a young woman with ANCA positive vasculitis and infammatory pseudotumor as a granulomatous manifestation, who had a good response to surgical removal and mycophenolate mofetil.

Extra-articular disease in patients with spondyloarthritis. Baseline characteristics of the spondyloarthritis cohort of the AQUILES study.

OBJECTIVES: To describe the prevalence of extra-articular disease (uveitis, psoriasis and inflammatory bowel disease [IBD]), in a cohort of patients with spondyloarthritis (SpA). PATIENTS AND METHODS: AQUILES is an observational, prospective and multicentric study of three cohorts of patients with one of the following immune-mediated inflammatory diseases (IMID): SpA, psoriasis, or IBD. In the present cohort, patients ≥18 years of age with SpA were enrolled from Rheumatology clinics. The main objective was to assess the coexistence of these diseases and of uveitis, based on the patients' clinical history up to the study entry. RESULTS: A total of 601 patients with SpA (men: 63.1%; women: 36.9%) were enrolled. The specific diagnoses were: ankylosing spondylitis (55.1%), psoriatic arthritis (25.1%), undifferentiated spondyloarthritis (16.1%), enteropathic arthritis (2.5%), and others (1.3%). In 43.6% (95% CI: 39.7-47.6) of the patients, at least one of the three abovementioned diseases was encountered, predominantly psoriasis (prevalence 27.8%, 95% CI: 24.4-31.5), uveitis (13.6%, CI 95%: 11.1-16.6) and IBD (5.1%, 95% CI: 3.7-7.2). In patients with ankylosing spondylitis the proportion of other disease was 25.3% (IBD: 3.9%, psoriasis: 5.4%, uveitis: 19.0%) whilst it was 94.7% in psoriatic arthritis, due to the presence of psoriasis (94.0%). The coexistence of these diseases was associated with age, female gender and the presence of other extra-articular manifestations associated with SpA. CONCLUSIONS: Extra-articular disease in patients with SpA is common and, in this study, it was associated to age, female gender and the presence of other SpA-related extra-articular manifestations.

Cumulative gender disadvantage in contract employment.

Women's wages do not grow with experience or tenure as much as men's do. Many accounts of this cumulative gender disadvantage attribute it to women's underinvestment in firm-specific skills. Yet if that were true, this disadvantage would not exist where firm-specific skills are not rewarded by the labor market. This article investigates this argument in the context of contract employment, where demand for firm specificity is minimal. Contrary to expectations, men still receive higher rewards than women over time. Drawing on quantitative evidence and qualitative fieldwork using job histories of high-skill contractors affiliated with a staffing firm, the author finds support for two sources of women's disadvantage: lower rates of movement across clients on the supply side and unmeasured demand-side factors by which similar levels of tenure and client transitions accrue lower rewards to women. Implications for research on gender stratification and career advancement in non-formalized labor markets are discussed.

Multiple avascular necrosis of bone and polyarticular septic arthritis in patients with systemic lupus erythematosus.

OBJECTIVE: Avascular necrosis of bone (AVN) and osteoarticular infection share similar risk factors in systemic lupus erythematosus (SLE) patients. However, their coincidental development in SLE has rarely been described. We describe four cases of AVN complicated by Staphylococcus aureus infection in SLE. METHODS: Patients were identified by retrospectively reviewing an SLE cohort followed between 1979 and 2003. A review of the literature from 1960 until 2003 was also done. RESULTS: Among 315 SLE patients, four developed joint infection by S. aureus following or coincidentally with AVN. All presented multifocal disease with severe or relapsing course, resulting in severe incapacity. The clinical course suggests that AVN developed first in active SLE patients with positive antiphospholipid (aPL) antibodies treated with high-dose corticosteroids (CS), and subsequent bone infarcts favor infection. Our patients often required prolonged antibiotic therapy and surgical treatment. CONCLUSIONS: Active SLE patients with aPL antibodies on high-dose CS seem at high risk of developing multiple AVN complicated by infection. Avascular necrosis and bone or joint infection by S. aureus in these patients is a major complication that leads to severe joint destruction and disability.

Mycophenolate mofetil induced myopathy in a patient with lupus nephritis.

We describe a case of mycophenolate mofetil (MMF) induced myopathy in a patient with lupus nephritis. Two months after starting MMF treatment she developed asthenia, lower limb weakness, and abnormal increase of muscle enzymes. An electromyogram showed a myogenic pattern with small polyphasic discharges without neurogenic signs involving proximal muscles of lower limbs. Muscle biopsy revealed the presence of fibers of variable size with irregular sarcoplasmic basophilic areas. Using oxidative enzyme techniques, many type I fibers showed a moth-eaten appearance resembling minicores. The ultrastructural findings consisted of myofibrillary lesions with multiple small foci of Z-band streaming. MMF withdrawal was followed by complete clinical and enzymatic recovery.