Ochronotic arthropathy in the context of spondyloarthritis differential diagnosis: a case-based review.

Alkaptonuria is a disease often forgotten because of its rarity. Its pathogenic mechanism is the deficiency of one of the enzymes of the tyrosine degradation pathway-homogentisate-1, 2-dioxygenase, which sequelae is accumulation and deposition of its metabolite homogentisic acid in connective tissues and urine. Alkaptonuria presents as a clinical triad-darkening urine upon prolonged exposure to air, pigmentation of connective tissues and debilitating arthropathy. We present a case report of a 67-year old patient with alkaptonuria who presented with the clinical triad, but was mistakenly diagnosed as having ankylosing spondylitis in the past. Currently there is no treatment for the disease hence the management strategy was focused on symptoms control with analgesics, physical therapy, dietary modification, vitamin C supplementation, and joint arthroplasty. Alkaptonuria's clinical features are extensively described in the literature and despite the fact that it is a rare disease, due to the similar radiographic changes with spondyloarthropathies, it should be included in the differential diagnosis in young patients presenting with severe joint involvement. Early recognition of the disease is necessary since its natural evolution is joint destruction leading to significant reduction in the quality of life. Alkaptonuria's articular features in the spine and peripheral tissues are well described using the classical imaging techniques. Musculoskeletal ultrasonography shows a characteristic set of findings in the soft tissues, including synovium, cartilage, tendons and entheses.

Balneotherapy in spondyloarthropathy: A systematic review.

AIM OF THE STUDY: To evaluate the effectiveness of balneotherapy on spondyloarthritis. METHODS: Two authors independently searched the CENTRAL, MEDLINE, SCOPUS, EMBASE and WEB OF SCIENCE databases until July 2017, for randomized controlled trials published in French or English, that included participants, and interventions: adults with spondyloarthritis, treated by balneotherapy program or one of its components and compared with any other intervention or no treatment. Internal validity, external validity, quality of the statistical analysis, and publication bias were systematically evaluated. We report the best level of evidence. RESULTS: Nine articles were selected; the internal validity was high in two studies, average in one study, and low in six studies. With high internal validity, one study found a difference for pain between immersion in radon-rich water and tap water for the whole population or rheumatic disease, but the BASFI is not improved for the subgroup of patients with spondyloarthritis. The other study with high validity reported a significant 28-week improvement in quality of life and a composite index. In a study with moderate internal validity involving ankylosing spondylitis patients with associated with inflammatory bowel disease, a balneotherapy program demonstrated a relevant clinical improvement when compared to patients on waiting list. With low internal validity, TNFa inhibitors+spa therapy were found to be superior to a treatment with TNFa inhibitors alone in patients with psoriatic arthritis. CONCLUSIONS: Two trials with high validity demonstrated improvements, but this systematic review is not sufficient to prove the efficacy of balneotherapy in spondyloarthritis. More trials are needed with larger sample size to confirm the preliminary results observed and conclusively determine the benefits of balneotherapy.

2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis.

BACKGROUND: An important but often insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire a good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. Self-management skills can be helpful in this regard. OBJECTIVES: To develop recommendations for the implementation of self-management strategies in IA. METHODS: A multidisciplinary taskforce of 18 members from 11 European countries was convened. A systematic review and other supportive information (survey of healthcare professionals (HCPs) and patient organisations) were used to formulate the recommendations. RESULTS: Three overarching principles and nine recommendations were formulated. These focused on empowering patients to become active partners of the team and to take a more proactive role. The importance of patient education and key self-management interventions such as problem solving, goal setting and cognitive behavioural therapy were highlighted. Role of patient organisations and HCPs in promoting and signposting patients to available resources has been highlighted through the promotion of physical activity, lifestyle advice, support with mental health aspects and ability to remain at work. Digital healthcare is essential in supporting and optimising self-management and the HCPs need to be aware of available resources to signpost patients. CONCLUSION: These recommendations support the inclusion of self-management advice and resources in the routine management of people with IA and aim to empower and support patients and encourage a more holistic, patient-centred approach to care which could result in improved patient experience of care and outcomes.

