A new perspective on vitamin B12 deficiency in rheumatology: a case-based review.

Vitamin B12 (cobalamin) deficiency is common in patients with rheumatic diseases. Pernicious anemia is a well-known cause, but recent reports suggest that autoimmune-derived deficiency may not be limited to this cause alone. Symptoms of low vitamin B12 concentration are often deceptive, mimicking and overlapping with symptoms of other conditions. Neuropsychiatric manifestations, anemia, and fatigue are frequently attributed to a rheumatic disease without further evaluation. In this study, we present three cases of patients with neuropathic pain, depression, fatigue, and muscle weakness, initially attributed to a rheumatic disease, which almost completely resolved after implementing vitamin B12 supplementation. Furthermore, we provide an overview of current scientific reports regarding the potential use of cobalamin in rheumatology. Treatment of pain and neuropathy, often very challenging in long-lasting rheumatic diseases, can be more effective after a course of vitamin B12, even when no apparent deficiency is detected in laboratory tests. Considering recent research demonstrating vitamin B12's nerve-protecting properties, we recommend that physicians should assess vitamin B12 levels early in the diagnostic process of rheumatic diseases. In specific cases, physicians should consider cobalamin supplementation regardless of vitamin B12 serum concentration.

The effect of COVID-19 infection on patients with rheumatic diseases in China.

OBJECTIVES: At the end of 2022, the COVID-19 outbreak erupted in China, and BA.5.2 or BF.7 subtypes of Omicron novel variations were implicated in more than 90% of the cases. We created a real-world questionnaire survey to better understand how this new variant pandemic was affecting rheumatic patients in China. METHODS: During the COVID-19 outbreak in China, the subjects of this study were rheumatic patients and non-rheumatic individuals (control group), who were matched for sex and age. Professional physicians carefully questioned the participants before administering a questionnaire as part of the study. This study focused on the general baseline characteristics, clinical symptoms and treatment after COVID-19 infection, and the target populations' awareness of COVID-19. RESULTS: The study included 1130 participants, of whom 572 were assigned to the rheumatic group and 558 to the control group. The percentage of vaccinated controls was significantly higher than that of rheumatic patients (90.1% vs. 62.8%, p < 0.001), while the rate of COVID-19 infection was not significantly different between the two groups (82.3% vs. 86.6%, p = 0.051). Patients with rheumatic disease experienced substantially more days of fever following infection (2.87 ± 3.42 vs. 2.18 ± 1.65, p = 0.002) compared to individuals in the control group. The rheumatic patients had a greater prevalence of cough (67.1% vs. 54.0%, p < 0.001), somnipathy (13.8% vs. 6.0%, p < 0.001), and conjunctivitis/ophthalmodynia (5.3% vs. 2.1%, p = 0.008), while dry throat/throat pain/weakness (49.9% vs. 59.4%, p = 0.003), myalgia/osteodynia (33.3% vs. 41.8%, p = 0.003), and dyspnea (14.0% vs. 25.3%, p < 0.001) were more likely to occur in non-rheumatic group after infection. Human immunoglobulin (2.1% vs. 0.2%, p = 0.006), glucocorticoids (19.5% vs. 1.6%, p < 0.001), oxygen support (6.8% vs. 2.1%, p < 0.001), and traditional Chinese medicine (21.9% vs. 16.6%, p = 0.037) were all more frequently used by rheumatic patients with COVID-19 infection. People in the control group were more confused about whether to use masks in following social activities after contracting COVID-19 (14.7% vs. 7.6%, p = 0.001). In the control group, more individuals than patients with rheumatic disease (25.1% vs. 13.4%, p < 0.001) expressed an interest to receive the vaccine again. After being exposed to COVID-19, the majority of rheumatic patients (66.9%) reported no discernible change, only 29.1% reported a worsening of their symptoms, and the remaining 4% indicated an improvement. CONCLUSIONS: After the COVID-19 outbreak in China, the proportion of patients with rheumatic diseases infected with the virus was similar to that of normal individuals. But the clinical symptoms, follow-up treatment requirements, and awareness of the COVID-19 among rheumatic patients were distinct from those among non-rheumatic patients, necessitating the use of individualized diagnosis and treatment plans as well as health advice by medical professionals in clinical work. Key Points • Despite there were different comorbidities and vaccination rates, the rate of COVID-19 infection in patients with rheumatic disease was similar to that of normal individuals. • After COVID-19 infection, rheumatic patients and normal controls had different clinical symptoms and drug usage. • After being exposed to COVID-19, the majority of rheumatic patients felt no significant change in the primary disease, while the normal controls was more likely to accept a new vaccine injection and confused about whether to use masks in following social activities.

