Frecuencia de eventos cardiovasculares en pacientes con lupus eritematoso sistémico / Frequency of cardiovascular events in patients with systemic lupus erythematosus

Resumen Introducción: el progreso en los tratamientos para el lupus eritematoso sistémico (LES) resultó en una disminución de la mortalidad; sin embargo, la enfermedad cardiovascular y las complicaciones infecciosas aún son las principales causas de muerte. La evidencia apoya la participación del sistema inmunológico en la generación de la placa aterosclerótica, así como su conexión con las enfermedades autoinmunes. Objetivos: describir la frecuencia de eventos cardiovasculares (ECV) en el Registro de Lupus Eritematoso Sistémico de la Sociedad Argentina de Reumatología (RELESSAR) transversal, así como sus principales factores de riesgo asociados. Materiales y métodos: estudio descriptivo y transversal para el cual se tomaron los pacientes ingresados en el registro RELESSAR transversal. Se describieron las variables sociodemográficas y clínicas, las comorbilidades, score de actividad y daño. ECV se definió como la presencia de al menos una de las siguientes patologías: enfermedad arterial periférica, cardiopatía isquémica o accidente cerebrovascular. El evento clasificado para el análisis fue aquel posterior al diagnóstico del LES. Se conformaron dos grupos macheados por edad y sexo 1:2. Resultados: 1515 pacientes mayores de 18 años participaron del registro. Se describieron 80 pacientes con ECV (5,3%). En este análisis se incluyeron 240 pacientes conformando dos grupos. La edad media fue de 47,8 (14,4) y 47,6 (14,2) en el grupo con y sin ECV respectivamente. Los pacientes con ECV tuvieron mayor duración del LES en meses, mayor índice de Charlson, mayor SLICC (Systemic Lupus International Collaborating Clinics/American College of Rheumatology), mayor frecuencia de manifestaciones neurológicas, síndrome antifosfolípido, hospitalizaciones y uso de ciclofosfamida. Las únicas variables asociadas en el análisis multivariado fueron el índice de Charlson (p=0,004) y el SLICC (p<0,001). Conclusiones: los ECV influyen significativamente en nuestros pacientes, y se asocian a mayor posibilidad de daño irreversible y comorbilidades.

Abstract Introduction: progress in treatments for systemic lupus erythematosus (SLE) has resulted in a decrease in mortality; however, cardiovascular and infectious diseases remain the leading causes of death. Evidence supports the involvement of the immune system in the generation of atherosclerotic plaque, as well as its connection to autoimmune diseases. Objectives: to describe the frequency of cardiovascular disease (CVD) in the cross-sectional RELESSAR registry, as well as its associated variables. Materials and methods: a descriptive and cross-sectional study was performed using patients admitted to the cross-sectional RELESSAR registry. Sociodemographic variables, clinical variables, comorbidities, activity and damage scores were described. CVD was defined as at least one of the following: peripheral arterial disease, ischemic heart disease, or cerebrovascular accident. All patients with at least one CVD were included in our analysis (heart attack, central nervous system vascular disease, and peripheral arteries atherosclerotic disease). The event classified for the analysis was that after the diagnosis of SLE. SLE diagnosis was previous to CVD. Two groups matched by age and sex, 1:2 were formed. Results: a total of 1515 patients older than 18 years participated in the registry. Eighty patients with CVD (5.3%) were described in the registry. Two-hundred and forty patients were included, according to two groups. The mean age was 47.8 (SD 14.4) and 47.6 (SD 14.2) in patients with and without CVD, respectively. Patients with CVD had a longer duration of SLE in months, a higher Charlson index, a higher SLICC, increased frequency of neurological manifestations, antiphospholipid syndrome, hospitalizations, and use of cyclophosphamide. The associated variables in the multivariate were the Charlson Index (p=0.004) and the SLICC (p<0.001). Conclusions: CVDs have a significant influence on our patients, being associated with a greater possibility of damage and comorbidities.

Multicenter lupus register from Argentina, the RELESSAR database: Influence of ethnicity on disease phenotype.

OBJECTIVE: The objective is to describe the main characteristics of patients with systemic lupus erythematosus (SLE) in Argentina and to examine the influence of ethnicity on the expression of the disease. PATIENTS AND METHODS: RELESSAR is a multicentre register carried out by 106 researchers from 67 rheumatologic Argentine centres. It is a cross-sectional study of SLE (1982/1997 ACR) patients. RELESSAR electronic database includes demographic, cumulative SLE manifestations, SELENA-SLEDAI, SLICC-SDI, Katz's severity and Charlson's comorbidity indexes and treatment patterns. RESULTS: We included 1,610 patients, 91.7% were female with a median age at diagnosis of 28.1 ± 12.8; 96.2% met ≥4 ACR 1982/97 criteria. Frequent manifestations were arthritis (83.5%), malar rash (79.5%), photosensitivity (75.3%), haematological (63.8%) and renal disease (47.4%), antinuclear antibodies (96%), anti-dsDNA (66.5%) and anti-Smith antibodies (29%). The mean Selena-SLEDAI score at last visit was 3.18 (SD 4.3) and mean SDI was 1 (SD 1.3). The accumulated treatments most frequently used were antimalarials (90.4%), corticosteroids (90%), azathioprine (31.8%), intravenous cyclophosphamide (30.2%), mycophenolate mofetil or mycophenolic acid (24.5%), methotrexate (19.3%), belimumab 5.3% and rituximab 5.1%. Refractory lupus was diagnosed in 9.3% of the cases. The main causes of death were lupus activity (25.0%), activity and concomitant infections (25.0%), infections (18.2%), vascular disease (13.6%) and cancer (4.5%). Mortality was associated with higher SLEDAI, Katz, damage indexes and comorbidities. Of the 1610 patients included, 44.6% were Caucasian, 44.5% Mestizo, 8.1% Amerindian and 1.2% Afro-Latin American. Mestizo patients had higher male representation, low socioeconomic status, more inadequate medical coverage, fewer formal years of education and shorter disease duration. Polyadenopathies and Raynaud's phenomenon were more frequent in Caucasians. In the logistic regression analysis higher damage index (OR 1.28, CI 95% 1.02-1.61, p = 0.03) remained associated to mestizo ethnicity. CONCLUSIONS: This study represents the largest number of adult patients with SLE studied in Argentina. Caucasian patients were differentiated by having Raynaud's phenomenon and polyadenopathy more frequently, while patients of Mestizo origin had higher damage indexes.