Impact of Janus Kinase Inhibition on the Treatment of Axial Spondyloarthropathies.

Many immune cells and effector molecules (e.g. cytokines, Interferons, growth factors) utilize different combinations of Janus kinase (JAK) and signal transducer and activator of transcription (STAT) molecules to transduce signals from the cell surface to the nucleus, where they regulate transcription. This pathway is basically involved in almost all inflammatory diseases and also in the interleukin (IL)-23/IL-17 cascade, which is an essential part of the pathogenesis of spondyloarthropathies (SpA). Upon evidence from in vitro and in vivo experiments indicating disease-modifying effects of JAK inhibition in inflammatory joint disease, numerous inhibitors of the JAK/STAT pathway (= JAKinibs) with different selectivity against the four members of the JAK family [JAK1, JAK2, JAK3, and tyrosine kinase 2 (TYK2)] were developed. Trials in rheumatoid arthritis were successful with respect to efficacy and safety, and currently, three JAKinibs are approved for the treatment of rheumatoid arthritis in the European Union. Although new treatment options (anti-IL-23, anti-IL-17, and phosphodiesterase 4 inhibitors) have become available for spondyloarthritis and especially psoriatic arthritis (PsA) within the last years, most of them are biologics and do not address all disease manifestations equally. Therefore, multiple trials were initiated to evaluate JAKinibs in PsA and axial spondyloarthritis (axSpA). A trial of Tofacitinib (OPAL) was successful in PsA and has led to the inclusion of JAKinibs into the treatment algorithm. Currently many trials with JAKinibs are ongoing for PsA and axSpA, with one phase III trial of upadacitinib (selective JAK1 inhibitor) showing good therapeutic response in active radiographic axSpA.

Traditional Chinese medicine (TCM) collaborative care for patients with axial spondyloarthritis (AcuSpA): protocol for a pragmatic randomized controlled trial.

BACKGROUND: Axial spondyloarthritis (AxSpA) is a chronic disease which results in fatigue, pain, and reduced quality of life (QoL). Traditional Chinese medicine (TCM), especially acupuncture, has shown promise in managing pain. Although a TCM collaborative model of care (TCMCMC) has been studied in cancer, there are no randomized controlled trials investigating TCM in AxSpA. Therefore, we will conduct a pragmatic trial to determine the clinical effectiveness, safety, and cost-effectiveness of TCMCMC for patients with AxSpA. We define TCMCMC as standard TCM history taking and physical examination, acupuncture, and TCM non-pharmacological advice and communications with rheumatologists in addition to usual rheumatologic care. The purpose of this paper is to describe the rationale for and methodology of this trial. METHODS/DESIGN: This pragmatic randomized controlled trial will recruit 160 patients who are diagnosed with AxSpA and have inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). Simple randomization to usual rheumatologic care or the intervention (TCMCMC) with a 1:1 allocation ratio will be used. Ten 30-min acupuncture sessions will be provided to patients assigned to the TCMCMC arm. All participants will continue to receive usual rheumatologic care. The primary endpoint - spinal pain - will be evaluated at week 6. Secondary endpoints include clinical, quality of life, and economic outcome measures. Patients will be followed up for up to 52 weeks, and adverse events will be documented. DISCUSSION: This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of a TCMCMC for patients with AxSpA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03420404 . Registered on 14 February 2018.

Axial spondyloarthritis in the USA: diagnostic challenges and missed opportunities.