Anemia and iron deficiency in pregnant women with rheumatic diseases.

INTRODUCTION: Anemia and iron deficiency are the most common pathologies in pregnancy and associated with adverse pregnancy outcome. As patients with rheumatic diseases are also at high risk for anemia, we aimed to investigate the frequency of anemia and iron deficiency during pregnancy in this group and whether anemia is a risk factor for adverse maternal or child outcome. METHODS: We analyzed 368 pregnancies from a German registry for pregnancies in patients with rheumatic diseases (TURIRE) from 2014-2022. Anemia and iron deficiency were defined according to the World Health Organization. Main outcome measures were prevalence of anemia, iron deficiency, and adverse outcomes. RESULTS: From the 368 patients 61% were diagnosed with a connective tissue disease, 16% with rheumatoid arthritis or juvenile idiopathic arthritis, 14% with spondyloarthritis, 3% with vasculitis and 7% with other. Prevalence of anemia/iron deficiency was 18%/28% in the first, 27%/51% in the second and 33%/62% in the third trimester. Low hemoglobin levels (OR 0.52) or iron deficiency (OR 0.86) had a negative impact on child outcome. However, lower hemoglobin levels were associated with a lower risk for maternal complications (OR 1.47). CONCLUSION: Prevalence of anemia and iron deficiency is high in pregnant women with rheumatic diseases. Compared to previously published cohorts of the general population from different countries, the prevalence of anemia and iron deficiency is distinctly higher. Furthermore, patients with rheumatic diseases already start with impaired iron storage and/or hemoglobin levels. Thus, iron supplementation should be initiated early on in this vulnerable in this patient group.

Can vitamin D be an adjuvant therapy for juvenile rheumatic diseases?

Vitamin D, known for its essential role in calcium and bone homeostasis, has multiple effects beyond the skeleton, including regulation of immunity and modulation of autoimmune processes. Several reports have shown suboptimal serum 25 hydroxyvitamin D [25(OH)D] levels in people with different inflammatory and autoimmune rheumatic conditions, and an association between 25(OH)D levels, disease activity and outcomes. Although most available data pertain to adults, insights often are extended to children. Juvenile rheumatic diseases (JRDs) are a significant health problem during growth because of their complex pathogenesis, chronic nature, multisystemic involvement, and long-term consequences. So far, there is no definitive or clear evidence to confirm the preventive or therapeutic effect of vitamin D supplementation in JRDs, because results from randomized controlled trials (RCTs) have produced inconsistent outcomes. This review aims to explore and discuss the potential role of vitamin D in treating selected JRDs. Medline/PubMed, EMBASE, and Scopus were comprehensively searched in June 2023 for any study on vitamin D supplementary role in treating the most common JRDs. We used the following keywords: "vitamin D" combined with the terms "juvenile idiopathic arthritis", "juvenile systemic scleroderma", "juvenile systemic lupus erythematosus", "juvenile inflammatory myopathies", "Behcet disease", "periodic fever syndromes" and "juvenile rheumatic diseases". Observational studies have found that serum 25(OH)D concentrations are lower in juvenile idiopathic arthritis, juvenile systemic lupus erythematosus, juvenile systemic scleroderma, Behcet disease and proinflammatory cytokine concentrations are higher. This suggests that vitamin D supplementation might be beneficial, however, current data are insufficient to confirm definitively the complementary role of vitamin D in the treatment of JRDs. Considering the high prevalence of vitamin D deficiency worldwide, children and adolescents should be encouraged to supplement vitamin D according to current recommendations. More interventional studies, especially well-designed RCTs, assessing the dose-response effect and adjuvant effect in specific diseases, are needed to determine the potential significance of vitamin D in JRDs treatment.

Effects of yoga on depressive symptoms, anxiety, sleep quality, and mood in patients with rheumatic diseases: Systematic review and meta-analysis.

