Routine invasive strategy in acute coronary syndrome patients with renal dysfunction. Results of the ARIAM-SEMICYUC registry. / Estrategia invasiva de rutina en el síndrome coronario agudo sin elevación del segmento ST con disfunción renal. Resultados del registro ARIAM-SEMICYUC.

OBJECTIVE: To evaluate the use and effectiveness of a routine invasive strategy (RIS) in patients with acute coronary syndrome without persistent ST-segment elevation with renal dysfunction in the real world scenario. METHODS: A retrospective cohort study based on the ARIAM-SEMICYUC Registry (2011-2014) was carried out. Renal dysfunction was defined as GFR (Cockroft-Gault)<60ml/min (moderate dysfunction) or<30ml/min (severe dysfunction). Patients in which early angiography (<72h) was performed due to cardiogenic shock or recurrent myocardial ischemia were excluded. The primary endpoint was hospital mortality. Confounding factors were controlled using propensity score analysis. RESULTS: A total of 4,279 patients were analyzed, of which 26% had moderate renal dysfunction and 5% severe dysfunction. Patients with renal dysfunction had greater severity and comorbidity, higher hospital mortality (8.6 vs. 1.8%), and lesser use of the RIS (40 vs. 52%). The adjusted OR for mortality in patients without/with renal dysfunction were 0.38 (95% confidence interval [95%CI] 0.17 to 0.81) and 0.52 (95%CI 0.32 to 0.87), respectively (interaction P-value=.4779). The impact (adjusted risk difference) of RIS was higher in the group with renal dysfunction (-5.1%, 95%CI -8.1 to -2.1 vs. -1.6%, 95%CI -2.6 to -0.6; interaction P-value=.0335). No significant interaction was detected for the other endpoints considered (ICU mortality, 30-day mortality, myocardial infarction, acute renal failure or moderate/severe bleeding). CONCLUSIONS: The results suggest that the effectiveness of IRS is similar in patients with normal or abnormal renal function, and alert to the under-utilization of this strategy in such patients.

Use of noninvasive measurement of the indocyanine green plasma disappearance rate in patients with septic shock.

OBJECTIVE: Our aim was to analyse the relation between serial values of the indocyanine green plasma disappearance rate (ICG-PDR) with hospital mortality in the first 48 hours of ICU admission in patients with septic shock. METHODS: A prospective observational study was carried out over 12 months of patients admitted to the ICU with septic shock. Each patient underwent noninvasive determination of ICG-PDR at 24 and 48 hours with the LiMON® module. Follow-up was performed until hospital discharge or exitus. RESULTS: 63 patients. Age 61.1±12.3 years. 60.3% men. SOFA score on admission 8.7±3.3, APACHE II score was 27.9±10.7 points. A total of 44.4% of patients died. The ICG-PDR values in the first 24 hours of ICU admission were lower in nonsurvivors: 10.5 (5.7-13.0)%/min vs. 15.9 (11.4-28.0)%/min, p <0.001. Furthermore, in nonsurvivors, there was no improvement in ICG-PDR between 24 h and 48 h, while in survivors, there was an increase of 25%: 15.9 (11.4-28.0)%/min and 20.9 (18.0-27.0)%/min, p=0.020. The silhouette measure of ICG-PDR cohesion and separation for the clusters analysed (nonsurvivors and survivors) was satisfactory (0.6). ICG-PDR<11.7%/min was related to in-hospital mortality, ICG-PDR> 18%/min to survival, and the interval between 11.7% and 18%/min covered a range of uncertainty. In the two-stage cluster, ICG-PDR, SOFA and APACHE II present satisfactory predictive scores 24 hours after patient admission. CONCLUSIONS: ICG-PDR in our setting is a useful clinical prognostic tool and could optimise the decision tree in patients with septic shock.

Association study of IRAK-M and SIGIRR genes with SLE in a large European-descent population.