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease that primarily affects the sacroiliac joints and spine. Delayed or inadequate treatment may decrease quality of life and lead to poor long-term outcomes, including irreversible loss of spinal function. In this review, we discuss clinical practice related to axSpA within the USA, including prevalence, diagnosis, reasons for delayed/missed diagnosis, and suggestions for making early diagnosis. The US population prevalence of axSpA (0.9-1.4%) is higher than the diagnostic prevalence (0.2-0.7%). Although the estimated diagnostic delay for axSpA is 14 years in the USA, the disease can be identified earlier if appropriately preselected patients are quickly referred to rheumatologists. Only 37% of patients with ankylosing spondylitis in the USA are diagnosed by rheumatologists; the remaining 63% are diagnosed by primary care (26%), chiropractic/physical therapy (7%), orthopedic surgery (4%), pain clinics (4%), acute care (3%), and other settings (19%). To help reduce diagnostic delay, non-rheumatologist-healthcare professionals are urged to refer patients with back pain and ≥ 1 of 3 SpA features (HLA-B27 positivity, current inflammatory back pain, or x-ray/MRI evidence of sacroiliitis) to a rheumatologist. Prevalence and diagnosis rates of axSpA are disparate in the USA due to the lack of awareness and knowledge among non-rheumatologists. Progress has been made in identifying hurdles causing diagnostic delays. Public health initiatives are needed to guide primary care physicians, physical therapists, chiropractors, and other specialists seeing patients with chronic back pain on methods for suspecting or identifying axSpA and early referral to rheumatologists.

Adherence to biologic therapy - Does it vary with ethnicity?

BackgroundPoor adherence to therapy remains a significant barrier to improving clinical outcomes in rheumatic diseases and carries a major financial burden. It has been linked to medication related patient beliefs, which were reported to differ between ethnic groups. Little is known about these variations in biologic therapies cohorts. The purpose of this study was to identify potential determinants of adherence to biologic drugs including an assessment of the influence of beliefs about medicines and compare determinants of adherence between patients of Caucasian versus other ethnicities (OE). Relationship of adherence to disease outcome was further explored. MethodsA prospective survey was undertaken of patients with inflammatory arthritis prescribed self-administered subcutaneous biologic therapies at our centre. Data were collected using a) self reported adherence b) five item compliance questionnaire for Rheumatology (CQR5) and c) Beliefs about Medications questionnaire (BMQ) specific-five items each for necessity and concern scales. The replies were assessed against the disease activity score measured on the day of recruitment to the survey. Results80 patients contributed to the survey. 90% were prescribed TNF inhibitors. 40 patients were of Caucasian origin and 40 belonged to OE-predominantly of South Asian descent (85%). Disease activity score (DAS) was significantly higher in OE patients with 3.7 (standard deviation (SD) 1.3) compared to Caucasian patients with a DAS of 2.9 (1.6) (p = 0.031). Negative beliefs (i.e. higher concern scale scores) about therapy were significantly more prevalent (24/40) (60%) in the OE group compared to the Caucasian cohort (14/40 (35%) (p = 0.043). 17/40 (42.5%) of OE patients were poorly adherent to biologic therapy compared to 12/40 (30%) of Caucasian participants (p = 0.308). Most respondents (68/80, 85%) agreed that their biologic therapies were necessary for their health. Amongst 12/80 (15%) who disagreed, only two were in the non-adherent group. ConclusionTo our knowledge, this is the first study to demonstrate ethnic differences in disease activity score and related negative beliefs regarding subcutaneous biologic therapies in people with rheumatic diseases.

[Mesotherapy as a treatment of pain and disability in patients affected by neck pain in spondylartrosis]. / La mesoterapia come trattamento del dolore e della disabilità in pazienti affetti da cervicalgia in spondilartrosi.

Mesotherapy is a technique that treats locoregional pain with intradermal injection of a drug in the affected area. Its short-term efficacy was observed in patients with low back pain using both normal saline solution, if there were contraindications to drugs' use, or a cocktail of drugs (normal saline solution, lidocaine hydrochloride, and lysine acetylsalicylate), whereas only the latter provided benefit for up to three months after treatment. The aim of this study was to measure the effects of mesotherapy in patients affected by neck pain in spondylarthrosis, a common pathology in rehabilitation, associated with significant disability and increased health expenditure. One hundred patients participated in the study, of whom 50 (mean age 66.9 years) were treated with mesotherapy with a cocktail of drugs and 50 (mean age 64.7 years) with normal saline solution. Pain and disability were measured at different times (i.e. before treatment, at the end of five weeks of treatment, four weeks and 12 weeks after treatment), by using different pain scales, including a visual analogue scale, the short-form McGill pain questionnaire, the Present Pain Intensity scale and the Neck Disability Index. Mesotherapy with either normal saline solution or with a cocktail of drugs were both found to be effective in the short term in reducing pain and disability. However, only patients treated with a cocktail of drugs showed improvement at three months following treatment.