OBJECTIVE: To investigate the effects of yoga on depressive symptoms, anxiety, sleep quality, and mood of patients with rheumatic diseases through a systematic literature review with meta-analysis. LITERATURE SURVEY: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and the Cochrane recommendations and risk of bias tool. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO). Studies were selected using the PICOS (participants, intervention, comparison, outcome, and study) strategy. Searches were carried out until March 2022 and performed in Web of Science, PubMed, SportDiscus, Scopus, Cochrane, and EBSCO databases. METHODOLOGY: Data were extracted to identify the differences between yoga and control and exercise groups and effect sizes. SYNTHESIS: In total, 27 studies were included for qualitative analysis and 18 for meta-analysis. The studies found investigated yoga in patients with osteoarthritis, fibromyalgia, rheumatoid arthritis, and chronic fatigue syndrome. Regarding the risk of bias, the majority of studies showed a high risk or uncertain risk of bias in several criteria. Regarding the meta-analysis, yoga was favored to decrease depressive symptoms (standard mean difference [SMD]:-0.88; 95% confidence interval [CI]:-1.42; -0.34), anxiety (SMD: -0.51; 95% CI = -0.81 to -0.20), and improve sleep quality SMD = -0.96; 95% CI = -1.36 to -0.56). No differences were found between yoga and other exercise modalities in depression (p < .01). CONCLUSIONS: Yoga is effective in improving depression, anxiety, and sleep quality of patients with rheumatic diseases. However, research in this field still needs further studies, because of methodological issues in the studies and a reduced number of studies conducted on each rheumatic disease and on the effects of yoga on each variable.

[Assessment of pain in patients with rheumatic disease under biological therapy treatment].

BACKGROUND: To assess pain in patients with rheumatic disease under biological therapy treatment. METHODS: Observational retrospective study of patients with rheumatic disease under biological therapy treatment who visited the health care center as outpatients in February/August 2020. We collected demographic (sex and age), clinical (diagnosis, pain presence, intensity, and location), and pharmacological (biological therapy, concomitant treatment with traditional DMARDs, and analgesic treatment) variables from the electronic medical records and Farmatools Dominion®. RESULTS: We included 138 patients; mean age was 56 years and 71% were female. The most frequent diagnosis (47%) was ankylosing spondylitis. Anti-TNF-a was the most prescribed biological drug (64%); 60.1% of study patients received traditional drugs, particularly methotrexate and leflunomide (51.8 and 28.9%, respectively). Pain was reported in 81% of the cases, particularly in hands (73.2%) and knees (69.6%); mean pain intensity was 6.5 (VAS). Although 83.3% of the patients had been prescribed analgesics, pain persisted in 84.8% of the cases (VAS >4), being severe or very severe in 67.9%. Over half of the patients (52.2%) used more than one analgesic. The most frequently prescribed medications were non-steroidal anti-inflammatory drugs (NSAIDs) (60%), paracetamol (52.2%), and opioids (56.5%). NSAIDs controlled pain (14.5%) better than opioids (8.3%); there was no post-treatment improvement of pain in 29.6% of the patients. The number of prescribed drugs increased with pain intensity (rho= 0.264; p= 0.006). CONCLUSION: Almost 70% of study patients had uncontrolled severe rheumatic-related pain. This implies a challenge for esta­blishing effective treatments for this type of pain.

Active tuberculosis infection in moroccan patients with rheumatic diseases under biologic therapy: A multicenter national study.

Background: The aim of this study was to evaluate the prevalence of active tuberculosis (TB) infection in Moroccan patients with rheumatic diseases under biologic therapy, and to describe the demographic characteristics of these patients as well as to explore potential risk factors. Methods: This 14-year nationally representative multicenter study enrolled Moroccan patients with rheumatic diseases who had been treated with biologic therapy. Patient medical records were reviewed retrospectively for demographic characteristics, underlying rheumatic diseases, associated comorbidities, and TB-related data. Results: In total, 1407 eligible patients were studied, detailed records were obtained for only 130 patients; 33 cases with active TB were identified at an estimated prevalence rate of 2.3%. The mean age was 42.9 ± 12 years and 75.8% were males. Ankylosing spondylitis accounted for 84.8% of active TB cases, and the majority of the cases (31/33) occurred among antitumor necrosis factor-alpha (TNF-α) users. A total of 8 out of 33 patients were positive at initial latent TB infection (LTBI) screening by tuberculin skin test and/or interferon-gamma release assay. Consumption of unpasteurized dairy products (odds ratio [OR], 34.841; 95% confidence interval [CI], 3.1-389.7; P = 0.04), diabetes (OR, 38.468; 95% CI, 1.6-878.3; P = 0,022), smoking (OR, 3.941; 95% CI, 1-159.9; P = 0.047), and long biologic therapy duration (OR, 1.991; 95% CI, 1.4-16.3; P = 0.001) were identified as risk factors for developing active TB. Conclusion: Moroccan patients with rheumatic diseases under anti-TNF-α agents are at an increased TB risk, especially when risk factors are present. Strict initial screening and regular monitoring of LTBI is recommended for patients living in high TB prevalence areas.

