A Comprehensive Perspective on Intracranial Pressure Monitoring and Individualized Management in Neurocritical Care: Results of a Survey with Global Experts.

BACKGROUND: Numerous trials have addressed intracranial pressure (ICP) management in neurocritical care. However, identifying its harmful thresholds and controlling ICP remain challenging in terms of improving outcomes. Evidence suggests that an individualized approach is necessary for establishing tolerance limits for ICP, incorporating factors such as ICP waveform (ICPW) or pulse morphology along with additional data provided by other invasive (e.g., brain oximetry) and noninvasive monitoring (NIM) methods (e.g., transcranial Doppler, optic nerve sheath diameter ultrasound, and pupillometry). This study aims to assess current ICP monitoring practices among experienced clinicians and explore whether guidelines should incorporate ancillary parameters from NIM and ICPW in future updates. METHODS: We conducted a survey among experienced professionals involved in researching and managing patients with severe injury across low-middle-income countries (LMICs) and high-income countries (HICs). We sought their insights on ICP monitoring, particularly focusing on the impact of NIM and ICPW in various clinical scenarios. RESULTS: From October to December 2023, 109 professionals from the Americas and Europe participated in the survey, evenly distributed between LMIC and HIC. When ICP ranged from 22 to 25 mm Hg, 62.3% of respondents were open to considering additional information, such as ICPW and other monitoring techniques, before adjusting therapy intensity levels. Moreover, 77% of respondents were inclined to reassess patients with ICP in the 18-22 mm Hg range, potentially escalating therapy intensity levels with the support of ICPW and NIM. Differences emerged between LMIC and HIC participants, with more LMIC respondents preferring arterial blood pressure transducer leveling at the heart and endorsing the use of NIM techniques and ICPW as ancillary information. CONCLUSIONS: Experienced clinicians tend to personalize ICP management, emphasizing the importance of considering various monitoring techniques. ICPW and noninvasive techniques, particularly in LMIC settings, warrant further exploration and could potentially enhance individualized patient care. The study suggests updating guidelines to include these additional components for a more personalized approach to ICP management.

Peripheral blood regulatory T cells and disease activity, quality of life, and outcomes in children with juvenile idiopathic arthritis.

OBJECTIVES: To measure regulatory T cell (Treg) levels in the peripheral blood of children with juvenile idiopathic arthritis (JIA) and analyse the association of this measure with disease activity, quality of life, adjustment of treatment, and hospitalisation. METHODS: We conducted a two-phase study (cross-sectional and prospective), including consecutive children with a JIA diagnosis according to ILAR criteria. Our independent variables were Tregs, Th1, Th2, and cytokines in peripheral blood, and our dependent variables in the cross-sectional phase were arthritis category, JIA activity, and patient-reported outcomes. To test associations, we used Spearman's correlation coefficient and the Mann-Whitney U test. In the prospective phase, we explored the probability of treatment adjustment and hospitalisation for JIA during follow-up according to Tregs levels at baseline, using Cox proportional regression. RESULTS: Our sample included 87 participants (median age 11 years, 63.2% girls). Tregs were not associated with most variables of interest. However, we found that higher Tregs concentration was associated with lower erythrocyte sedimentation rate (ESR) and better subjective disease status and course, while higher IL-10 and TGF-ß levels were associated with lower ESR, less pain, and better subjective disease status We found no association between Tregs and treatment adjustments or hospitalisation. CONCLUSIONS: Higher baseline Treg levels in the peripheral blood of children with JIA may be associated with reduced disease activity and better quality of life, though were not informative on the inflammatory progression on the follow-up.

Unraveling the pathological biomineralization of monosodium urate crystals in gout patients.