The Efficacy of Tai Chi and Yoga in Rheumatoid Arthritis and Spondyloarthropathies: A narrative biomedical review.

Rheumatoid arthritis (RA) and spondyloarthropathies (SpA) are among the most common inflammatory rheumatic diseases, which might induce chronic pain for their sufferers. Mind-body interventions like Tai Chi and yoga are among the many alternative therapies for combatting chronic pain. This review aims to overview the articles about their effectiveness in RA and SpA. We searched PubMed/MEDLINE, Scopus, and Web of Science for English-language sources from their inception through September 2017. Case-control studies, interventional studies, and case series that included more than three cases and randomized crossover studies were included. The literature search retrieved 133 non-duplicate records, and 15 of them were eligible and were included in this review. The influence of Tai Chi remains debatable in RA, while there is only one study that investigated its efficacy in SpA. Yoga seems effective in decreasing pain and inflammation while increasing quality of life. There are no data available about its effect on SpA. Even after a thorough research, the number of articles is quite limited on the effectiveness of Tai Chi and yoga in RA and SpA. While these complementary approaches still show some promise as alternative therapies in RA and SpA, the literature lacks long-term studies with larger patient groups.

[Short-term and medium-term efficacy of mesotherapy in patients with lower back pain due to spondyloarthrosis]. / Efficacia della mesoterapia a breve e medio termine in pazienti affetti da lombalgia muscolotensiva da spondilartrosi.

Mesotherapy is an intradermal treatment for patients with local pain. The literature describes the efficacy of mesotherapy in the treatment of musculoskeletal disorders measuring a reduction of analgesic drug intake and of healthcare spending. The aim of this study was to measure the effects of mesotherapy on pain and disability in patients with low back pain due to spondyloarthrosis.

Spine Conditions: Mechanical and Inflammatory Low Back Pain.

Mechanical low back pain (LBP) is an injury or derangement of an anatomic structure in the low back. When evaluating patients with LBP, clinicians should maintain clinical suspicion for vertebral fracture, cancer, and cauda equina syndrome. Management includes patient education focused on exercise, massage, and behavioral approaches such as cognitive behavioral therapy. Acupuncture can be an effective alternative and specific herbal supplements may provide short-term pain relief. The prognosis for patients with mechanical LBP is good. Inflammatory LBP is pain resulting from a systemic inflammatory condition, often referred to as axial spondyloarthritis. Ankylosing spondylitis is chronic inflammatory LBP characterized by early onset (mean age 24 years), with a higher prevalence in men. Five clinical parameters can help identify inflammatory LBP: improvement with exercise, pain at night, insidious onset, onset at younger than 40 years, and no improvement with rest. Management of inflammatory LBP typically includes nonsteroidal anti-inflammatory drugs and structured exercise programs, with emphasis on the involvement of a rheumatology subspecialist. Spondyloarthritis is associated with other rheumatic or autoimmune conditions, including rheumatoid arthritis, inflammatory bowel disease, and psoriasis. These should be considered when evaluating patients with inflammatory LBP.

Biologic Therapy for HLA-B27-associated Ocular Disorders.

The treatment of articular and extra-articular manifestations associated with HLA-B27 has undergone dramatic changes over the past two decades, mainly as a consequence of the introduction of biologic agents and in particular anti-tumor necrosis factor α (anti-TNFα) agents. Uveitis is known to be the most frequent extra-articular feature in HLA-B27-associated spondyloarthritides. Topical corticosteroids and cycloplegic agents remain the cornerstones of treatment. However, biologic therapy may be effective in the management of refractory or recurrent forms of uveitis. This review gives an update on the management of HLA-B27-associated ocular disorders with biologics, including anti-TNFα agents and non-anti-TNFα biologic modifier drugs. There is an emerging role for newer biologics targeting interleukin-12/23 and interleukin-17 for the treatment of spondyloarthritides but data on their efficacy on anterior uveitis are sparse.