Lupus en Argentina. Pacientes no respondedores al tratamiento estándar y belimumab como posible opción. Datos del registro RELESSAR / Lupus in Argentina. Non-responders to standard treatment and belimumab as a possible option. RELESSAR record data

Introducción: el lupus es una enfermedad compleja y varias veces de difícil abordaje. Alcanzar la remisión es uno de los objetivos, incorporando opciones terapéuticas. Objetivos: describir las características generales de los pacientes según el estado de la enfermedad y el uso de belimumab. Materiales y métodos: estudio de corte transversal, registro RELESSAR. Se definió el estado de la enfermedad como: remisión: SLEDAI=0 y sin corticoides; baja actividad de la enfermedad: SLEDAI >0 y ≤4 y sin corticoides; control no óptimo: SLEDAI >4 y cualquier dosis de corticoides. Resultados: se incluyeron 1.277 pacientes, 23,4% en remisión, 12,6% en baja actividad y 63,8% con control no óptimo. En este último grupo eran más jóvenes y con menor duración de la enfermedad; presentaban mayores índices de actividad y cronicidad, y mayor empleo de inmunosupresores. Solo el 22,3% de los pacientes con criterio potencial de uso de belimumab (lupus eritematoso sistémico activo a pesar del tratamiento estándar) lo recibía en ese momento. Las variables asociadas a hospitalizaciones fueron: terapia con corticoides, ciclofosfamida y mayor SLICC. Conclusiones: se refleja la complejidad del manejo de estos pacientes y se visualizan aspectos estructurales como la desigualdad. El uso del belimumab resultaría beneficioso en los pacientes seleccionados.

Introduction: lupus is a complex disease and often difficult to approach. Achieving remission is one of the objectives, incorporating therapeutic options. Objectives: to describe the characteristics of the patients and the use of belimumab, according to the status of the disease. Materials and methods: cross-sectional study. Patients of the RELESSAR registry. Stratification: Remission: SLEDAI=0 and without corticosteroids. Low disease activity SLEDAI> 0 and ≤4 and without corticosteroids and non-optimal control: SLEDAI> 4 and any dose of corticosteroids. Results: a total of 1,277 patients were included, 23.4% in remission, 12.6% in low disease activity and 63.8% in non-optimal control. The last group was younger and had a shorter duration of the disease. They had higher activity and chronicity indices and greater use of immunosuppressants. Only 22.3% of the patients with potential criteria for the use of belimumab (activity disease despite standard treatment) were receiving it. The variables associated with hospitalizations were: corticosteroids, cyclophosphamide and higher SLICC. Those associated with severe infection: mycophenolate mofetil, azathioprine, corticosteroids, and higher SLICC. Conclusions: the complexity of the management of these patients is reflected, visualizing structural aspects such as inequality. The use of belimumab could be beneficial in selected patients.

Lupus en Argentina. Pacientes no respondedores al tratamiento estándar y belimumab como posible opción. Datos del registro RELESSAR / Lupus in Argentina. Non-responders to standard treatment and belimumab as a possible option. RELESSAR record data

Introducción: el lupus es una enfermedad compleja y varias veces de difícil abordaje. Alcanzar la remisión es uno de los objetivos, incorporando opciones terapéuticas. Objetivos: describir las características generales de los pacientes según el estado de la enfermedad y el uso de belimumab. Materiales y métodos: estudio de corte transversal, registro RELESSAR. Se definió el estado de la enfermedad como: remisión: SLEDAI=0 y sin corticoides; baja actividad de la enfermedad: SLEDAI >0 y ≤4 y sin corticoides; control no óptimo: SLEDAI >4 y cualquier dosis de corticoides. Resultados: se incluyeron 1.277 pacientes, 23,4% en remisión, 12,6% en baja actividad y 63,8% con control no óptimo. En este último grupo eran más jóvenes y con menor duración de la enfermedad; presentaban mayores índices de actividad y cronicidad, y mayor empleo de inmunosupresores. Solo el 22,3% de los pacientes con criterio potencial de uso de belimumab (lupus eritematoso sistémico activo a pesar del tratamiento estándar) lo recibía en ese momento. Las variables asociadas a hospitalizaciones fueron: terapia con corticoides, ciclofosfamida y mayor SLICC. Conclusiones: se refleja la complejidad del manejo de estos pacientes y se visualizan aspectos estructurales como la desigualdad. El uso del belimumab resultaría beneficioso en los pacientes seleccionados.

Introduction: lupus is a complex disease and often difficult to approach. Achieving remission is one of the objectives, incorporating therapeutic options. Objectives: to describe the characteristics of the patients and the use of belimumab, according to the status of the disease. Materials and methods: cross-sectional study. Patients of the RELESSAR registry. Stratification: Remission: SLEDAI=0 and without corticosteroids. Low disease activity SLEDAI> 0 and ≤4 and without corticosteroids and non-optimal control: SLEDAI> 4 and any dose of corticosteroids. Results: a total of 1,277 patients were included, 23.4% in remission, 12.6% in low disease activity and 63.8% in non-optimal control. The last group was younger and had a shorter duration of the disease. They had higher activity and chronicity indices and greater use of immunosuppressants. Only 22.3% of the patients with potential criteria for the use of belimumab (activity disease despite standard treatment) were receiving it. The variables associated with hospitalizations were: corticosteroids, cyclophosphamide and higher SLICC. Those associated with severe infection: mycophenolate mofetil, azathioprine, corticosteroids, and higher SLICC. Conclusions: the complexity of the management of these patients is reflected, visualizing structural aspects such as inequality. The use of belimumab could be beneficial in selected patients.