OBJECTIVE: The aim of this study was to evaluate the relevance of genetic variants of interleukin receptor-associated kinase-M (IRAK-M) (rs11465955, rs1624395, rs1152888 and rs1370128) and single immunoglobulin IL1-1R-related molecule (SIGIRR) (rs3210908) genes in systemic lupus erythematosus (SLE) in four independent European-descent populations. METHODS: Our study population consisted of a total of 2033 SLE patients and 2357 healthy controls from Spain, Germany, Italy and Argentina. The genotyping was performed using a polymerase chain reaction (PCR) system with pre-developed TaqMan allelic discrimination assay. Genetic association between the genotyped markers was determined by PLINK v1.07. RESULTS: After a meta-analysis including these four populations, a trend of association between rs11465955 (P(meta) (-analysis) = 0.06), rs1370128 (P(meta) (-analysis) = 0.07) and rs1624395 (P(meta) (-analysis) = 0.06) polymorphisms was found. However, these differences did not reach statistical significance. In addition, we did not find any association between SLE and the rs1152888 IRAK-M (P(meta) (-analysis) = 0.13) and the rs3210908 SIGIRR (P(meta) (-analysis) = 0.40) polymorphisms after the meta-analysis. No evidence of association with IRAK-M haplotypes was found. CONCLUSION: These results suggest that the tested variations of IRAK-M and SIGIRR genes do not confer a relevant role in the susceptibility to SLE in European-descent populations.

The STAT4 gene influences the genetic predisposition to systemic sclerosis phenotype.

The aim of this study was to investigate the possible role of STAT4 gene in the genetic predisposition to systemic sclerosis (SSc) susceptibility or clinical phenotype. A total of 1317 SSc patients [896 with limited cutaneous SSc (lcSSc) and 421 with diffuse cutaneous SSc (dcSSc)] and 3113 healthy controls, from an initial case-control set of Spanish Caucasian ancestry and five independent cohorts of European ancestry (The Netherlands, Germany, Sweden, Italy and USA), were included in the study. The rs7574865 polymorphism was selected as STAT4 genetic marker. We observed that the rs7574865 T allele was significantly associated with susceptibility to lcSSc in the Spanish population [P = 1.9 x 10(-5) odds ratio (OR) 1.61 95% confidence intervals (CI) 1.29-1.99], but not with dcSSc (P = 0.41 OR 0.84 95% CI 0.59-1.21). Additionally, a dosage effect was observed showing individuals with rs7574865 TT genotype higher risk for lcSSc (OR 3.34, P = 1.02 x 10(-7) 95% CI 2.11-5.31). The association of the rs7574865 T allele with lcSSc was confirmed in all the replication cohorts with different effect sizes (OR ranging between 1.15 and 1.86), as well as the lack of association of STAT4 with dcSSc. A meta-analysis to test the overall effect of the rs7574865 polymorphism showed a strong risk effect of the T allele for lcSSc susceptibility (pooled OR 1.54 95% CI 1.36-1.74; P < 0.0001). Our data show a strong and reproducible association of the STAT4 gene with the genetic predisposition to lcSSc suggesting that this gene seems to be one of the genetic markers influencing SSc phenotype.

Failure of intravenous immunoglobulin to prevent congenital heart block: Findings of a multicenter, prospective, observational study.

OBJECTIVE: Congenital heart block (CHB) is presumed to be caused by transplacental passage of maternal immunoglobulin against Ro and La ribonucleoproteins. The recurrence rate in subsequent pregnancies following the birth of a child with CHB is approximately 19%. The purpose of this study was to determine whether intravenous immunoglobulin (IVIG) therapy could prevent the development of CHB in the fetuses of high-risk pregnant women. METHODS: A total of 24 pregnancies in 22 women who had a previous pregnancy in which CHB developed, were over the age of 18 years, were <12 weeks pregnant, and had anti-Ro, anti-La, or both antibodies were monitored in this multicenter, prospective, observational study. Fifteen patients received infusions of IVIG. The 9 pregnancies in the remaining 7 patients served as controls. IVIG was administered at a dose of 400 mg/kg at weeks 12, 15, 18, 21, and 24 of pregnancy. Echocardiograms were performed at least every 3 weeks from week 15 to week 30 of gestation. Electrocardiograms were obtained at birth. The outcome measure was the development of third-degree CHB detected by fetal echocardiogram. RESULTS: CHB developed in 3 babies among the 15 pregnancies in the treatment group (20%) and in 1 baby among the 9 pregnancies in the control group (11%). CHB was detected at weeks 18, 23, and 26, respectively, in the 3 babies in the treated group and at week 19 in the baby in the control group. Three of the affected pregnancies ended in termination; 2 for reasons related to the fetal disease and 1 for reasons related to both maternal (severe pulmonary hypertension) and fetal disease (at 21 weeks of gestation). CONCLUSION: IVIG at the dose and frequency used in this study was not effective as prophylactic therapy for CHB in high-risk mothers.