Crystallization of monosodium urate monohydrate (MSU) leads to painful gouty arthritis. Despite extensive research it is still unknown how this pathological biomineralization occurs, which hampers its prevention. Here we show how inflammatory MSU crystals form after a non-inflammatory amorphous precursor (AMSU) that nucleates heterogeneously on collagen fibrils from damaged articular cartilage of gout patients. This non-classical crystallization route imprints a nanogranular structure to biogenic acicular MSU crystals, which have smaller unit cell volume, lower microstrain, and higher crystallinity than synthetic MSU. These distinctive biosignatures are consistent with the template-promoted crystallization of biotic MSU crystals after AMSU at low supersaturation, and their slow growth over long periods of time (possibly years) in hyperuricemic gout patients. Our results help to better understand gout pathophysiology, underline the role of cartilage damage in promoting MSU crystallization, and suggest that there is a time-window to treat potential gouty patients before a critical amount of MSU has slowly formed as to trigger a gout flare.

Prevalence of crystal deposits in asymptomatic hyperuricemia according to different scanning definitions: A comparative study.

BACKGROUND/AIM: The appropriate sonographic protocol for assessing urate crystal deposits in asymptomatic hyperuricemia (AH) is undefined, as well as how the choice would impact on deposit rates and accompanying sonographic, clinical and laboratory features. METHODS: Patients with AH (serum urate ≥7 mg/dL) underwent musculoskeletal ultrasound of 10 locations for OMERACT elementary gout lesions (double contour [DC] signs, tophi, aggregates). Different definitions for AH with deposits were applied, varying according to deposits (any deposits; only DC and/or tophi); gradation (any grade; only grade 2-3 deposits), location (10 locations; 4-joint scheme including knees and 1MTPs; >1 location with deposits), or pre-defined definitions (DC sign in femoral condyles/1MTP and/or tophi in 1MTP). We evaluated crystal deposits rates and compared between other sonographic features, clinical and laboratory variables. RESULTS: Seventy-seven participants with AH showed a median 1 location (IQR 0-2) with tophi, 1 (IQR 1-2) with aggregates, and 0 locations (IQR 0-1) with DC sign. The deposition rate ranged from 23.4% (in >1 location with grade 2-3 DC or tophi) to 87.0% (in any deposit in all 10 locations). Accompanying inflammation - assessed by a positive power-Doppler (PD) signal - and erosions were found in 19.5% and 28.4% of participants, respectively. Positive PD signal was better discriminated by criteria requiring grade 2-3 or >1 location with lesions. Erosions and the different clinical and laboratory variables were similar among protocols. CONCLUSION: Rates of sonographic deposition in AH varied dramatically among studied protocols, while some could discriminate accompanying inflammation, all highlighting the need for a validated, consensus-based definition.

Features Associated With Different Inflammatory Phenotypes of Calcium Pyrophosphate Deposition Disease: Study Using Data From the International American College of Rheumatology/EULAR Calcium Pyrophosphate Deposition Classification Criteria Cohort.

OBJECTIVE: The study objective was to examine the disease, demographic, and imaging features associated with different inflammatory phenotypes of calcium pyrophosphate deposition (CPPD) disease, ie, recurrent acute calcium pyrophosphate (CPP) crystal arthritis, chronic CPP crystal inflammatory arthritis, and crowned dens syndrome (CDS). METHODS: Data from an international cohort (assembled from 25 sites in 7 countries for the development and validation of the 2023 CPPD classification criteria from the American College of Rheumatology/EULAR) that met the criteria were included. Three cross-sectional studies were conducted to determine the phenotypic characteristics of recurrent acute CPP crystal arthritis, chronic CPP crystal inflammatory arthritis, and CDS. Multivariable logistic regression analysis was used to calculate adjusted odds ratio (aOR) and 95% confidence interval (CI) to examine the association between potential risk factors and the inflammatory phenotype. RESULTS: Among the 618 people included (56% female; mean age [standard deviation] 74.0 [11.9] years), 602 (97.4%) had experienced acute CPP crystal arthritis, 332 (53.7%) had recurrent acute arthritis, 158 (25.6%) had persistent inflammatory arthritis, and 45 (7.3%) had had CDS. Recurrent acute CPP crystal arthritis associated with longer disease duration (aOR 2.88 [95% CI 2.00-4.14]). Chronic CPP crystal inflammatory arthritis was associated with acute wrist arthritis (aOR 2.92 [95% CI 1.81-4.73]), metacarpophalangeal joint osteoarthritis (aOR 1.87 [95% CI 1.17-2.97]), and scapho-trapezo-trapezoid (STT) joint osteoarthritis (aOR 1.83 [95% CI 1.15-2.91]), and it was negatively associated with either metabolic or familial risk for CPPD (aOR 0.60 [95% CI 0.37-0.96]). CDS was associated with male sex (aOR 2.35 [95% CI 1.21-4.59]), STT joint osteoarthritis (aOR 2.71 [95% CI 1.22-6.05]), and more joints affected with chondrocalcinosis (aOR 1.46 [95% CI 1.15-1.85]). CONCLUSION: CPPD disease encompasses acute and chronic inflammatory phenotypes, each with specific clinical and imaging features that need to be considered in the diagnostic workup.