Asociación entre Artritis Reumatoidea y otras enfermedades autoinmunes / Association between Rheumatoid Arthritis and other autoimmune diseases

Objetivos: Determinar la frecuencia de enfermedades autoinmunes (EAI) en pacientes con Artritis Reumatoidea (AR) y comparar la frecuencia de EAI entre pacientes con AR y sin AR ni otra EAI reumatológica. Material y Métodos: Estudio multicéntrico, observacional, analítico, retrospectivo. Se incluyeron pacientes consecutivos con AR (ACR/EULAR 2010) y como grupo control pacientes con diagnóstico inicial de Osteoartritis primaria (OA). Resultados: Se incluyeron 1549 pacientes: 831 con AR (84% mujeres, edad media 55.2 años [DE 13.6]) y 718 con OA (82% mujeres, edad media 67 años [DE 11.1]). La frecuencia de EAI en el grupo AR fue del 22% (n=183). Estos presentaron mayor frecuencia de EAI reumatológicas (9.4 vs 3.3%, p< 0.001), y menor frecuencia de EAI no reumatológicas que aquellos con OA (15.3 vs 20.5, p=0.007). La EAI reumatológica más prevalente fue el Síndrome de Sjögren, el cual fue más frecuente en el grupo AR (87.2 vs 29.2%, p< 0,001). La frecuencia de EAI reumatológicas en los pacientes con AR fue mayor en la forma erosiva (11 vs 6.8%, p=0.048). Conclusión: La frecuencia de EAI en los pacientes con AR fue del 22%, en quienes predominaron las de etiología reumatológica mientras que, las no reumatológicas predominaron en pacientes con OA.

Objectives: To determine the frequency of autoimmune diseases (AID) in Rheumatoid Arthritis (RA) patients and to compare this frequency between patients with and without RA or other rheumatologic AID. Methods: Multicenter, observational, analytical, retrospective study. Consecutive patients with diagnosis of RA (ACR/EULAR 2010) were included. Patients with initial diagnosis of primary ostearthritis (OA) were used as control group. Results: A total of 1549 patients were included: 831 RA (84% women, mean age 55.2 [±13.6]) and 718 OA (82% women, mean age 67 [± 11.1]). The frequency of AID in the RA group was 22% (n=183). RA patients showed higher frequency of rheumatologic AID (9.4 vs 3.3%, p< 0.001), and lower frequency of non-rheumatologic AID than OA patients (15.3 vs 20.5%, p= 0.007). The most prevalent rheumatic AID was Sjögren's Syndrome, which was more frequent in the AR group (87.2 vs 29.2%, p<0.001). The frequency of rheumatologic AID in RA patients was higher in those with erosive RA (11 vs 6.8%, p=0.048). Conclusion: The frequency of AID in RA patients was 22%. Rheumatologic AID were more frequent in RA patients, whereas non-rheumatologic AID prevailed in OA patients.

Métodos de diagnóstico en el estudio de las Miopatías Inflamatorias Autoinmunes: Datos del Registro Argentino de Miopatías Inflamatorias de la Sociedad Argentina de Reumatología / Diagnostic methods in the study of Inflammatory Myopathies. Data from the Argentine Register: Argentine Rheumatology Society

Las Miopatías Inflamatorias Autoinmunes (MI) comprenden un grupo de enfermedades heterogéneas con presentación y características clínicas variables. Se distinguen subtipos clínicos como Polimiositis (PM), Dermatomiositis (DM), Miositis por cuerpos de Inclusión (MCI), Miopatía Necrotizante Inmunomediada (MNIM), Miositis de los Síndromes de Superposición, formas juveniles de MI (DMJ), Síndrome Antisintetasa (SAS) y Miopatía Asociada a Cáncer (MAC). La presencia de anticuerpos séricos y el infiltrado inflamatorio en la biopsia de músculo sugiere que se trata de una condición autoinmune. Realizar el diagnóstico de las MI suele ser un desafío y las herramientas diagnósticas no siempre están disponibles en la práctica diaria. Se obtuvo información sobre la disponibilidad de estos métodos del Registro Argentino de Miopatías Inflamatorias. El estudio de enzimas musculares, Anticuerpos Antinucleares (ANA), anticuerpo anti-Jo-1 y la tomografía computada de tórax, estuvieron disponibles para la mayoría de los pacientes mientras que la Resonancia Magnética de musculo (RM), el estudio de difusión de monóxido de carbono (DLco) y la biopsia muscular se realizaron en menos del 50% de los casos. La determinación de otros anticuerpos específicos de miositis, de importancia en el diagnóstico y pronóstico de la enfermedad se realizó, en mayor parte, a través de un subsidio de la SAR.

The Idiopathic Inflammatory Myopathies (IIM) comprise a heterogeneous group of acquired muscle diseases classified as polymyositis (PM), dermatomyositis (DM), Inclusion Body Myositis (IBM), Immuno Mediated Necrotizing Myopathies (IMNM), Overlap Myositis (OM), juvenile myositis, Antisynthethase Syndrome (ASS) and cancer related myositis (CAM). The presence of myositis specific antibodies in the serum and autoantibodies against target antigens and inflammatory infiltrates in muscle tissue suggests the autoimmune condition of the disease. The diagnosis of inflammatory myopathies is often a challenge and the disposal of diagnostic tools are not always available in daily practice. Information on the accessibility of these methods was obtained from the Argentine Register of Myopathies. The study of muscle enzymes, ANA, anti-Jo-1 antibodies and chest tomography were easy to get to most patients while muscle MRI, lung diffusion capacity for carbon monoxide (DLco) and muscle biopsy were performed in less than 50% of cases. Other myositis specific antibodies, necessary for disease diagnosis and prognosis, were mostly done through a subsidy from the Argentine Rheumatology Society.