[Preoperative anemia in patients with rheumatic diseases]. / Präoperative Anämie beim Rheumatiker.

A preoperative anemia is an independent risk factor for the occurrence of complications during and after surgical interventions. It is associated with an increased length of hospital stay, higher mortality and an increased use of blood transfusions. Anemia affects some 30-70% of patients suffering from inflammatory rheumatic diseases, mostly caused by iron deficiency and/or chronic inflammation. The possibilities to treat anemia in rheumatic patients were extremely limited for a long period of time as older studies showed life-threatening side effects, the need of high doses of iron supplements or the occurrence of many nonresponders. Further development of the supplements, new dosage schemes and the combination of supplements increased the efficacy and reduced the occurrence of side effects to a minimum. In addition to orthopedic surgical interventions for rheumatism that despite new therapeutic options in some cases still represent the only way to alleviate the complaints, more and more patients with inflammatory rheumatic diseases also need surgical interventions due to comorbidities. Therefore, anemia should be clarified and preoperatively treated in accordance with the new study situation, to minimize additional complications due to anemia and to increase patient safety.

[COVID-19 and inflammatory rheumatic diseases]. / COVID-19 und rheumatische Erkrankungen ­ bisherige Erkenntnisse der Pandemie.

Older age, cardiovascular comorbidities, chronic lung diseases, and GC use were identified as independent risk factors for severe courses of COVID-19 resulting in the need of hospitalization. Glucocorticoid dosis of > 10 mg over a longer period of time should be very carefully used as there are various immunomodulatory alternatives. Of particular note, disease activity of inflammatory rheumatic diseases (IRD) was also identified as an independent predictor of COVID-19 related hospitalization.Already in the early phase of the pandemic case reports of fatal courses of IRD patients under treatment with rituximab were reported. Meanwhile, several data could demonstrate higher rates of hospitalization and COVID-19-related deaths. Whether a similar effect is detectable regarding Janus kinase inhibitors in patients with rheumatoid arthritis is currently under investigation.Preliminary data indicate that all available COVID-19 vaccines in Europe are not associated with higher rates of disease flares or differences of side effect profiles compared to the general population. There is no recommendation to discontinue or reduce immunomodulatory treatment in general to achieve better immune response. In the case of Rituximab, consideration should be given to postponing or switching to alternative therapies, taking into account the risk of reactivation of the underlying disease on the one hand and the improvement of a potential vaccine response on the other.

Reducing fatigue in pediatric rheumatic conditions: a systematic review.

BACKGROUND: Although fatigue is a prevalent distressing symptom in children and adolescents with Pediatric Rheumatic Conditions (PRCs), intervention studies designed for reducing fatigue in PRCs are limited. AIM: To systematically review evidence regarding the efficacy of interventions intended to reduce fatigue in patients with PRCs. METHODS: Comprehensive electronic searches were performed in PubMed/ MEDLINE, Embase, Web of Science and Cinahl. The risk of bias was assessed using the 'Revised Cochrane risk-of-bias tool for randomized trials' and 'Quality Assessment Tool for Before-After Studies With No Control Group' for respectively studies with and without a control group. RESULTS: Ten out of 418 studies were included with a total of 240 participants (age range 5-23 years). Interventions included land-based and aquatic-based exercise therapy, prednisolone, vitamin-D and creatine supplementation, psychological therapy and a transition program into an adult rheumatology program. Fatigue was assessed with self-reported questionnaires in all included studies. Land-based exercise therapy was effective in one pre-post intervention study, whereas not effective in two randomized controlled trials. Aquatic-based exercise therapy was found more effective than land-based exercise therapy. Two placebo-controlled studies showed a significant positive effect in reducing subjective fatigue with prednisolone and vitamin-D. Creatine was not found effective. Cognitive therapy was effective in one pre-post intervention study, while one RCT did not show an effect in reducing fatigue. A transition program based on health education showed a small reducing effect, however, it was not clear if this was a significant effect. Six studies showed a high risk of bias, three studies a moderate risk, and one study had a low risk of bias. CONCLUSIONS: Insufficient evidence is provided to substantiate the efficacy of current interventions to reduce fatigue in PRCs. The low number of studies, non-comparable interventions, risk of bias, and inconclusive outcomes of the included studies denote future research should focus on intervention studies aimed at the treatment of fatigue in children and adolescents with PRCs. Identification of possible underlying biological and psychosocial mechanisms as possible treatment targets to reduce complaints of fatigue in children and adolescents with PRCs is warranted.