Invasive and Noninvasive Techniques for Intracranial Pressure Monitoring After Decompressive Craniectomy: A Systematic Review and Meta-Analysis.

The use of invasive or noninvasive intracranial pressure (ICP) monitoring post-decompressive craniectomy (DC) has been a continuous matter of debate. Accordingly, this meta-analysis aims to examine the existing evidence of both approaches and compare their impact among patients undergoing DC, guiding clinical decision-making in the management of elevated ICP. The databases used were Pubmed, Cochrane, Web of Science, and Embase. Inclusion criteria included: (1) English studies; (2) randomized and nonrandomized studies; (3) reporting on invasive OR noninvasive ICP monitoring after DC; (4) with at least one of the outcomes of interest: incidence of mortality, new cerebral hemorrhages, and the Glasgow Outcome Scale. The study followed the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Thirty-six studies were included in this meta-analysis, resulting in a sample of 1624 patients. One thousand two hundred eighty-six underwent invasive monitoring, and 338 underwent noninvasive methods. In the invasive group, a mortality rate of 17% (95% confidence interval [CI]: 12%-22%), a good outcome rate of 58% (95% CI: 38%-49%), a poor outcome rate of 42% (95% CI: 21%-62%), and an overall incidence of new hemorrhages of 4% (95% CI: 0%-8%) were found. Whereas in the noninvasive sample, a mortality rate of 20% (95% CI: 15%-26%) and a good outcome rate of 38% (95% CI: 25%-52%) were obtained. It seems that the effectiveness of invasive and noninvasive ICP monitoring methods are comparable in post-DC patients. While invasive monitoring remains gold standard, noninvasive methods offer a safer and cost-effective alternative, potentially improving post-DC patient care, and can mostly be used simultaneously with invasive methods.

Riesgo de fracturas vertebrales dorsales osteoporóticas en pacientes con gota / Risk of osteoporotic thoracic vertebral fractures in patients with gout

Objetivos: La osteoporosis causa gran morbilidad y mortalidad por el desarrollo de fracturas por fragilidad, entre ellas las vertebrales. Los pacientes con gota podrían mostrar un incremento de riesgo de fracturas osteoporóticas debido a una mayor resorción ósea por un estado inflamatorio producido por los cristales de urato. El objetivo de este estudio fue evaluar el riesgo de fracturas vertebrales dorsales osteoporóticas asociado a padecer gota. Métodos: Estudio transversal realizado con pacientes ingresados por evento cardiovascular. Se seleccionaron pacientes con radiografía torácica lateral reciente al ingreso o en los seis meses previos, que fueron revisadas de forma simultánea por dos observadores desconocedores de los datos clínicos. Se definió fractura vertebral como reducción de la altura vertebral ≥20%, registrando su presencia, número y grado mediante la escala semicuantitativa de Genant. Para analizar la relación entre gota y fractura vertebral, se calculó la odds ratio (OR) con intervalo de confianza al 95% (IC 95%) mediante regresión logística múltiple. Resultados: Seleccionamos 126 pacientes, de los que 21 (16,67%) padecían gota. Se detectaron 18 casos con fracturas, siendo la prevalencia 14,3%. Se encontró una asociación estadísticamente significativa entre gota y fractura vertebral (28,6% gota, 11,4% no gota; OR 3,10, IC 95% 1,01-9,52). No hubo mayor número de fracturas por grupos, y la severidad fue superior en los controles. La asociación entre gota y fractura vertebral persistió tras ajuste multivariante (OR 5,21, IC 95% 1,32-20,61). Conclusión: Se ha identificado una asociación independiente entre gota y fracturas vertebrales dorsales radiográficas en pacientes con evento cardiovascular.(AU)