Off-label use of rituximab in 196 patients with severe, refractory systemic autoimmune diseases.

OBJECTIVES: To analyse the safety and efficacy of the off-label use of rituximab in patients with severe, refractory systemic autoimmune diseases. METHODS: In 2006, the Study Group on Autoimmune Diseases of the Spanish Society of Internal Medicine created the BIOGEAS project, a multicenter study devoted to collecting data on the use of biological agents in adult patients with systemic autoimmune diseases refractory to standard therapies (failure of at least two immunosuppressive agents). RESULTS: One hundred and ninety-six patients with systemic autoimmune diseases treated with rituximab have been included in the Registry (158 women and 38 men, mean age 43 years). Systemic autoimmune diseases included systemic lupus erythematosus (107 cases), inflammatory myopathies (20 cases), ANCA-related vasculitides (19 cases), Sjögren's syndrome (15 cases) and other diseases (35 cases). A therapeutic response was evaluable in 194 cases: 99 (51%) achieved a complete response, 51 (26%) a partial response and 44 (23%) were classified as non-responders. After a mean follow-up of 27.56+/-1.32 months, 44 (29%) out of the 150 responders patients relapsed. There were 40 adverse events reported in 33 (16%) of the 196 patients. The most frequent adverse events were infections, with 24 episodes being described in 19 patients. Thirteen (7%) patients died, mainly due to disease progression (7 cases) and infection (3 cases). CONCLUSIONS: Although not yet licensed for this use, rituximab is currently used to treat severe, refractory systemic autoimmune diseases, with the most favourable results being observed in Sjögren's syndrome, inflammatory myopathies, systemic lupus erythematosus and cryoglobulinemia.

The interleukin 23 receptor gene does not confer risk to systemic sclerosis and is not associated with systemic sclerosis disease phenotype.

OBJECTIVES: Multiple studies indicate the role of the interleukin (IL)-17/IL-23 axis in autoimmune diseases, including systemic sclerosis (SSc). The aim of the current study was to investigate the possible implication of the IL23R gene in SSc susceptibility and/or clinical phenotype. METHODS: An initial case-control study in 143 Dutch patients with SSc and geographically matched healthy individuals (n = 246) was carried out and followed by a replication study in a cohort of 365 Spanish patients with SSc and 515 healthy individuals. Seven single nucleotide polymorphisms (SNPs) spanning the IL23R gene were selected and genotyped using a Taqman assay. RESULTS: Using a Dutch cohort of patients with SSc and controls we observed an association between two (rs11209032, rs1495965) of the seven tested SNPs and disease susceptibility (allelic p values: p = 0.02 and p = 0.01 respectively). However, a replication study in an independent Spanish cohort did not confirm these findings and reveal no association of any of the IL23R-tested SNP with disease susceptibility or clinical phenotype. Similarly, a meta-analysis considering both populations did not reveal any significant association. In addition, no association was observed between IL23R genetic variants and SSc clinical phenotypes. CONCLUSIONS: Our results suggest that the IL23R gene is not associated with SSc susceptibility or clinical phenotype.

A large multicentre analysis of CTGF -945 promoter polymorphism does not confirm association with systemic sclerosis susceptibility or phenotype.