Efficacy of a fixed combination of palmitoylethanolamide and acetyl-l-carnitine (PEA+ALC FC) in the treatment of neuropathies secondary to rheumatic diseases.

BACKGROUND: The neurologic complications of rheumatic diseases (RDs) are highly variable, and their manifestations are linked to the pathogenesis and clinical phenotype of the specific RDs. In rheumatoid arthritis, for example, the peripheral nervous system is most commonly involved and mononeuritis multiplex, nerve entrapment and vasculitic sensorimotor neuropathies are not uncommon. Often the therapy for these disorders is not easy and is characterized by the use of different drugs. Palmitoylethanolamide (PEA) has been tested in a wide variety of animal models and has been evaluated in several clinical studies for nerve compression syndromes, demonstrating that PEA acts as an effective and safe analgesic compound. Acetyl-L-Carnitine (ALC) has also been shown to be an effective and safe treatment in painful peripheral neuropathy. In the last years the synergistic effect between PEA and ALC has been demonstrated. The aim of our study was to evaluate the efficacy of supplementation of standard therapy (STh) with Kalanit® (Chiesi Italia Spa; Parma, Italy) in patients with peripheral neuropathy secondary to RDs. METHODS: Patients at the time of enrollment were affected by RDs with neuropathy from <12 months, documented by electromyography. The analyzed patients were treated with the STh chosen according to their rheumatic disease (RA or SpA) and for their neuropathy (e.g. analgesic, NSAIDs, pregabalin or gabapentin) as per clinical practice. The sample was divided into 2 groups: group 1, patients treated with STh, to which a fixed combination of PEA (600 mg) + ALC (500 mg) (Kalanit®) was added twice a day for 2 weeks and then once a day for 6 months; group 2, patients treated only with STh. Each patient underwent clinical evaluations and questionnaires were administered in order to evaluate their neuropathy and the efficacy of the therapy. RESULTS: In group 1, 18 patients suffering from sciatic pain, 16 patients from carpal tunnel syndrome and 8 patients with peripheral neuropathy of the lower limbs were included and PEA + ALC FC was added to STh. These patients were compared with patients from group 2, who had the same pathology and demographic characteristics: 20 patients with sciatic pain, 15 with carpal tunnel syndrome and 5 with peripheral neuropathy of the lower limbs, respectively; this group was treated with STh only. Patients treated with PEA + ALC FC had a significant improvement in pain VAS compared to patients treated with group 2 in all the diseases analyzed (P value: sciatic pain 0.032, carpal tunnel syndrome 0.025 and lower limbs neuropathy 0.041). Patients in group 1 showed a significant improvement compared to patients treated in group 2 also from a specific score. Specifically, LBP-IQ showed significant improvement in group one (P value: 0.031), as did CHFD (P=0.011) and NPQ (P=0.025). CONCLUSIONS: The synergistic effect of PEA and ALC seems to have a further advantage in the treatment of this type of pathology, including the anti-inflammatory effect but also in terms of therapy optimization and therefore of better adherence to treatments. Our study shows that it is important to identify the type of pain to follow an accurate diagnostic algorithm, considering the clinical characteristics of the patient and carefully evaluate the indication, preferring a multimodal approach.

Carpal Tunnel Syndrome in Autoimmune Rheumatic Diseases and Inflammatory Bowel Diseases: Retrospective Population Cohort Study.