Dolor en la articulación sacroilíaca: estudio prospectivo, aleatorizado, experimental y comparativo de la radiofrecuencia térmica con el bloqueo de la articulación sacroilíaca / Sacroiliac joint pain: Prospective, randomised, experimental and comparative study of thermal radiofrequency with sacroiliac joint block

Objetivo. Comparar el bloqueo con la radiofrecuencia térmica bipolar para el dolor de la articulación sacroilíaca. Método. Estudio prospectivo, aleatorizado y experimental en 60 pacientes, seleccionados en 9 meses en 2 centros, con dolor intenso (escala visual analógica [EVA] > 6) de > 3 meses de duración. Fueron divididos en 3 grupos (n = 20). Grupo A: pacientes a los que se les realizaron 2 bloqueos intraarticulares, con control ecográfico en 7 días. Grupo B: radiofrecuencia bipolar «palisade» utilizando 6 agujas perpendiculares a la zona dorsal del sacro, a una distancia de 1 cm, para producir lesiones contiguas entre los forámenes S1-S2-S3 y la línea articular. Grupo C: radiofrecuencia bipolar «palisade» modificada (distancia entre agujas > 1 cm). Los pacientes fueron evaluados al mes, a los 3 y a los 12 meses del tratamiento. Se valoraron los datos demográficos (en la visita basal), la eficacia analgésica y los efectos secundarios (en el resto). Resultados. Al mes, la reducción del dolor en los 3 grupos fue > 50% (p ≤ 0,001). A los 3 y 12 meses el grupo A no refirió disminución significativa del dolor. El grupo B, a los 3 meses, alivio cercano al 50% (p = 0,03), y < 25% (23,8) a los 12 meses (p = 0,01). En el grupo C, alivio próximo al 50% a los 3 y 12 meses (p < 0,001) respecto al basal. Todos los pacientes finalizaron el estudio. Conclusiones. La radiofrecuencia bipolar «palisade», especialmente aumentando la distancia entre las agujas, ha sido eficaz, a más largo plazo, que el bloqueo con anestésicos y corticoides en el alivio del dolor de la articulación sacroilíaca (AU)

Objective. To compare the analgesic effects between the blockade and bipolar thermal radiofrequency in the treatment of sacroiliac joint pain. Method. Prospective, randomised and experimental study conducted on 60 patients selected in the two hospitals over a period of nine months, who had intense sacroiliac joint pain (Visual Analogue Scale [VAS] > 6) that lasted more than 3 months. Patients were randomised into three groups (n = 20): Group A (two intra-articular sacroiliac injections of local anaesthetic/corticosteroid guided by ultrasound in 7 days). Group B: conventional bipolar radiofrequency «palisade». Target points were the lateral branch nerves of S1, S2, and S3, distance needles 1 cm. Group C: modified bipolar radiofrequency «palisade» (needle distance > 1 cm). Patients were evaluated at one month, three months, and one year. Demographic data, VAS reduction, and side effects of the techniques were assessed. Results. One month after the treatment, pain reduction was > 50% in the three groups P < .001. Three and 12 months after the technique, the patients of the group A did not have a significant reduction in pain. At 3 months, almost 50% patients of the group B referred to improvement of the pain (P = .03), and < 25% at 12 months, and those results were statistically significant (P = .01) compared to the baseline. Group C showed an improvement of 50% at 3 and 12 months (P < .001). All patients completed the study. Conclusions. Bipolar radiofrequency «palisade», especially when the distance between the needles was increased, was more effective and lasted longer, compared to join block and steroids, in relieving pain sacroiliac joint (AU)

Impaired quality of life in adults with X-linked hypophosphatemia and skeletal symptoms.