OBJECTIVE: To conduct a replication study to investigate whether the -945 CTGF genetic variant is associated with systemic sclerosis (SSc) susceptibility or specific SSc phenotype. METHODS: The study population comprised 1180 patients with SSc and 1784 healthy controls from seven independent case-control sets of European ancestry (Spanish, French, Dutch, German, British, Swedish and North American). The -945 CTGF genetic variant was genotyped using a Taqman 5' allelic discrimination assay. RESULTS: An independent association study showed in all the case-control cohorts no association of the CTGF -945 polymorphism with SSc susceptibility. These findings were confirmed by a meta-analysis giving a pooled OR = 1.12 (95% CI 0.99 to 1.25), p = 0.06. Investigation of the possible contribution of the -945 CTGF genetic variant to SSc phenotype showed that stratification according to SSc subtypes (limited or diffuse), selective autoantibodies (anti-topoisomerase I or anticentromere) or pulmonary involvement reached no statistically significant skewing. CONCLUSION: The results do not confirm previous findings and suggest that the CTGF -945 promoter polymorphism does not play a major role in SSc susceptibility or clinical phenotype.

Investigation of TLR5 and TLR7 as candidate genes for susceptibility to systemic lupus erythematosus.

OBJECTIVES: The aim of this study was to evaluate the relevance of genetic variants of TLR5 (rs5744168) and TLR7 (rs179008) gene in systemic lupus erythematosus (SLE) in a Spanish population. MATERIAL AND METHODS: Our study population consisted of 752 SLE patients and 1107 healthy controls. All individual were of Spanish Caucasian origin. The TLR5 and TLR7 polymorphisms were genotyped using a PCR system with pre-developed TaqMan allelic discrimination assay. RESULTS: No statistically significant differences were observed when the allele and genotype distribution of TLR5 rs5744168 and TLR7 rs179008 polymorphisms was compared between SLE patients and healthy controls. A significant increase frequency in the CC genotype of the TLR5 rs5744168 polymorphism among SLE patients without nephritis was found (93% vs. 87% in SLE patients with nephritis, p=0.03, OR=2.11 95%CI 0.93-3.51). However, this difference did not reach statistical significance in the allele frequencies (p=0.08). CONCLUSION: These results suggest that the tested variations of TLR5 and TLR7 genes do not confer a relevant role in the susceptibility or severity to SLE in the Spanish population.

Screening for PAH in patients with systemic sclerosis: focus on Doppler echocardiography.

It is well established that patients with CTDs such as SSc carry a considerable risk of developing pulmonary arterial hypertension (PAH). Such SSc-PAH patients have an even worse prognosis than patients with only one of these two conditions. In view of the high incidence and prevalence of PAH in SSc, and the available treatment options that improve quality of life, exercise capacity and possibly survival, systematic screening has been recommended. The present article reviews current recommendations from PAH guidelines, focusing on studies that used Doppler echocardiography for screening, and describes limitations associated with the procedure. Furthermore, characteristics and parameters used to identify patients at high risk of developing PAH are summarized.

[Ocular toxocariasis. A case report]. / Toxocariasis ocular. A propósito de un caso.

CASE REPORT: We present the case of a seven-year-old male with ocular toxocariasis. The fundus of the eye showed a vitritis, as a result of which the retina could not be seen. Following treatment with systemic corticosteroids the condition evolved favorably. However, due to a papillary and peripheral granuloma that raised the macula, a vitrectomy was performed which stabilized the process. DISCUSSION: Ocular toxocariasis is not common in developed countries. The diagnosis is based on funduscopic aspects, serology and IgG positivity of the vitreous. In relation to treatment, as the use of anthelminthics therapy is controversial, the use of corticosteroids and vitrectomy is recommended.

Registry of the Spanish Network for Systemic Sclerosis: Survival, Prognostic Factors, and Causes of Death.