Objectives: Osteoporosis causes significant morbidity and mortality by the development of fragility fractures, including vertebral fractures. Patients with gout may show an increased risk of osteoporotic fractures, as accelerated bone resorption is likely linked to urate crystal-led inflammatory state. This study aims to evaluate the risk of osteoporotic dorsal vertebral fractures associated with gout. Methods: Cross-sectional study carried out in patients admitted for cardiovascular events. Patients with available lateral view of chest radiography (on admission or in the previous six months) were selected. Two observers blinded to clinical data reviewed the radiographies simultaneously. Vertebral fracture was defined as a vertebral height loss ≥20%, and presence, number, and severity (by Genant semi-quantitative scale) were registered. To analyse the relationship between gout and the presence of vertebral fractures, the odds ratio (OR) with 95% confidence interval (95%CI) was calculated by multiple logistic regression. Results: 126 patients were analysed, 21 of them (16.67%) suffered from gout. Eighteen cases with fractures were detected, with a prevalence of 14.3%. A significant association was found between gout and vertebral fracture (28.6% gout, 11.4% controls; OR 3.10, 95%CI 1.01-9.52). There were no differences in the number of fractures, while the severity was found to be higher in the controls. The association between gout and vertebral fracture persisted after multivariate adjustment (OR 5.21, 95% CI 1.32-20.61). Conclusion: An independent association between gout and radiological thoracic vertebral fractures was revealed in patients with a cardiovascular event.(AU)

Gouty Involvement of Foot and Ankle: Beyond Flares / Implicación de los tobillos y pies en gota: Algo más que ataques

The foot and ankle are common locations of deposition of monosodium urate (MSU) crystals, as indicated by the clinical manifestations presented by patients with gout, which are not limited to the acute inflammation of the big toe. We present a narrative literature review aimed to update the gout involvement of foot and ankle and how it affects the quality of life. Cumulative reports indicate that gout, even at the non-tophaceous stage, could cause pain, gait impairment and limit the mobility at lower limbs. These patients may present difficulties in some activities of daily living such as choosing footwear, thus leading to an impaired quality of life. Gout is a curable disease by dissolving MSU crystals but remains unclear how this could modify some of these foot and ankle manifestations, especially when structural damage has already occurred. Furthermore, a collaboration between rheumatologists and podiatrists seems helpful to understand, relieve these symptoms and improve the quality of life in gouty patients.(AU)

El pie y el tobillo son lugares comunes de depósito de cristales de urato monosódico (UMS), como indican las manifestaciones clínicas que presentan los pacientes con gota, que no se limitan a la inflamación aguda del primer dedo del pie. Presentamos una revisión narrativa de la literatura con el objetivo de actualizar la implicación de la gota en pie y tobillo y cómo afecta a la calidad de vida. En la literatura se describe que la gota, incluso en la etapa no tofácea, podría causar dolor, deterioro de la marcha y limitaciones de la movilidad en las extremidades inferiores. Estos pacientes pueden presentar dificultades en algunas actividades de la vida diaria, como la elección de calzado, lo cual implica una calidad de vida deteriorada. La gota es una enfermedad curable si se disuelven los cristales de UMS, pero resulta incierto cómo esto podría modificar algunas de estas manifestaciones en pie y el tobillo, especialmente cuando el daño estructural ya ha ocurrido. Además, una colaboración entre reumatólogos y podólogos sería de utilidad para comprender y aliviar estos síntomas así como mejorar la calidad de vida de los pacientes con gota.(AU)