OBJECTIVE: The relationship between autoimmune rheumatic diseases, inflammatory bowel diseases, and carpal tunnel syndrome is unclear. We aimed to survey the occurrence and characteristics of carpal tunnel syndrome in autoimmune rheumatic diseases and inflammatory bowel diseases, compared with the general population. METHODS: We used the Longitudinal Health Insurance Database 2015 from Taiwan's National Health Insurance Research Database. Patients diagnosed with autoimmune rheumatic diseases/inflammatory bowel diseases were identified. The incidence rates and surgical rates of carpal tunnel syndrome among individual diseases were calculated. The hazard ratios when compared with age and sex matched, and 1:1 ratio control groups were surveyed. RESULTS: A total of 2591 women and 701 men were identified. The incidence rate of carpal tunnel syndrome was highest in Crohn disease (1001 per 100,000 person-years, 95% confidence interval = 0-2747), followed by scleroderma and Sjögren syndrome. The incidence rate in the control group was 571 per 100,000 person-years (95% confidence interval = 314-829). Significantly increased adjusted hazard ratios were seen in Sjögren syndrome (1.44, 95% confidence interval = 1.09-1.90) and rheumatic arthritis (1.33, 95% confidence interval = 1.05-1.70). The overall surgical rate was 0.2% in patients with autoimmune rheumatic diseases/inflammatory bowel diseases and 0.3% in the control group, without a significant difference (P = 0.85). CONCLUSIONS: Patients with Sjögren syndrome and rheumatic arthritis are susceptible to carpal tunnel syndrome. Patients with autoimmune rheumatic diseases/inflammatory bowel diseases have similar surgical rates as general population.

Approach to Patients with Unintentional Weight Loss.

Unintentional weight loss is a common clinical problem with a broad differential diagnosis that is clinically important because of the associated risks of morbidity and mortality. Community-dwelling adults are often diagnosed with malignancy, nonmalignant gastrointestinal disorders, and psychiatric disorders as the cause of unintentional weight loss, whereas institutionalized older adults are diagnosed most often with psychiatric disorders. Up to a quarter of patients do not have a diagnosis after comprehensive workup, and close follow-up is warranted. Treatment involves management of underlying causes.

Cannabis use assessment and its impact on pain in rheumatologic diseases: a systematic review and meta-analysis.

OBJECTIVES: Despite classic analgesic or effective treatments in rheumatic diseases, such as synthetic DMARDs in RA, patients remain in pain and often turn to non-prescribed pharmacological alternatives, such as cannabis self-therapeutic use. However, this medical use of cannabis has not been thoroughly studied. METHODS: We performed a systematic literature review up to June 2020. The incidence of cannabis consumption was calculated by metaproportion. Differences between cannabis users and non-users were expressed as standardized mean differences using the inverse-variance method. We also assessed the effects of cannabis on pain. RESULTS: A total of 2900 patients reported cannabis consumption in a sample of 10 873 patients [incidence 40.4% (95% confidence interval (CI): 0.28, 0.54)], and 15.3% (95% CI: 0.07, 0.27) specified that they were currently taking cannabis. Cannabis use was higher in the four fibromyalgia studies [68.2% (95% CI: 0.41, 0.90), n = 611] compared with seven articles concerning RA or lupus [26.0% (95% CI: 0.14, 0.41), n = 8168]. Cannabis consumption was associated with a decrease in pain intensity [VAS pain at baseline 8.2 (2.9) vs 5.6 (3.5) mm over time; pooled effect size -1.75 (95% CI: -2.75, -0.76)]. Cannabis users were younger [58.4 (11.4) vs 63.6 (12.1) years; P <0.001], more often smokers [OR 2.91 (95% CI: 1.84, 4.60)] or unemployed [OR 2.40 (95% CI: 1.31, 4.40)], and had higher pain intensity [5.0 (2.4) vs 4.1(2.6) mm; P <0.001] than non-users. CONCLUSION: Nearly 20% of patients suffering from rheumatologic diseases actively consume cannabis, with an improvement in pain. The issue of cannabis use in the management of these patients should be addressed during medical consultation, essentially with cannabis-based standardized pharmaceutical products.

[Chronic pain syndrome in diseases of periarticular tissues]. / Khronicheskii bolevoi sindrom pri zabolevaniyakh periartikulyarnykh tkanei.