Métodos de diagnóstico en el estudio de las Miopatías Inflamatorias Autoinmunes: Datos del Registro Argentino de Miopatías Inflamatorias de la Sociedad Argentina de Reumatología / Diagnostic methods in the study of myopathies Inflammatory Autoimmune: Data from the Argentine Registry of Inflammatory Myopathies of the Argentine Society of Rheumatology

Las Miopatías Inflamatorias Autoinmunes (MI) comprenden un grupo de enfermedades heterogéneas con presentación y características clínicas variables. Se distinguen subtipos clínicos como Polimiositis (PM), Dermatomiositis (DM), Miositis por cuerpos de Inclusión (MCI), Miopatía Necrotizante Inmunomediada (MNIM), Miositis de los Síndromes de Superposición, formas juveniles de MI (DMJ), Síndrome Antisintetasa (SAS) y Miopatía Asociada a Cáncer (MAC).La presencia de anticuerpos séricos y el infiltrado inflamatorio en la biopsia de músculo sugiere que se trata de una condición autoinmune. Realizar el diagnóstico de las MI suele ser un desafío y las herramientas diagnósticas no siempre están disponibles en la práctica diaria. Se obtuvo información sobre la disponibilidad de estos métodos del Registro Argentino de Miopatías Inflamatorias. El estudio de enzimas musculares, Anticuerpos Antinucleares (ANA), anticuerpo anti-Jo-1 y la tomografía computada de tórax, estuvieron disponibles para la mayoría de los pacientes mientras que la Resonancia Magnética de musculo (RM), el estudio de difusión de monóxido de carbono (DLco) y la biopsia muscular se realizaron en menos del 50% de los casos. La determinación de otros anticuerpos específicos de miositis, de importancia en el diagnóstico y pronóstico de la enfermedad se realizó, en mayor parte, a través de un subsidio de la SAR.

The Idiopathic Inflammatory Myopathies (IIM) comprise a heterogeneous group of acquired muscle diseases classified as polymyositis (PM), dermatomyositis (DM), Inclusion Body Myositis(IBM), ImmunoMediated Necrotizing Myopathies, (IMNM), Overlap Myositis(OM), juvenile myositis, Antisynthethase Syndrome (ASS) and cancer related myositis(CAM).The presence of myositis specific antibodies in the serum and autoantibodies against target antigens and inflammatory infiltrates in muscle tissue suggests the autoimmune condition of the disease. The diagnosis of inflammatory myopathies is often a challenge and the disposal of diagnostic tools are not always available in daily practice. Information on the accessibility of these methods was obtained from the Argentine Register of Myopathies. The study of muscle enzymes, ANA, anti-Jo-1 antibodies and chest tomography were easy to get to most patients while muscle MRI, lung diffusion capacity for carbon monoxide (DLco%) and muscle biopsy were performed in less than 50% of cases. Other myositis specific antibodies, necessary for disease diagnosis and prognosis, were mostly done through a subsidy from the Argentine Rheumatology Society.

Nivel de estrés, medido a través de la Escala de Estrés Percibido (EEP-10), y su asociación con la actividad de la enfermedad en pacientes con Artritis Reumatoidea / Stress level, measured through Perceived Stress Scale (PSS-10), and it's association with disease activity in patients with Rheumatoid Arthritis

El estrés es un factor de riesgo en la patogénesis de las enfermedades reumáticas autoinmunes. Objetivo: Evaluar la asociación entre la actividad de la enfermedad en pacientes con artritis reumatoidea y estrés. Secundarios: Evaluar la asociación de los niveles de estrés percibido con otros índices de actividad, así como también con discapacidad, ansiedad y depresión y calidad de vida. Material y métodos: Se incluyeron pacientes consecutivos, mayores de 18 años, con diagnóstico de AR (ACR 1987 y/o ACR/EULAR 2010). Se consignaron datos sociodemográficos, características de la enfermedad, parámetros de laboratorio y tratamiento actual. Resultados: Se incluyeron 45 pacientes, edad 48 (DE 11) años. Factor reumatoide + 96%, ACPA + 90%. El 26% de los pacientes presentó Remisión/Baja actividad (R/BA) por RAPID3 (2.6±2) VS 74% con moderada/alta actividad (MA/AA) (15±4). Análisis comparativo entre ambos grupos según nivel de estrés percibido: EEP-10 13±6 (RAPID3 R/BA) VS EEP-10 18±6 (RAPID3 MA/AA) (p=0.02). La EEP-10 presentó correlación con ansiedad (HAD-A) (r=0.7, p<0.001), depresión (HAD-D) (r=0.7, p<0.001), con calidad de vida (EQ5D) (r=-0.36, p=0.02) y con discapacidad funcional (HAQ-A) (r=0.55, p=0.001). Conclusión: Los pacientes con AR con elevada actividad de la enfermedad evaluados por RAPID3, DAS28 e IAS presentaron mayores niveles de estrés percibido con respecto a los pacientes con remisión o baja actividad.