OBJECTIVE: Adults with X-linked hypophosphatemia (XLH) may suffer from skeletal symptoms leading to functional disability. No data on their quality of life (QoL) have been reported so far. Our objectives were to evaluate the QoL and its determinants in XLH adults. PATIENTS AND METHODS: We conducted a prospective study in XLH adults, who consulted for musculoskeletal symptoms between 2013 and 2014. We assessed their QoL using HAQ, RAPID3 and SF36, and analysed the variables associated with low QoL. We compared their QoL to that of patients affected with axial spondyloarthritis (ax-SpA) (paired on age and gender), a rheumatologic disorder with a known low QoL. RESULTS: Fifty-two XLH adults (37 women (71.1%); mean age 41.8±13.3 years) were included; 44 (84.6%) patients had an altered QoL. Increased age and presence of structural lesions were significantly associated with worse QoL (HAQ, RAPID3) (P<0.05). Presence of enthesopathies was significantly associated with worse RAPID3 (OR=4.45 (1.09-18.29), P=0.038). Treatment with phosphate supplements and vitamin D in XLH adults were significantly associated with a better SF36-mental component score (OR=0.14 (0.03-0.57), P=0.007 and OR=0.26 (0.07-0.98), P=0.047 respectively). QoL was significantly worse in XLH than in ax-SpA adults (VAS pain, SF36-PCS, RAPID3) (P<0.05). CONCLUSION: Our study showed i) QoL of XLH adults is altered and significantly worse than that of ax-SpA patients (VAS pain, SF36-PCS and RAPID3), ii) structural lesions and especially enthesopathies are associated with a worse QoL and iii) treatment using phosphate supplements and/or vitamin D is associated with a better mental health score.

How good is the coverage and how accurate are exposure data in the Swedish Biologics Register (ARTIS)?

OBJECTIVES: To assess the coverage of the Swedish Biologics Register (Anti-Rheumatic Therapy in Sweden, ARTIS) across indications, and the accuracy of the registered information on treatment with biologics. METHOD: Through cross-reference of ARTIS to almost complete national health registers on prescriptions (adalimumab and etanercept), outpatient visits, and death/residency during 2008-2010, we assessed: the treatment coverage of ARTIS for each treatment indication, the validity of the registered start and stop dates, ARTIS treatments with no corresponding drug dispensations, and the accuracy of the registered information on concomitant anti-rheumatic therapies. RESULTS: According to the national health registers, 3945 individuals with a spondyloarthropathy (SpA) and 8032 patients with rheumatoid arthritis (RA) had filled at least one adalimumab or etanercept prescription during the study period. Of these, 86% of those with SpAs and 95% of patients with RA were also found in ARTIS with the corresponding treatment. Tumour necrosis factor (TNF) inhibitor prescriptions had been filled by 95% of patients between the ARTIS start and stop dates (allowing a 90-day window). More than 60 days before and more than 60 days after the registered start date in ARTIS, 5% and 4% respectively of patients had filled their first TNF inhibitor prescription. More than 90 days after the registered stop date in ARTIS, 8% of patients had filled one or more TNF inhibitor prescriptions. CONCLUSIONS: We observed a high coverage and accuracy of ARTIS data on biologics exposure, for both SpAs and RA. The combination of data from clinical registers such as ARTIS with data from national health registers offers a high quality measurement of actual treatment.

Evidencia científica de la rehabilitación en la espondilitis anquilosante / Scientific evidence on rehabilitation in ankylosing spondylitis

Objetivo. Revisar la evidencia que justifica el tratamiento rehabilitador de la espondilitis anquilosante (EA) mediante ejercicio y educación, y analizar el contenido más adecuado. Estrategia de búsqueda. Revisión sistemática de estudios controlados, revisiones sistemáticas, metaanálisis y guías de práctica clínica de las bases de datos MEDLINE, SCOPUS, Web of Knowledge, Cochrane Library y PEDro desde enero de 2008 a diciembre de 2013. Selección de estudios. Se seleccionaron 14 artículos. Resultados. Todos los estudios, así como las publicaciones de revisión, que investigan la eficacia del ejercicio terapéutico, exponen beneficios en los diferentes parámetros funcionales que definen la enfermedad. Se prefieren los ejercicios grupales supervisados, ya sean dentro o fuera del agua y, en su defecto o de manera complementaria, en el domicilio. Deben tenerse presentes las motivaciones, deseos, expectativas y fatiga del paciente. Los programas de rehabilitación han demostrado ser costo-eficaces. Conclusión. La rehabilitación se muestra eficaz para el tratamiento de la EA (AU)