Systemic sclerosis (SSc) is a rare, multisystem disease showing a large individual variability in disease progression and prognosis. In the present study, we assess survival, causes of death, and risk factors of mortality in a large series of Spanish SSc patients. Consecutive SSc patients fulfilling criteria of the classification by LeRoy were recruited in the survey. Kaplan-Meier and Cox proportional-hazards models were used to analyze survival and to identify predictors of mortality. Among 879 consecutive patients, 138 (15.7%) deaths were registered. Seventy-six out of 138 (55%) deceased patients were due to causes attributed to SSc, and pulmonary hypertension (PH) was the leading cause in 23 (16.6%) patients. Survival rates were 96%, 93%, 83%, and 73% at 5, 10, 20, and 30 years after the first symptom, respectively. Survival rates for diffuse cutaneous SSc (dcSSc) and limited cutaneous SSc were 91%, 86%, 64%, and 39%; and 97%, 95%, 85%, and 81% at 5, 10, 20, and 30 years, respectively (log-rank: 67.63, P < 0.0001). The dcSSc subset, male sex, age at disease onset older than 65 years, digital ulcers, interstitial lung disease (ILD), PH, heart involvement, scleroderma renal crisis (SRC), presence of antitopoisomerase I and absence of anticentromere antibodies, and active capillaroscopic pattern showed reduced survival rate. In a multivariate analysis, older age at disease onset, dcSSc, ILD, PH, and SRC were independent risk factors for mortality. In the present study involving a large cohort of SSc patients, a high prevalence of disease-related causes of death was demonstrated. Older age at disease onset, dcSSc, ILD, PH, and SRC were identified as independent prognostic factors.

[Antiribosomal antibodies and the neurological manifestations in systemic lupus erythematosus]. / Anticuerpos antirribosómicos y manifestaciones neurológicas en el lupus eritematoso sistémico.

BACKGROUND: The possible positive correlation between the presence of antiribosomic antibodies and neurologic and neuropsychiatric manifestations in patients with systemic lupus erythematosus, cited in the literature, was analyzed. METHODS: Neurological involvement (current or previous) was evaluated in 71 successive patients. The anti-ENA antibodies (extractable nuclear antigens) were studied with special attention to the antiribosomic antibodies by: a) indirect immunofluorescence (IFI) on triple rat substrate, Hep2 and Crithidia luciliae; b) counter immunoelectrophoresis (CIE); c) double immunodiffusion (DI), and d) Western blot (WB) in the Molt-4 cell line. The statistical study was performed by the Fisher exact test. RESULTS: RibosomAL dyeing was observed in only 2 patients by IFI on triple rat substrate and HEp2. With CIE and DI, 14 patients (20%) were anti-ENA positive. Detectable bands were obtained with WB in 47 patients (66%) with 9 corresponding to antiribosomic antibodies. No statistical differences were found (p > 0.3) in relation with the presence of antirobosomic antibodies in particular and anti-ENA in general, between the groups with and without neurologic involvement. CONCLUSIONS: No relation was observed between antiribosomic antibodies and neurolupus by determinations of anti-ENA antibodies by Western blot (superior method--p < 0.0001--to direct immunofluorescence, counter immunoelectrophoresis and double immunodiffusion in the comparative study of sensitivity.

[Lymphomatoid granulomatosis: clinicopathologic analysis of 7 cases]. / Granulomatosis linfomatoidea: análisis clinicopatológico de 7 casos.

The aim of the present was to study the possible clinical histological correlations in the cases of lymphomatoid granulomatosis (LG) diagnosed in the last 10 years. Clinic evolutive data were collected in 7 patients diagnosed LG. The histological samples related to the same were revised and an immunohistochemical study was carried out with the oxidase/antiperoxidase technique. Seven patients (5 females and 2 men) with a mean age of 47 years (limit 23-47) were studied. The form of presentation was alteration of the general state in 5 cases accompanied by respiratory symptoms in 4. In 2 cases lung involvement was not found. In 7 biopsies performed at the initiation of the disease, 3 presented characteristics of lymphoma. Three patients are presently alive with a mean follow up time of 31 months and 4 have died (mean survival 17 months). Immunohistochemistry demonstrated T lymphocyte predominance in most of the cases (5 out of 6). The first case of LG in a patient simultaneously infected with the HIV and HTLV-1 is presented. Lymphomatoid granulomatosis possesses a symptomatology which is very inspecific and has histological features which may be superposed to other lymphoproliferative disorders, specially those of the T strain. Given the known relation between HTLV-1 and T lymphomas the role of HTLV-1 in the genesis of LG should be studied in these patients specially in those with the HIV.