Cribado del virus de papiloma humano: evaluación de grado de vigilancia en artritis reumatoide, artritis psoriásica y lupus eritematoso sistémico / Human papilloma virus screening: evaluation of testing and surveillance in rheumatoid arthritis, psoriatic arthritis and systemic lupus erythematosus

Introducción y objetivos: La inmunosupresión es un factor de riesgo conocido para el cáncer de cérvix uterino. Las mujeres con enfermedades reumáticas están inmunosuprimidas por la enfermedad de base y los tratamientos recibidos. Uno de los principales factores de riesgo consiste en no acudir al programa de detección precoz del virus del papiloma humano. Los objetivos de este trabajo fueron evaluar la adherencia al programa de cribado de pacientes seguidas en consultas externas de reumatología, así como estudiar la prevalencia de lesiones cervicales y su asociación con distintos aspectos de la enfermedad y los tratamientos recibidos. Material y métodos: Estudio retrospectivo en el que se revisaron las historias clínicas electrónicas de pacientes con seguimiento activo en un hospital terciario con artritis reumatoide, artritis psoriásica y lupus eritematoso sistémico. Resultados: Se incluyó 307 pacientes. No se hallaron datos de asistencia al cribado en 42,4% (39,6% en artritis reumatoide, 43,8% en artritis psoriásica y 46% en lupus eritematoso sistémico). Entre las pacientes que asistieron al menos una vez (57,6%), la prevalencia de displasia de cérvix fue del 5,1%. No se encontró ningún caso de neoplasia. En el análisis de regresión logística simple no se encontró asociación entre las variables recogidas y la presencia de infección y displasia. Conclusión: Es remarcable la ausencia de datos de asistencia al cribado de cáncer de cérvix en un porcentaje considerable de las pacientes con enfermedades reumáticas, lo cual dificulta el estudio del papel de la enfermedad y su tratamiento.(AU)

Background and objectives: Immunosuppression is a known risk factor for cervical cancer. Women with rheumatic conditions are immunosuppressed due to the disease and the treatments. One of the main risk factors for this neoplasm is the lack of adherence to early detection programmes for human papillomavirus. The objectives of this study were to evaluate the adherence to the screening programme of patients in the Rheumatology Clinic, as well as to evaluate the prevalence of cervical lesions and their association with the different disease characteristics and the treatments received. Material and Methods: A descriptive retrospective study. The electronic medical history of patients actively being followed up in a tertiary hospital with rheumatoid arthritis, psoriatic arthritis and systemic lupus erythematosus were reviewed. Results: Finally, 307 patients were included. No data were found for screening programme attendance in up to 42.4% of the patients (39.6% in rheumatoid arthritis, 43.8% in psoriatic arthritis and 46% in systemic lupus erythematosus). Among the patients who attended the screening programme at least once (57.6%), the prevalence of cervical dysplasia was 5.1%. No cases of neoplasia were found. In the simple logistic regression analysis, there was no association between attending the screening programme and any variable. The study also showed no association between the variables collected and the presence of infection and dysplasia. Conclusion: These results are influenced by the absence of screening data in a significant percentage of patients and by the low prevalence of dysplasia found in this series of patients with rheumatic diseases.(AU)

Aplicación de escalas pronósticas de gravedad en la neumonía por SARS-CoV-2 / Application of validated severity scores for pneumonia caused by SARS-CoV-2