Objective. To review the evidence on the rehabilitation treatment of ankylosing spondylitis (AS) through exercise and education and to analyze the most appropriate content. Search strategy. We carried out a systematic review of controlled trials, systematic reviews, meta-analyses and clinical practice guidelines in MEDLINE, SCOPUS, Web of Knowledge, Cochrane Library, and PEDro published from January 2008 to December 2013. Study selection. 14 articles were selected. Results. All studies, as well as review articles, that investigated the efficacy of therapeutic exercise demonstrated benefits in the various functional parameters of the disease. Supervised group exercises are preferred, whether in or out of water, or even at home as a supplement or alternative. Factors that should be considered are patients’ motivations, desires, expectations, and fatigue. Rehabilitation programs have been demonstrated to be cost-effective. Conclusion. Rehabilitation is effective in the treatment of AS (AU)

[Analisis of the budget impact of adalimumab and etanercept in rheumatoid arthritis and spondyloarthropathies]. / Análisis del impacto presupuestario de adalimumab y etanercept en artritis reumatoide y espondiloartropatías.

PURPOSE: To assess the economic impact derived from the widening of the administration intervals of adalimumab (ADA) and etanercept (ETN) for the treatment of rheumatoid arthritis (RA) and spondyloarthropathies (SAP) at our working environment. MATERIAL AND METHODS: A budget impact model (BIM) was developed to estimate the economic impact that would have widening the usual administration intervals of ADA, 40 mg every 2 weeks and ETN, 50 mg weekly (scenario A), to ADA, 40 mg every 3 weeks, and ETN, 50 mg every 2 weeks (scenario B) according to the guidelines and recommendations applied to these studies, specifying the target population, the study perspective, the temporal horizon, and analysing the study robustness by a threshold univariate sensitivity analysis. RESULTS: 71 patients were included in the study. The application of the BIM showed yearly savings for ADA and ETN of 19.784 ??and 38.271 ?, respectively. The net cost, that is to say the saving that this would imply within the temporal horizon considered (2 years), was 116.110 ?. The sensitivity analysis showed that the estimated BIM for the study period was very robust since the net result in the different scenarios varied very little, being negative in the new scenarios. CONCLUSIONS: widening the administration intervals of ADA and ETN to every 3 weeks and 2 weeks respectively, would be a strategy that would allow generating savings in the hospital budget close to 116.110 ??for the temporal horizon considered, achieving this way optimization of the treatment with these two drugs.

Objetivo: Evaluar el impacto económico derivado de la ampliación de los intervalos de administración de adalimumab (ADA) y etanercept (ETN), en el tratamiento de la artritis reumatoide (AR) y espondiloartropatias (EAP) en nuestro ámbito de trabajo. Material y método: Se desarrolló un modelo de impacto presupuestario (MIP) para estimar la repercusión económica que tendría la ampliación en los intervalos habituales de administración de ADA 40 mg cada dos semanas y ETN 50 mg semanal (escenario A), por ADA 40 mg cada tres semanas y ETN 50 mg cada dos semanas (escenario B) de acuerdo a las guías y recomendaciones que se aplican a estos estudios, especificando la población diana, la perspectiva del estudio, el horizonte temporal y analizando la robustez del estudio a través de un análisis de sensibilidad univariante de tipo umbral. Resultados: Se incluyeron un total de 71 pacientes en el estudio. La aplicación del MIP mostró unos ahorros anuales para ADA y ETN de 19.784??y 38.271 ??respectivamente. El coste neto, es decir, el ahorro que esto supuso en el horizonte temporal considerado (dos años) ascendió a 116.110 ?. El análisis de sensibilidad realizado mostró que el MIP estimado para el periodo de estudio fue muy robusto ya que el resultado neto en diferentes escenarios apenas variaba, manteniéndose negativo en los nuevos escenarios. Conclusiones: La ampliación de los intervalos de administración de ADA y ETN cada tres semanas y dos semanas respectivamente, sería una estrategia que permitiría generar ahorros en el presupuesto hospitalario cercanos a los 116.110 ??en el horizonte temporal considerado, consiguiendo así una optimización del tratamiento con estos fármacos.

Synovial fluid metabolomics in different forms of arthritis assessed by nuclear magnetic resonance spectroscopy.