[Type I herpes virus, HLA phenotype and Behçet disease]. / Virus herpes tipo I, fenotipo HLA y enfermedad de Behçet.

BACKGROUND: The pathogenic factors of Behçet's disease (BD) differentiate according to geographical zones. The aim of this study was to evaluate the possible relation between this process and infection by type I herpes simplex virus (HSV-1) in Spain. METHODS: The prevalence of antibodies vs HSV-1 and cytomegalovirus (CMV) was studied by complement fixation in three series: A) 34 patients with BD; B) 21 with primary uveitis; C) 40 controls. HSV-1 specificity was established by ELISA. HLA typing was performed in 32 individuals from series A. RESULTS: The frequency of anti HSV-1 in A (76%) was greater (p = 0.045) than in C (55%) and B (66%). These differences were more evident when titers equal/superior to 1/64 were considered as positive, with this being a value exceeding the 97.5% percentage of the control series (A = 21%, C = 2%, p = 0.015), specially for the ocular BD subgroup (26%, p = 0.011 with respect to C). The B series did not differ from C (p = 0.88). To the contrary no differences were observed in the distribution of titers vs CMV. Although a greater frequency of anti HSV-1 was observed in HLA-B51+ the differences were not significant (p = 0.09). CONCLUSIONS: The frequency of evaluable titers of anti-HSV-1 is greater in patients with BD (specially with ocular involvement) than in the control series. No association was found between higher titers and HLA PB51+ phenotype.

[Serologic and molecular HLA typing in patients from Andalucia with Behçet's disease. Genetic and clinical correlations]. / Tipificación HLA serológica y molecular en pacientes andaluces con enfermedad de Behçet. Correlaciones geneticoclínicas.

BACKGROUND: HLA typing was performed in 67 patients with Behçet's disease from Andalucia, Spain to: 1) analyze the association of class I and II molecules with Behçet's disease in Spain; 2) study the clinical correlations and 3) evaluate its diagnostic and/or prognostic role. PATIENTS AND METHODS: 1) Serologic typing (microlymphocytotoxicity): class I molecules in 67 patients and class II molecules in 47 patients (controls: 223 healthy volunteers). 2) Oligotyping (PCR-SSO): class II molecules (DQB1 and generic DRB1) in 47 patients and 189 controls. 3) STATISTICAL ANALYSIS: chi square test (dicotomic variables) and Student t test (continuous variables), and calculation of the relative risk by the Wolff and Haldane formulas. RESULTS: The HLA B51 antigen was the most frequently observed in the whole series (p = 0.003) in males with ocular disease (p = 0.0001) and in patients with cutaneous (p = 0.001) and digestive involvement (p = 0.05). The HLA B51-positive males were younger at disease onset (p = 0.01) with neurologic involvement being infrequent (p = 0.03). The HLA B51 antigen was associated with neurologic (p = 0.06) and articular involvement (p = 0.05). The DQB1*0303 was associated with uveitis of bad evolution (p = 0.01). The DR11 and DQB1*0301 were more frequent in HLA B51-positive patients and the DQ5 was negatively associated with Behçet's disease, particularly in the HLA B51-positive patients. CONCLUSIONS: The study of the HLA antigens provides useful information for the diagnosis of Behçet's disease, aids in differentiating the different clinical forms and has prognostic significance.

[Iliopsoas abscess and systemic lupus erythematosus]. / Absceso del músculo iliopsoas y lupus eritematoso sistémico.

Iliopsoas muscle abscess (IPA) is an uncommon condition, and it is usually associated with immunosuppression. Three out of a cohort of 552 patients diagnosed of systemic lupus erythematosus (SLE) developing an IPA, are reported herein. Patients showed fever and other symptoms related to SLE. They improved only partially under SLE therapy, and showed pain suggestive of IPA. It was confirmed by CT in all cases. S. aureus was isolated in one patient (primary IPA), and M. tuberculosis in the others. Specific antimicrobial therapy and surgical drainage were required. In summary, SLE might be considered as a risk condition for the development of IPA, due to the immunosuppression inherent in the disease and its treatment.