Objetivos: Comparar el rendimiento de las escalas pronósticas PSI, CURB-65, MuLBSTA y COVID-GRAM para predecir mortalidad y necesidad de ventilación mecánica invasiva en pacientes con neumonía por SARS-CoV-2. Valorar la existencia de coinfección bacteriana respiratoria durante el ingreso.MétodoEstudio observacional retrospectivo que incluyó a adultos hospitalizados con neumonía por SARS-CoV-2 del 15 de marzo al 15 de mayo de 2020. Se excluyó a aquellos inmunodeprimidos, institucionalizados e ingresados en los 14 días previos por otro motivo. Se realizó un análisis de curvas ROC, calculando el área bajo la curva para las diferentes escalas, así como sensibilidad, especificidad y valores predictivos.ResultadosSe incluyó a 208 pacientes, con edad de 63±17 años; el 57,7% eran hombres. Ingresaron en UCI 38 (23,5%), de estos, 33 precisaron ventilación mecánica invasiva (86,8%), con una mortalidad global del 12,5%. Las áreas bajo las curvas ROC para mortalidad de los clasificaciones fueron: PSI 0,82 (IC 95%: 0,73-0,91); CURB-65 0,82 (0,73-0,91); MuLBSTA 0,72 (0,62-0,81) y COVID-GRAM 0,86 (0,70-1). Las áreas para necesidad de ventilación mecánica invasiva fueron: PSI 0,73 (IC 95%: 0,64-0,82); CURB-65 0,66 (0,55-0,77); MuLBSTA 0,78 (0,69-0,86) y COVID-GRAM 0,76 (0,67-0,85), respectivamente. Los pacientes que presentaron coinfección bacteriana respiratoria fueron 20 (9,6%); los gérmenes más frecuentes fueron Pseudomonas aeruginosa y Klebsiella pneumoniae.ConclusionesEn nuestro estudio la escala COVID-GRAM fue la más precisa para identificar a los pacientes con mayor mortalidad ingresados con neumonía por SARS-CoV-2; no obstante, ninguna de estas escalas predice de forma precisa la necesidad de ventilación mecánica invasiva con ingreso en UCI. El 10% de los pacientes presentó coinfección bacteriana respiratoria.

Objectives: Compare the accuracy of PSI, CURB-65, MuLBSTA and COVID-GRAM prognostic scores to predict mortality, the need for invasive mechanical ventilation in patients with pneumonia caused by SARS-CoV-2 and assess the coexistence of bacterial respiratory tract infection during admission.MethodsRetrospective observational study that included hospitalized adults with pneumonia caused by SARS-CoV-2 from 15/03 to 15/05/2020. We excluded immunocompromised patients, nursing home residents and those admitted in the previous 14 days for another reasons. Analysis of ROC curves was performed, calculating the area under the curve for the different scales, as well as sensitivity, specificity and predictive values.ResultsA total of 208 patients were enrolled, aged 63±17 years, 57,7% were men; 38 patients were admitted to ICU (23,5%), of these patients 33 required invasive mechanical ventilation (86,8%), with an overall mortality of 12,5%. Area under the ROC curves for mortality of the scores were: PSI 0,82 (95% CI: 0,73-0,91), CURB-65 0,82 (0,73-0,91), MuLBSTA 0,72 (0,62-0,81) and COVID-GRAM 0,86 (0,70-1). Area under the curve for needing invasive mechanical ventilation was: PSI 0,73 (95% CI: 0,64-0,82), CURB-65 0,66 (0,55-0,77), MuLBSTA 0,78 (0,69-0,86) and COVID-GRAM 0,76 (0,67-0,85), respectively. Patients with bacterial co-infections of the respiratory tract were 20 (9,6%), the most frequent strains being Pseudomonas aeruginosa and Klebsiella pneumoniae.ConclusionsIn our study, the COVID-GRAM score was the most accurate to identify patients with higher mortality with pneumonia caused by SARS-CoV-2; however, none of these scores accurately predicts the need for invasive mechanical ventilation with ICU admission. The 10% of patients admitted presented bacterial respiratory co-infection. (AU)

Complex regional pain syndrome secondary to sacrococcygeal dislocation following trauma to the lumbosacral region. case report