Stress is a risk factor in the pathogenesis of autoimmune rheumatic diseases. Objective: To evaluate the association between disease activity in patients with RA. Secondary: To evaluate the association of perceived stress levels with other activity indexes (SDAI, CDAI, DAS28 and IAS) as well as with disability, anxiety and depression and quality of life. Material and methods: Patients consecutive, older than 18 years, with diagnosis of RA (ACR 1987 and / or ACR / EULAR 2010) were included. Sociodemographic data, characteristics of the disease, laboratory parameters and current treatment were recorded. The patients completed: SSP-10, HAQ-A, HAD, EQ-5D, RAPID3, VAS Pain and PGA, the physicians calculated DAS28, IAS, CDAI, SDAI and completed PGA. Results: Forty-five patients with an average age of 48 (SD 11) years were included. Rheumatoid factor + 96%, ACPA + 90%. Twenty six percent of the patients had Remission/Low activity (R/LA) by RAPID3 (2.6 ± 2) VS 74% with Moderate / High Activity (MA/HA) (15 ± 4).Comparative analysis between both groups according to perceived stress scale: PSS-10 13±6 (RAPID3 R/LA) Vs PSS-1018±6 (RAPID3 MA/HA) (p=0.02). The same happened when comparing DAS28 and IAS, where there was a significant difference according to PSS-10. The PSS-10 presented correlation with anxiety (HAD-A) (r=0.7, p<0.001), depression (HAD-D) (r=0.7, p<0.001), with quality of life (EQ5D) (r=- 0.36, p=0.02) and with functional disability (HAQ-A) (r=0.55, p=0.001). Conclusion: Patients with RA with high disease activity evaluated by RAPID3, DAS28 and IAS presented higher levels of perceived stress with respect to patients with remission or low activity

Estenosis de las arterias cubital y radial en pacientes con esclerosis sistémica, comparado con un grupo control / Ulnar and radial stenosis in systemic sclerosis

Objetivos: describir la frecuencia de estenosis arterial (cubital y radial) en pa-cientes con esclerosis sistémica (ES); analizar la relación entre estenosis macro-vascular y úlceras digitales. Método: se incluyeron 57 pacientes con ES, según la clasificación del Colegio Americano de Reumatología de 1980 y 21 pacientes sin ES. Se realizó ecografía doppler arterial de miembros superiores. Resultados: la estenosis en al menos una arteria cubital se objetivó en 31% de pacientes con ES (18/57) (p=0.003). Se objetivó estenosis radial en 9 de 57 pacientes con ES (15%) y en uno de los 21 controles (p=0.19). En el modelo multivariado, los predicto-res de úlceras digitales fueron inicio de Raynaud antes de los 40 años (OR 5.3 IC95% 1.54-18.22, p=0.008) y patrón tardío en la capilaroscopia (OR 4.4 IC95% 1.29-15.63, p=0.018). Conclusiones: un tercio de los pacientes ES presentó este-nosis cubital. El compromiso de los grandes vasos no se asoció a úlceras digitales.

Objectives: to describe the frequency of ulnar and radial stenosis in SSc patients. Analyze the correlation between arterial stenosis and digital ulcers. Methods: we included 57 SSc consecutive patients who fulfilled ACR 1980 classification criteria, and 21 healthy controls. An arterial ecodoppler was performed to all participants. Results: the presence of stenosis in at least one ulnar artery was observed in 18 of 57 patients with SSc (31%) and in none of the 21 controls (p=0.003). Stenosis was present in at least one radial artery in 9 of 57 SSc patients (15%) (p=0.19). In multivariate model, the best predictors of digital ulcers were age at onset of Ray-naud phenomenon before 40 years (OR 5.3 95%CI 1.54-18.22, p=0.008) and late SD pattern (OR 4.4 95%CI 1.29-15.63, p=0.018). Conclusion: in the present series, ulnar stenosis was observed frequently in SSc patients. Stenosis of large vessels was not associated with digital ulcers.

Safety of Tofacitinib in the Treatment of Rheumatoid Arthritis in Latin America Compared With the Rest of the World Population.

OBJECTIVE: Rheumatoid arthritis (RA) is a chronic, autoimmune disease characterized by joint destruction. Tofacitinib is an oral Janus kinase inhibitor for the treatment of RA. This post hoc analysis assessed the safety of tofacitinib in Latin American (LA) patients with RA versus the Rest of World (RoW) population. METHODS: Data were pooled from 14 clinical studies of tofacitinib: six Phase 2, six Phase 3 and two long-term extension studies. Incidence rates (IRs; patients with events/100 patient-years of treatment exposure) were calculated for safety events of special interest combined across tofacitinib doses. 95% confidence intervals (CI) for IRs were calculated using the maximum likelihood method. Descriptive comparisons were made between LA and RoW (excluding LA) populations. RESULTS: This analysis included data from 984 LA patients and 4687 RoW patients. IRs for safety events of special interest were generally similar between LA and RoW populations, with overlapping 95% CIs. IRs for discontinuation due to adverse events, serious infections, tuberculosis, all herpes zoster (HZ), serious HZ, malignancies (excluding non-melanoma skin cancer) and major adverse cardiovascular events were numerically lower for LA versus RoW patients; IR for mortality was numerically higher. No lymphoma was reported in the LA population versus eight cases in the RoW population. Exposure (extent and length) was lower in the LA population (2148.33 patient-years [mean = 2.18 years]) versus RoW (10515.68 patient-years [mean = 2.24 years]). CONCLUSION: This analysis of pooled data from clinical studies of tofacitinib in patients with RA demonstrates that tofacitinib has a consistent safety profile across LA and RoW patient populations.

Effects of cigarette smoking on early arthritis: a cross-sectional study-data from the Argentine Consortium for Early Arthritis (CONAART).

