Differences in clinical manifestations and increased severity of systemic lupus erythematosus between two groups of Hispanics: European Caucasians versus Latin American mestizos (data from the RELESSER registry).

BACKGROUND: Systemic lupus erythematosus (SLE) is regarded as a prototype autoimmune disease because it can serve as a means for studying differences between ethnic minorities and sex. Traditionally, all Hispanics have been bracketed within the same ethnic group, but there are differences between Hispanics from Spain and those from Latin America, not to mention other Spanish-speaking populations. OBJECTIVES: This study aimed to determine the demographic and clinical characteristics, severity, activity, damage, mortality and co-morbidity of SLE in Hispanics belonging to the two ethnic groups resident in Spain, and to identify any differences. METHODS: This was an observational, multi-centre, retrospective study. The demographic and clinical variables of patients with SLE from 45 rheumatology units were collected. The study was conducted in accordance with Good Clinical Practice guidelines. Hispanic patients from the registry were divided into two groups: Spaniards or European Caucasians (EC) and Latin American mestizos (LAM). Comparative univariate and multivariate statistical analyses were carried out. RESULTS: A total of 3490 SLE patients were included, 90% of whom were female; 3305 (92%) EC and 185 (5%) LAM. LAM patients experienced their first lupus symptoms four years earlier than EC patients and were diagnosed and included in the registry younger, and their SLE was of a shorter duration. The time in months from the first SLE symptoms to diagnosis was longer in EC patients, as were the follow-up periods. LAM patients exhibited higher prevalence rates of myositis, haemolytic anaemia and nephritis, but there were no differences in histological type or serositis. Anti-Sm, anti-Ro and anti-RNP antibodies were more frequently found in LAM patients. LAM patients also had higher levels of disease activity, severity and hospital admissions. However, there were no differences in damage index, mortality or co-morbidity index. In the multivariate analysis, after adjusting for confounders, in several models the odds ratio (95% confidence interval) for a Katz severity index >3 in LAM patients was 1.45 (1.038-2.026; p = 0.02). This difference did not extend to activity levels (i.e. SLEDAI >3; 0.98 (0.30-1.66)). CONCLUSION: SLE in Hispanic EC patients showed clinical differences compared to Hispanic LAM patients. The latter more frequently suffered nephritis and higher severity indices. This study shows that where lupus is concerned, not all Hispanics are equal.

Secondary prevention program for osteoporotic fractures and long-term adherence to bisphosphonates.

UNLABELLED: Our purpose was to assess the impact of a secondary prevention program for osteoporotic fractures in patients with fragility fracture and to determine its effect on long-term compliance with bisphosphonate treatment. Persistence with bisphosphonate use was 71%. Attending follow-up visits was the only variable significantly associated with adherence to bisphosphonates. INTRODUCTION: The aim of this study is to assess the impact a secondary prevention program for osteoporotic fractures in a prospective cohort of patients with at least one fragility fracture and to determine the effect of this intervention on long-term compliance with bisphosphonate treatment. METHODS: All patients older than 50 years with a fragility fracture attended at the emergency department over a 2-year period were appointed for a clinical visit through a telephone call. Two follow-up controls at 4 and 12 months were scheduled. After a mean of 4 years, a telephone survey was conducted to assess compliance with treatment. RESULTS: Of 683 eligible patients, 380 (55.6%) were visited at the hospital. Previous treatment with bisphosphonates was recorded in 17.9% of patients. DXA scan was considered normal in 61 patients and revealed osteopenia in 184 and osteoporosis in 135. Pharmacological treatment was indicated in 90% of patients (alendronate in 76%). Among 241 patients who participated in the survey, eight patients had new fractures (four were on treatment with bisphosphonates and four had discontinued treatment). Of 187 patients in which bisphosphonates were prescribed at the initial visit, 133 (71.1%) continued using bisphosphonates. Attendance of scheduled visits was associated with adherence to bisphosphonates (odds ratio, 3.33; 95% confidence interval, 2.99-3.67). CONCLUSIONS: The efficacy of the program to recruit patients was 55%. In patients visited at the hospital, treatment with bisphosphonates increased from 17.9% to 76%. Persistence with bisphosphonate use after a mean of 4 years was 71%. Attending follow-up visits was significantly associated with adherence to bisphosphonates.

Factors involved in the progress of preclinical atherosclerosis associated with systemic lupus erythematosus: a 2-year longitudinal study.

OBJECTIVES: To assess the changes in carotid intima-media thickness (IMT) and the associated risks factors in patients with low severity systemic lupus erythematosus (SLE). METHODS: Common carotid IMT measurements were obtained by ultrasound from 101 patients with SLE at an interval of 2 years. Cardiovascular risk factors, disease activity, accumulated damage, severity (Katz index) and biochemical parameters (including high sensitivity C-reactive protein, interleukin 6, C3a, C4a, C5a and homocysteine) were also assessed. Multiple linear regression was used to assess the effect of these variables on the end IMT measurement (eIMT) adjusted to the baseline measurement (bIMT). RESULTS: The cohort comprised 94.1% women, with a mean age at entry of 41.5 years and a mean disease duration of 12.1 years. An increase of 0.078 mm in IMT was detected over 2 years, from a mean bIMT of 0.37 mm to a mean eIMT of 0.44 mm (p<0.001). When adjusted for the bIMT, multiple linear regression identified bIMT, age at diagnosis, homocysteine, C3 and C5a as risk factors for IMT progression. CONCLUSIONS: IMT significantly increases over 2 years in patients with SLE. Age, baseline IMT, C3, C5a anaphylatoxin and homocysteine are all associated risk factors, supporting a role for complement and homocysteine in the early stages of premature SLE-associated atherosclerosis.