ABSTRACT Introduction: The complex regional pain syndrome (CRPS) is a rare condition characterized by inflammatory, vasomotor and central nervous system (CNS) involvement. Its clinical presentation can be subacute, acute or chronic, and may have severe effects on the patient's quality of life. Case description: 21-year-old female patient with trauma in the lumbosacral region associated with pain and functional limitation. Diagnostic imaging showed sacrococcygeal dislocation with subsequent inflammatory and acute and chronic autonomic symptoms that were treated medically and surgically. The patient responded to treatment with long-term improvement of the symptoms. Discussion: In this case, CRPS occurred after trauma and caused subacute symptoms that became even more acute until reaching a chronic presentation. Inflammation, vasomotor dysfunction and CNS involvement made this case a multidisciplinary diagnostic and therapeutic challenge. Conclusion: CRPS is a rare disease that is difficult to diagnose. However, diagnosis should be timely in order to initiate personalized treatment, since this disease considerably affects the patient's quality of life.

RESUMEN Introducción. El síndrome doloroso regional complejo (SDRC) es una patología poco frecuente que se caracteriza por causar compromiso a nivel inflamatorio, vasomotor y del sistema nervioso central (SNC). Su presentación clínica puede ser subaguda, aguda o crónica y puede afectar considerablemente la calidad de vida del paciente. Presentación del caso. Paciente femenina de 21 años con trauma en región lumbosacra asociado a dolor y limitación funcional, a quien se le practicaron imágenes diagnosticas que evidenciaron luxofractura sacrococcígea con posterior presencia de síntomas inflamatorios y autonómicos (agudos y crónicos) que se trataron con medicamentos y cirugía. La paciente respondió al tratamiento con mejoría de la sintomatología a largo plazo. Discusión. El SDRC se presentó posterior a un traumatismo y ocasionó sintomatología subaguda que se agudizó hasta llegar a la presentación crónica de la enfermedad. La inflamación, la disfunción vasomotora y el compromiso del SNC hacen de este caso un reto diagnóstico y terapéutico multidisciplinario. Conclusión. El SDRC es una patología poco frecuente y de difícil diagnóstico; sin embrago, es necesario diagnosticarlo de forma oportuna para poder iniciar un tratamiento personalizado, ya que es una enfermedad que compromete considerablemente la calidad de vida del paciente.

Pure Membranous Lupus Nephritis: Description of a Cohort of 150 Patients and Review of the Literature / Nefritis lúpica membranosa pura: descripción de una cohorte de 150 pacientes y revisión de la literatura

Objectives: The course and long-term outcome of pure membranous lupus nephritis (MLN) are little understood. The aims of this study are to evaluate the clinical features, course, outcome and prognostic indicators in pure MLN and to determine the impact of ethnicity and the type of health insurance on the course and prognosis of pure MLN. Methods: We conducted a retrospective review of medical records of 150 patients with pure MLN from Spain and the USA. Results: Mean age was 34.2±12.5 and 80% were women. Sixty-eight percent of patients had nephrotic syndrome at diagnosis. The average serum creatinine was 0.98±0.78mg/dl. Six percent of patients died and 5.3% developed end-stage renal disease (ESRD). ESRD was predicted by male sex, hypertension, dyslipidemia, high basal 24h-proteinuria, high basal serum creatinine and a low basal creatinine clearance. Age, cardiac insufficiency, peripheral artheriopathy, hemodialysis and not having received mycophenolate mofetil or antimalarials for MLN predicted death. Conclusions: Pure MLN frequently presents with nephrotic syndrome, high proteinuria and normal serum creatinine. Its prognosis is favourable in maintaining renal function although proteinuria usually persists over time. Baseline cardiovascular disease and not having a health insurance are related with poor prognosis