The search for an effective method of treating diseases of the musculoskeletal system is a rather actual problem for a practicing physician nowadays in connection with the modern lifestyle of most people. A prolonged stay in the same position, as a rule, leads to overstrain of the capsule-joint complexes, and, as a consequence, to the development of degenerative changes in the joints and periarticular tissues. These changes can manifest themselves clinically in the form of a chronic or acute pain syndrome. One of the common diseases characterized by degenerative periarticular changes with a variety of clinical manifestations are periarthropathies. Periarthropathy or periarthrosis is still the subject of discussion by doctors of related specialties: neurologists, orthopedists, rheumatologists, etc. Pain in this case can be caused by the primary degenerative process in muscles and tendons in combination with their chronic microtraumatization, ischemia, and reactive inflammation. Periarthropathy can be considered as a «train¼ of any arthropathy, because pain always causes muscle spasm, a change in the motor stereotype, a limitation of motor activity in the joint, etc. In the absence of joint pathology, it should be considered as a primary disease. There is still no common understanding of this nosological unit, including pathogenesis, classification, diagnostic algorithms and therapy. Treatment is based on general recommendations: limiting the load on the damaged joint, massage (according to indications), exercise therapy, manual therapy, physiotherapy. Drug therapy includes intramuscular or intraarticular administration of glucocorticosteroids (GCS), non-steroidal anti-inflammatory drugs (NSAIDs) but these drugs have certain side-effects and contraindications. Treatment of peritropathy with chondroprotectors (chondrogard) is rapidly gaining momentum, as well as GCS and NSAIDs, they reduce pain and increase the functionality of the joints, but, unlike the latter, their safety profile is much higher. The authors summarize current findings on this issue.

Recommendations for coronavirus infection in rheumatic diseases treated with biologic therapy.

The Coronavirus-associated disease, that was first identified in 2019 in China (CoViD-19), is a pandemic caused by a bat-derived beta-coronavirus, named SARS-CoV2. It shares homology with SARS and MERS-CoV, responsible for past outbreaks in China and in Middle East. SARS-CoV2 spread from China where the first infections were described in December 2019 and is responsible for the respiratory symptoms that can lead to acute respiratory distress syndrome. A cytokine storm has been shown in patients who develop fatal complications, as observed in past coronavirus infections. The management includes ventilatory support and broad-spectrum antiviral drugs, empirically utilized, as a targeted therapy and vaccines have not been developed. Based upon our limited knowledge on the pathogenesis of CoViD-19, a potential role of some anti-rheumatic drugs may be hypothesized, acting as direct antivirals or targeting host immune response. Antimalarial drugs, commonly used in rheumatology, may alter the lysosomal proteases that mediates the viral entry into the cell and have demonstrated efficacy in improving the infection. Anti-IL-1 and anti-IL-6 may interfere with the cytokine storm in severe cases and use of tocilizumab has shown good outcomes in a small cohort. Baricitinib has both antiviral and anti-inflammatory properties. Checkpoints inhibitors such as anti-CD200 and anti-PD1 could have a role in the treatment of CoViD-19. Rheumatic disease patients taking immunosuppressive drugs should be recommended to maintain the chronic therapy, prevent infection by avoiding social contacts and pausing immunosuppressants in case of infection. National and international registries are being created to collect data on rheumatic patients with CoViD-19.

Evaluation of pneumococcal and influenza vaccination coverage in rheumatology patients receiving biological therapy in a regional referral hospital. / Evaluación de las coberturas de vacunación antineumocócica y antigripal en pacientes reumatológicos con terapia biológica de un hospital autonómico de referencia.

OBJECTIVE: Vaccination coverage for seasonal influenza and pneumococcus in rheumatology patients receiving biological treatment. To identify variables that predict vaccination adherence. MATERIAL AND METHOD: Descriptive cross-sectional study. The study involved rheumatology patients who initiated biological therapy between 01/01/2016 and 12/31/2016 in a regional referral hospital. Variables included sociodemographic information, diagnostic data, treating physician, referral to the vaccine unit and vaccination against pneumococcus with 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23), as well as seasonal influenza (2016/17). Univariate, bivariate (Chi-square) and multivariate analysis (logistic regression) were performed. The differences were considered significant (P<.05) and the PASW v.18 software package was used. RESULTS: In all, 222 patients were included. Vaccination coverage was: PCV13, 80.2%; PPSV23, 77.9%; influenza 2016/17, 78.8%; PCV13+PPSV23, 75.2%; PCV13+PPSV23+influenza 2016/17, 68.9%. Axial spondylitis had the highest coverage (>80%) for pneumococcal vaccination and combination of pneumococcal with influenza. Overall, 27% of the patients were not referred to the unit. The treating physician was associated with statistical significance in each vaccine alone or combined, but referral to the vaccine unit was independently associated with the highest vaccination coverage (P<.001) in all cases. CONCLUSIONS: Compared to the scientific literature, we consider that the coverage of our patients against pneumococcus and influenza is high. Referral of these patients to the vaccine unit is the key to guarantee a correct immunization and to minimize some of the possible infectious adverse effects of biological therapies.