Our objective was to analyze the effects of cigarette smoking on disease activity, functional capacity, radiographic damage, serology and presence of extraarticular manifestations in patients with rheumatoid arthritis and undifferentiated arthritis. This is a cross-sectional study of 1,305 patients (729 with rheumatoid arthritis and 576 with undifferentiated arthritis) from CONAART, the Argentine Consortium for Early Arthritis that includes patients older than 16 years with <2 years of disease. Sociodemographic data, clinical characteristics of the disease and smoking history were collected. In patients with rheumatoid arthritis the disease activity score of 28 joints was 5.4 ± 1.3 in current smokers, 5.2 ± 1.4 in former smokers and 5.1 ± 1.4 in never smokers (p = 0.011). The simple erosion narrowing score was higher in current smokers and former smokers than in never smokers (M 14.0, R Q 6.0-21.0; M 15.0, R Q 7.0-24.0; M 10.0, R Q 5.0-17.0; p = 0.006). Current smokers had higher rheumatoid factor titer (M 160.0, R Q 80.0-341.0) than former smokers (M 146.8, R Q 6.03-255.5) and never smokers (M 15.0, R Q 9.0-80.0) (p = 0.004). The variable independently associated with tobacco exposure was simple erosion narrowing score (OR = 1.03, 95 % CI 1.00-1.05; p = 0.012). In patients with undifferentiated arthritis, an association between smoking status and parameters of activity or radiographic damage was not observed. Neither was tobacco exposure related to the presence of extraarticular manifestations or to the degree of disability in any of the two groups of patients. No relation was found between disease activity and severity, and number of packs smoked per year. Tobacco.

Adherencia al tratamiento de pacientes con artritis reumatoidea que reciben medicamentos biológicos / Treatment adherence in patients with rheumatoid arthritis receiving biologics

Introducción: Al igual que en otras enfermedades crónicas, la adherencia al régimen terapéutico de los pacientes con artritis reumatoidea (AR) es baja (entre 30 y 80%), dependiendo de la definición de adherencia y de la metodología empleada para medirla. En este estudio se propone determinar el nivel de adherencia al tratamiento en pacientes con AR que reciben DMAR biológicas e identificar factores asociados a la falta de cumplimiento a la terapia. Material y métodos: Se realizó un estudio analítico, observacional de corte transversal en donde se incluyeron pacientes consecutivos con AR según criterios de clasificación (ACR’87) que se encontraban recibiendo fármacos biológicos para el tratamiento de su enfermedad en los últimos seis meses y que asistieron a la consulta ambulatoria. Para la valoración de la adherencia a DMAR se utilizaron los cuestionarios CQR (Compliance Questionnaire on Rheumatology) y el cuestionario SMAQ (Simplified Medication Adherence Questionnaire). Resultados: Se encuestaron 345 pacientes. Mediante el cuestionario SMAQ se observó una adherencia del 50% (159 pacientes). El Cuestionario CQR tuvo un puntaje mediano de 78 puntos (RIC 67-86). El 47% (147 pacientes) fueron adherentes (CQR >80). Sobre los pacientes incluidos, 151 (48%) refirieron no haber tenido ningún retraso, pérdida o adelanto de la dosis del biológico en los últimos 6 meses de tratamiento. El 52% no adherentes tuvo como causas: 146 (46%) pérdida de al menos una dosis del biológico con una mediana de dosis perdidas de 2 (RIQ: 1-3); 117 (37%) tuvo al menos un retraso en las dosis del biológico y 8 (2%) delantó la dosis. Los factores asociados al no cumplimiento de la terapia biológica fueron el tipo de cobertura médica, que el paciente no haya notado mejoría y la esperanza de una rápida respuesta al tratamiento, y la falta de adherencia a DMAR

Introduction: As in other chronic diseases, adherence to the therapeutic regimen of patients with rheumatoid arthritis (RA) is low (between 30 and 80%), depending on the definition of adherence and the methodology used to measure it. This study aims to determine the level of adherence to treatment in patients with RA who receive biological DMARs and to identify factors associated with non-compliance with therapy. MATERIAL AND METHODS: An observational, cross-sectional, observational study was performed in which consecutive patients with RA according to classification criteria (ACR'87) who were receiving biological drugs for the treatment of their disease in the last six months were included Attended the outpatient appointment. The CQR (Compliance Questionnaire on Rheumatology) and SMAQ (Simplified Medication Adherence Questionnaire) questionnaires were used to assess adherence to DMAR. Results: A total of 345 patients were surveyed. A 50% adherence (159 patients) was observed through the SMAQ questionnaire. The CQR Questionnaire had a median score of 78 points (RIC 67-86). 47% (147 patients) were adherent (CQR> 80). Regarding the patients included, 151 (48%) reported not having had any delay, loss or advancement of the biological dose in the last 6 months of treatment. The 52% of non-adherents had as causes: 146 (46%) loss of at least one dose of the biological with a median of doses lost of 2 (RIQ: 1-3); 117 (37%) had at least one biological dose delay and 8 (2%) delayed the dose. Factors associated with non-compliance with biological therapy were the type of medical coverage, the patient's perceived improvement and the expectation of a rapid response to treatment, and lack of adherence to DMAR.

Utilidad del ultrasonido en osteoartritis: un enfoque de su rol diagnóstico y de monitoreo / Ultrasound in osteoarthritis: its role in the diagnosis and the disease monitoring

Ultrasonography (US) has been steadily and progressively gaining ground in the diagnostic approach to different areas of Rheumatology due to a combination of factors ranging from its low cost and portability, advantages related to the characteristics of the method, as the absence of ionizing radiation, the possibility of multiplanar imaging, high resolution real time and dynamic maneuvers to assess musculoskeletal structures with maximum functionality. Its specific role in osteoarthritis (OA) has allowed a detailed evaluation of the degenerative process, quantification of early or pre-radiological OA stages. The superb resolution of high power ultrasound probes can identify minimum alterations in the articular cartilage, bone tissue and other anatomical elements that contribute to OA. The aim of this review is to describe the major ultrasound findings in OA, and its usefulness as a diagnostic and monitoring disease progression in this rheumatic disease.