What is the diagnostic value of ultrasonography compared to physical evaluation in patients with idiopathic carpal tunnel syndrome?

OBJECTIVE: Our hypothesis is that sonography performed by the rheumatologist in patients with suspected carpal tunnel syndrome (CTS) has higher diagnostic value compared to physical evaluation. METHODS: Adult patients with suspected idiopathic CTS, defined by sensory symptoms over the distribution of the median nerve with or without positive results with the Phalen and/or the Tinel's maneuvers were included. The diagnosis of CTS was indicated by typical symptoms daily for at least 3 months and a positive nerve conduction study. One rheumatologist unaware of the clinical and electrodiagnostic results performed an ultrasound examination of the median nerve for the area ranging from the inlet to the outlet of the carpal tunnel. Mean cross-sectional area at each level, flattening ratio and bowing of flexor retinaculum were obtained. RESULTS: Sixty-eight patients with 105 affected wrists were examined. Tinel's and Phalen's signs had a closer sensitivity (73% and 67% respectively) and specificity (40% and 30% respectively). The best swelling nerve cut-off by sonography was 9.7 mm2 at the tunnel inlet, with a sensitivity of 86%, a specificity of 48% and accuracy of 77%. A 100% positive predictive value was reached with a cross-sectional area of 13 mm2, involving 33 hands (31% of the whole sample). Maximal cross sectional area and the measurement of flexor retinaculum had an accuracy of 72% and 73% respectively. Combination of physical maneuvers and sonography not yielded more accuracy than cross-sectional area itself. CONCLUSION: In patients with clinical history of idiopathic CTS and positive nerve conduction study, sonography performed by the rheumatologist has higher diagnostic value than physical maneuvers.

Therapeutic effect of early thymic irradiation in (NZB x NZW)F1 mice, associated with a selective decrease in the levels of IgG3 and gp70-anti-gp70 immune complexes.

The lupus-prone (NZB x NZW)F1 female mice (NZB/W) develop an autoimmune disease characterized by production of autoAb and fatal glomerulonephritis. Since it has been previously shown that total lymphoid irradiation has a beneficial effect in this model, we have analyzed whether early thymic irradiation (ETI) could improve the course of the lupus-like syndrome in these mice. NZB/W mice received thymic irradiation (4500 rads) beginning at 10 weeks of age, prior to the onset of autoimmune manifestations. Then, they were evaluated for survival, renal histology, and serological markers of autoimmunity, in comparison to nonirradiated NZB/W females. The treatment with ETI improved nephritis and survival in NZB/W mice: 50% mortality was observed at 12 months in irradiated mice and at 9 months in untreated mice. This improved survival could not be attributed to a reduction in the titers of anti-dsDNA Ab nor in the levels of total immune complexes which were essentially identical in both groups. By contrast, this improvement was related to a selective normalization in the serum levels of IgG3 and gp70-anti-gp70 immune complexes (gp70IC) in ETI NZB/W female mice as compared to that seen in nonirradiated NZB/W females. These data show the therapeutical effect of ETI and support the pathogenic role of IgG3 and gp70IC in the development of glomerulonephritis in NZB/W mice.

Abnormal sonographic findings in the asymptomatic arthritic shoulder.

OBJECTIVE: To assess the diagnostic value of ultrasonography (US) in the evaluation of arthritic shoulder joints, especially in painless shoulders. METHODS: US examinations were performed in 57 consecutive patients with rheumatoid arthritis (114 shoulders) and in 32 controls (32 shoulders), using a 7.5 MHz linear probe and a standardized study protocol. US findings were compared with clinical, laboratory, and radiological data to find any relationship. RESULTS: Abnormal sonographic findings were found in 80 shoulders (70%); the most common were lesions in the supraspinatus tendon (38%), subacromial-subdeltoid bursitis (29%), bone erosions of the humeral head (20%), glenohumeral joint ellusion (19%), and biceps tendinitis (13%). Although US abnormalities were most frequent in patients with painful shoulders or abnormal findings on physical examination or radiography, a high rate of alterations was found in asymptomatic shoulders (51%), in normal shoulders on physical examination (44%) and in normal shoulders on radiographic assessment (61%). Differences of US findings in relation to time of evolution of rheumatoid arthritis, patient's age, and radiographic stage in hand and/or wrist joints were not found. CONCLUSION: US abnormalities in the shoulder joint are frequent in rheumatoid arthritis, both in patients with and without shoulder complaints as well as in patients with normal findings on physical examination.