Impacts of Fatigue, Stress, and Perceived Health Status on Women With Rheumatic Diseases: A Comparison Study.

BACKGROUND: Rheumatic conditions, which increase in prevalence as populations age, are a growing public health problem that disproportionately affects women. Understanding the influences of rheumatic diseases (RDs) on fatigue, stress, and perceived health status is deemed important to the improvement of physical and mental health for women with RDs. PURPOSE: This study was designed to compare the fatigue, stress, and perceived physical and mental health status of women with RDs (RD group) with those of peers who did not have chronic illnesses (comparison group). METHODS: A cross-sectional, purposive sample and comparative design was used. Four hundred forty-three women with a mean age of 46.2 years participated in this study. Those with physician-diagnosed RDs (n = 212) were enrolled in the RD group, and those without chronic disease were enrolled in the comparison group (n = 231). Measures used included a demographic datasheet, Fatigue Severity Scale, Perceived Stress Scale, and Short Form-12 Items Health Survey. Analysis of covariance was used to examine the intergroup differences for major variables based on demographic covariates. RESULTS: The RD group reported significantly more fatigue and stress than the comparison group. Moreover, the RD group reported significantly poorer perceived physical health status, significantly poorer physical functioning and general health, and greater bodily pain compared with the comparison group. Conversely, the RD group reported significantly better perceived mental health status, significantly lower vitality, and better role emotional status than the comparison group. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The findings support the theory that RDs have a negative impact on perceived stress and fatigue in women. Physical function, bodily pain, and general health may be the most significantly affected domains of perceived physical health in women with RDs. Of note, with the exception of the vitality subscale, RDs did not adversely affect the perceived mental health of participants with RD in this study. Healthcare professionals should cooperate with clinical rheumatologists, psychologists, and physiotherapists to provide comprehensive care that includes long-term education to help patients with RD self-manage stress, restore vitality, relieve pain, and increase physical function.

Terapias biológicas en tiempos de COVID-19 / Biological therapies in times of COVID-19

La infección por el virus SARS-CoV-2 (COVID-19) ha planteado importantes de-safíos para pacientes con enfermedades reumatológicas autoinmunes en tratamiento con agentes biológicos. Actualmente no hay evidencia contundente sobre cómo esta terapia afecta el riesgo de adquirir esta infección o su evolución. Sin embargo, hay datos sobre el riesgo de infecciones virales con agentes biológicos en pacientes con enfermedades reumatológicas y específicamente cuál ha sido la experiencia de pacientes inmunosuprimidos con otros coronavirus. Además, ya se han publicado algunos estudios observacionales que han examinado la incidencia y severidad de COVID-19 en pacientes usuarios de biológicos. Por último, el cre-ciente conocimiento sobre la fisiopatología de la infección por SARS-CoV-2 está paradójicamente apoyando el papel beneficioso de algunos agentes biológicos como los inhibidores de IL-6 (Tocilizumab) e IL-1 (Anakinra) en COVID-19 grave. Se revisará la evidencia disponible para el manejo de pacientes reumatológicos con terapias biológicas en tiempos de pandemia.

The infection caused by SARS-CoV-2 (COVID-19) has posed significant challenges for patients with autoimmune rheumatic diseases being treated with biological agents. There is currently no conclusive evidence on how this therapy affects the risk of acquiring this infection or its outcomes. However, there are data on the risk of viral infections with biological agents in patients with rheumatologic diseas-es, and specifically what has been the experience of immunosuppressed patients with other coronaviruses. In addition, some observational studies have already been published that have examined the incidence and severity of COVID-19 in pa-tients using biologics. Finally, the growing knowledge about the pathophysiology of SARS-CoV-2 infection is paradoxically supporting the beneficial role of some biological agents such as IL-6 (Tocilizumab) and IL-1 (Anakinra) inhibitors in severe COVID-19. The available evidence for the management of rheumatology patients with biological therapies in times of pandemic will be reviewed.