Objetivos: Los conocimientos sobre el curso y el desenlace a largo plazo de la nefritis lúpica membranosa (NLM) pura son todavía escasos. El objetivo de este estudio es evaluar las características clínicas, curso, desenlace e indicadores pronósticos de la NLM y determinar el impacto de la etnicidad y tipo de cobertura sanitaria en el curso y pronóstico de la NLM. Métodos: Se realizó una revisión retrospectiva de las historias de 150 pacientes con NLM de España y Estados Unidos. Resultados: La edad media fue 34,2±12,5 y el 80% eran mujeres. El 68% de los pacientes tenían síndrome nefrótico al diagnóstico. La creatinina sérica media fue 0,98±0,78mg/dl. El 6% de los pacientes fallecieron y el 5,3% desarrollaron insuficiencia renal terminal (IRT). El sexo masculino, la hipertensión, la dislipemia, la alta proteinuria basal, la alta creatininemia y un aclaramiento de creatinina reducido predijeron el desarrollo de IRT. La edad, la insuficiencia cardíaca, la arteriopatía periférica, la hemodiálisis y el no haber recibido micofenolato de mofetilo o antimaláricos predijeron el fallecimiento. Conclusiones: La NLM pura suele debutar con síndrome nefrótico, alta proteinuria y creatininemia normal. Su pronóstico es favourable en términos de mantenimiento de la función renal aunque la proteinuria habitualmente persiste durante el seguimiento. La enfermedad cardiovascular basal y no tener cobertura sanitaria se relacionan con mal pronóstico

Primoinfección tuberculosa en pacientes con anti-TNF-α y cribado inicial negativo / Primary tuberculosis infection in patients treated with tumor necrosis factor-alpha antagonists and a negative initial screening

Introducción. A pesar de las medidas de cribado de tuberculosis (TB) siguen detectándose casos en pacientes tratados con anti-TNF-α y cribado inicial negativo, algunos tras largo tiempo de tratamiento, lo que apunta más a una nueva infección. Objetivos. Describir los casos que presumiblemente han desarrollado primoinfección tuberculosa durante el tratamiento con fármacos anti-TNF-α. Métodos. Revisión retrospectiva (1999-2012), seleccionando según los siguientes criterios: a) tratamiento anti-TNF-α; b) cribado de TB inicial negativo; c) TB diagnosticada durante tratamiento anti-TNF-α, y d) sospecha de primoinfección tuberculosa (tras mínimo 12 meses de anti-TNF-α). Se han revisado sus variables clínicas, epidemiológicas, terapéuticas y de desenlace. Resultados. Dos casos de primoinfección tuberculosa de 771 pacientes tratados con anti-TNF-α (0,2%). Una mujer de 41 años y 35 meses de tratamiento con adalimumab y un varón de 37 años y 107 meses de tratamiento con infliximab. La mujer presentó una neumonía y el varón una TB diseminada. Conclusiones. Durante la terapia anti-TNF-α persiste el riesgo de TB a pesar de cribado inicial negativo, por lo que el grado de sospecha debe ser elevado durante todo el tratamiento (AU)

Introduction. Despite screening for latent tuberculosis (TB), new cases of TB infection are detected in patients treated with anti-TNF-α and negative initial screening, some of them after long treatment, which points more to a new infection. Objectives. To describe the cases that have presumably developed a primary tuberculous infection during treatment with anti-TNF-α drugs. Methods. Retrospective audit (1999-2012). Inclusion criteria were: a) anti-TNF-α treatment; b) initial latent TB screening negative; c) TB diagnosed during anti-TNF-α treatment; d) suspected primary TB infection (diagnosis after at least 12 months on anti-TNF-α). Clinical, epidemiological, therapeutic and outcome variables were reviewed. Results. Two cases of primary TB infection were found out of of 771 anti-TNF-α treated patients (0.2%). One woman aged 41 suffered TB pneumonia after 35 months of treatment with adalimumab, and a male aged 37 who developed disseminated TB after 107 months of treatment with infliximab. Conclusions. Although uncommon, during TNF antagonist therapy, TB risk persists despite negative initial screening, so clinicians should be aware of TB during the entire treatment (AU)

Pigmented villonodular synovitis diagnostic delay due to coexistence with ankylosing spondylitis / Retraso en el diagnóstico de sinovitis villonodular pigmentada por coexistencia con espondilitis anquilosante

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Diagnóstico y tratamiento de la gota / Gout: Diagnosis and treatment

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