La ultrasonografía (US) viene ganando espacios, de manera continua y progresiva, en el abordaje diagnóstico de distintas áreas de la Medicina debido a una suma de factores que van desde su bajo costo y su portabilidad hasta ventajas relacionadas con las características propias del método, como la ausencia de radiación ionizante, la posibilidad de obtención de imágenes multiplanares de alta resolución en tiempo real, y de realizar maniobras dinámicas que permiten evaluar las estructuras en su máxima funcionalidad. Su específico rol en la evaluación de la osteoartritis se va afirmando a medida que se van generando métodos de evaluación que permiten una detallada cuantificación del proceso degenerativo, inclusive en las fases precoces o prerradiológicas. El magnífico poder de resolución de las sondas de última generación permite individualizar alteraciones mínimas de los elementos anatómicos frecuentemente comprometidos en la osteoartritis, como el cartílago articular y el tejido óseo. El objetivo de esta revisión es el de describir los hallazgos ultrasonográficos en osteoartritis, y su utilidad como herramienta diagnóstica y de seguimiento.

Comparison of the clinical expression of patients with ankylosing spondylitis from Europe and Latin America.

OBJECTIVE: To compare the clinical, demographic, and serologic characteristics and the treatment of patients diagnosed with ankylosing spondylitis (AS) from Europe (EU) and Latin America (LA). METHODS: We included 3439 patients from national registries: the Spanish Registry of Spondyloarthritis (REGISPONSER), the Belgian registry (ASPECT), and the Latin American Registry of Spondyloarthropathies (RESPONDIA). We selected patients with diagnosis of AS who met the modified New York classification criteria. Demographic, clinical, disease activity, functional, and metrological measurement data were recorded. Current treatment was recorded. The population was classified into 2 groups: patients with disease duration < 10 years and those with disease duration ≥ 10 years. A descriptive and comparative analysis of variables of both groups was carried out. RESULTS: There were 2356 patients in EU group and 1083 in LA group. Prevalence of HLA-B27 was 71% in LA group and 83% in EU group (p < 0.001). We found a greater frequency of peripheral arthritis and enthesitis (p < 0.001) in the LA population; prevalence of arthritis was 57% in LA and 42% in EU, and for enthesitis, 54% and 38%. Except for treatment with anti-tumor necrosis factor (anti-TNF), the use of nonsteroidal antiinflammatory drugs (NSAID), corticosteroids, and disease-modifying antirheumatic drugs (DMARD), and the association of anti-TNF and methotrexate use showed a significant difference (p < 0.001) in the 2 populations. CONCLUSION: The principal differences in the clinical manifestations of patients with AS from EU and LA were the greater frequency of peripheral arthritis and enthesitis in LA group, the higher percentage of HLA-B27 in EU group, and the form of treatment, with a greater use of NSAID, steroids, and DMARD in the LA group.

[Conditions mimicking polymyalgia rheumatica]. / Enfermedades que simulan polimialgia reumática.

OBJECTIVE: To examine the main clinical and laboratory data of patients initially diagnosed with polymyalgia rheumatica (PMR), which then developed another conditions. MATERIAL AND METHODS: We reviewed the clinical records of patients diagnosed with PMR in three hospitals in Argentina. Patients had a diagnosis of PMR if they met the following criteria: age ≥ 50 years, erythrocyte sedimentation rate (ESR) at the time of diagnosis > 40 mm, persistent pain and stiffness of at least one month of evolution in two of the following areas: neck, shoulders or proximal arms, hips or proximal lower limbs. Special attention was paid to symptoms or signs of "alarm" (beginning or during disease progression) for suspecting the presence of other non PMR disease within a period of ≤ 12 months. RESULTS: Sixteen of the 200 patients (8%) had other diseases during follow up. Malignancies (n=4) and rheumatic diseases (n=4) were the most common entities, in addition to infective endocarditis (n=1), narrow cervical canal (n=1), Parkinson's disease (n=1), statin-related myalgia (n=1), hypothyroidism (n=1), vitamin D deficiency (n=1) and Calcium Pyrophosphate Deposition Disease (CPDD) (n=2). The average length change of diagnosis was 4.5±3 months. Ten patients had no response to steroids and two had persistently elevated ESR. CONCLUSION: In this study we highlight the importance of recognizing signs and symptoms along with laboratory data and lack of response to treatment as suspects for the diagnosis of other disease manifestations in patients with PMR symptoms.

General characteristics of an early arthritis cohort in Argentina.

OBJECTIVE: The aim of the present study is to describe the general characteristics of a cohort of patients with early arthritis in Argentina. METHODS: CONAART (Consorcio Argentino de Artritis Temprana--Argentine Consortium for Early Arthritis) is an initiative of seven rheumatology centres across Argentina. Patients were included if they had at least one or more swollen joints and <2 years of disease duration. Social, demographic, familiar, hereditary, clinical and laboratory data were recollected. At first visit and every year, X-rays of hands and feet were performed and working characteristics and pharmaco-economic data were re-collected. RESULTS: A total of 413 patients were included. Of them, 327 (79.2%) were women with a median age of 49 years and a median disease duration of 6 months. Of the total, 183 (44.3%) had RA (ACR 1987) and 167 (40.4%) undifferentiated arthritis (UA). Other diagnoses included: 12 crystalics, 11 PsA, 6 uSpA, 6 other CTD, 1 AS and 27 other diagnosis. As 85% of our population had RA and UA, we only compared these two groups of patients. Patients with RA had significantly worse activity parameters of the disease (DAS of 28 joints), functional capacity (HAQ) and quality of life (Rheumatoid Arthritis Quality of Life) than patients with UA. The frequency of RF and anti-CCP, and symmetrical distribution were also significantly higher in patients with RA compared with UA patients. All patients with RA initiated early specific treatment, in a period no longer than 6 months from the beginning of the disease. CONCLUSION: Early arthritis clinics are a useful tool to identify and treat patients with different forms of joint involvement.