OBJECTIVES: Currently there are no reliable biomarkers in the synovial fluid available to differentiate between septic and non-septic arthritis or to predict the prognosis of osteoarthritis, respectively. Nuclear magnetic resonance (NMR) spectroscopy is an analytical technique that allows a rapid, high throughput metabolic profiling of biological fluids or tissues. METHODS: Proton (1H)-nuclear magnetic resonance (NMR) spectroscopy was performed in synovial fluid samples from patients with septic arthritis, crystal arthropathy, different forms of inflammatory arthritis or osteoarthritis (OA). The metabolic environment based on the low molecular weight components was compared in disease subsets and principal component analysis (PCA) was performed. RESULTS: Fifty-nine samples from patients with OA, gout, calcium pyrophosphate disease, spondylarthritis, septic arthritis and rheumatoid arthritis (RA) were analysed. NMR yielded stable and reproducible metabolites over time. Thirty-five different metabolites as well as paracetamol and ibuprofen were identified in synovial fluid. The metabolic profile of septic arthritis assessed by PCA was distinguishable from the other samples whereas no differences were seen in OA compared to crystal-associated arthritis, RA or spondylarthritis. CONCLUSIONS: 1H-NMR is a fast analytic tool with possible implications in synovial fluid diagnostics. A distinctive metabolism is observed in septic arthritis whereas metabolites in OA are similar to those in inflammatory arthritis.

Renal osteodystrophy: neurosurgical considerations and challenges.

BACKGROUND: Dialysis-associated destructive spondyloarthropathy (DSA) is the major bony complication of end-stage renal disease, most commonly found in the lower cervical region. The risk factors for developing dialysis-associated DSA include duration of hemodialysis and patient age. Patients with DSA have a higher incidence of osteoporosis and poor bone mineral density, which may place them at greater risk of atraumatic fractures, instrumentation failure, and neurologic compromise. METHODS: We describe a case of cervical radiculopathy due to dialysis-associated DSA atraumatic vertebral body fractures with a postoperative course that was complicated by instrumentation failure. We reviewed the literature regarding all 138 published cases, presenting the complications, surgical treatment options, and outcomes. RESULTS: A 44-year-old dialysis-dependent man presented with acute neck pain, radiculopathy, and weakness due to atraumatic fracture of C5 and C6 vertebral bodies. He underwent anterior C5 and C6 corpectomies, reconstruction with mesh cage and plate, and supplemental posterior instrumentation (C4-T1). Six weeks later, a computed tomography scan revealed anterior translation across the instrumented area with failure of the posterior instrumentation. He subsequently underwent traction, revision reinstrumentation from C2 to T5, and placement of external halo ring/jacket for 6 months. At 18 months later, he remains ambulatory without evidence of construct failure. CONCLUSIONS: Patients with renal osteodystrophy present a challenge for the spine surgeon due to compromised bone density. Hardware failure at the bone-construct interface is common in these patients, with revision surgery needed in 22% of published cases. Longer constructs with circumferential instrumentation and halo immobilization may minimize the risk of pseudoarthrosis and construct pull-out.

Farmacoeconomía de la terapia biológica de las espondiloartropatías: [revisión] / Biological therapy pharmacoeconomics of the spondyloarthropathies: [review]

Las espondiloartropatías (EAS) son un grupo de enfermedades reumatológicas crónicas e inflamatorias. El diagnóstico de estas patologías frecuentemente es tardío; su curso evolutivo es progresivo, con el consecuente deterioro funcional y discapacidad, con compromiso articular que conlleva a la disminución en la calidad de vida con un alto impacto socioeconómico. La mayoría de los estudios farmacoeconómicos se enfocan en los aspectos de la sociedad o del proveedor de los servicios de salud, y sólo una minoría toma en cuenta la perspectiva del paciente, de donde se pueden estimar los recursos médicos directos e indirectos que el paciente y su familia destinan al tratamiento de la enfermedad. La terapia biológica ha demostrado control de todos los aspectos de la actividad de la enfermedad, incluyendo reactantes de fase aguda, dolor y rigidez, capacidad funcional, movilidad espinal, artritis periférica y entesitis.