Eritrosedimentación, leucopenia, linfopenia y anticuerpo anti-DNA nativo en lupus eritematoso sistémico. Asociación con actividad y daño orgánico / Erythrocyte sedimentation rate, leukopenia, lymphopenia and anti-double stranded DNA antibodies in systemic lupus erythematosus. Association with activity and organ damage

Introducción: La eritrosedimentación (VSG), la leucopenia, la linfopeniay los anticuerpos anti-DNA de doble cadena (anti-DNAn), se han asociado con la actividad del lupus eritematoso sistémico (LES). Su relación con el daño acumulado no es clara. Objetivo: Determinar si la elevación de la VSG, la leucopenia, la linfopenia y el anti-DNAn se relacionan con la actividad o el daño acumulado. Métodos: Se revisaron historias clinicas de pacientes con LES de tres centros de reumatología. Se registraron hemograma, VSG, anti DNAny actividad del LES (SLEDAI) en la primera consulta, cada tres a seis meses y en caso de sospecha de activación. Se evaluó daño orgánico (SLICC/ACR), al primero, tercero, quinto y décimo año de seguimiento. Para analizar leucopenia y actividad de LES, se elaboró una escala sin leucopenia (SLEDAI-L). Los pacientes fueron distribuidos en cuatro grupos de acuerdo al promedio de VSG, leucocitos, linfocitos y clasificados como anti-DNAn positivos o negativos. La media del promedio del SLEDAI y del último SLICC/ACR fueron comparadas entre los grupos de VSG, recuento de linfocitos y entre pacientes anti-DNAn positivos o negativos. La media del promedio de SLEDAI-L y del último SLICC/ACR se compararon entre los grupos de leucocitos. Resultados: De 86 pacientes (75 mujeres, edad media 35,5 ± 10,8 años), 60% tuvieron VSG elevada leve, con un promedio de recuento de leucocitos y linfocitos normal de 92% y 65%, respectivamente y 58% fueron anti-DNAn negativo. La comparación de la media del promedio de SLEDAI y el promedio de SLICC/ACR entre los grupos de VSG, recuento de linfocitos y entre pacientes anti-DNAn positivo y negativo no mostró diferencias significativas, de la misma forma que la media de SLEDAI-L y de SLICC/ACR entre los grupos de recuento de leucocitos. Conclusión: El promedio de elevación de VSG, leucopenia y linfopenia y el anti-DNAn no mostraron asociación con la actividad o el daño acumulado por el LES.

Evaluación de puntos de corte del Índice de Actividad Simplificado (IAS) mediante su comparación con DAS28 / Evaluation of cut-off points of the “Índice de Actividad Simplificado” (IAS) through comparison with DAS28

Introducción: El IAS es un índice de actividad desarrollado en el 2005 para Artritis Reumatoidea, el cual consiste en la suma de articulaciones dolorosas y tumefactas (de un recuento de 28 articulaciones), el valor en centímetros de la evaluación de actividad de la enfermedad realizada por el paciente y por el médico mediante Escala Analógica Visual (EVA), y el valor de la Velocidad de Sedimentación Globular (VSG) dividido en 10. Objetivo: Identificar puntos de corte del IAS para las categorías de actividad de la AR (remisión, baja, moderada y severa) en base a los puntos de cortes establecidos para DAS28. Métodos: Se incluyeron pacientes consecutivos con AR (ACR´87). Se evaluaron las siguientes variables: recuento de articulaciones dolorosas (28) y tumefactas (28), rigidez matinal, EVA del dolor, EVA global paciente y médico, HAQ-A, proteína C reactiva (PCR) en mg/dl y VSG. Se calcularon DAS28, Clinical Disease Activity Index (CDAI) y el IAS. Análisis estadístico: Correlación por test de Spearman (rs). Análisis por curvas ROC. Análisis de Varianza No Paramétrica de Kruskall- Wallis. Prueba No Paramétrica de Mann-Whitney. Un valor de p ≤0.05 fue considerado significativo. Resultados: Se incluyeron para el análisis 336 pacientes (86% mujeres). El IAS presentó una correlación positiva con CDAI y DAS28 (rs 0.9), recuento articular (rs 0.8), EVA global paciente y médico (rs 0.7), EVA del dolor (rs 0.6), HAQ-A y rigidez matinal (rs 0.5). Un valor de IAS de 5.5 diferenció remisión de baja actividad de la AR (Sensibilidad 90%, Especificidad 66%; Área Bajo la Curva - AUC - 0.78); un valor de 10 separó baja de moderada actividad (Sensibilidad 91%, Especificidad 73% - AUC 0.93); y 25 puntos diferenciaron actividad moderadade severa (Sensibilidad 91%, Especificidad 87% - AUC 0.96). Conclusiones: El IAS presenta buena correlación con otros índices de actividad (DAS28, CDAI).

Accrual of organ damage over time in Argentine patients with systemic lupus erythematosus: a multi-centre study.

The goals of this study were to ascertain damage in patients with systemic lupus erythematosus (SLE) from five rheumatologic centres in Argentina and to examine overall damage, damage by domain and damage by item within each domain. We performed a retrospective observational study including patients with SLE (ACR 1997 revised and modified criteria) from five rheumatology centres in Argentina. Organ damage was scored using the SLICC/ACR DI (SDI), ascertained at years 1, 2, 5 and 10. Three centres provided information up to the fifth year. Of the 197 patients, 88.3% were women and their mean age was 33.2 years. The mean disease duration and follow-up were 7.6 and 5.3 years, respectively. Damage accrued gradually over time with SDI ranging from 0.52 (+/-1.1) at year 1 up to 2.46 (+/-2.1) at year 10. The renal system was the most involved system, followed by the neuropsychiatric, the cardiovascular and the musculoskeletal systems. Proteinuria, cognitive impairment, pericarditis, avascular necrosis, cataract and alopecia were the predominant items in their respective systems. Systems such as peripheral vascular, pulmonary, gastrointestinal, diabetes, malignancy and premature gonadal failure were not frequent. Overall SDI had a gradual increase over time. Damage in each domain of SDI, except for diabetes, had a similar behaviour. Behaviour of items in each domain varied.