LAUDES Study: impact of digital ulcers on hand functional limitation, work productivity and daily activities, in systemic sclerosis patients.

The objective of this study was to evaluate the impact of digital ulcers (DUs) in daily life of systemic sclerosis (SSc) Spanish patients. We developed a multicenter observational study to compare functional disability in SSc patients with active DUs vs. those without DUs. An additional correlation between perception of patients and physicians on disability due to DUs was performed. A total of 199 patients were enrolled, 70 (35%) with DUs. Patients with DUs were younger (48 vs. 58 years; p < 0.001) and had more frequently the diffuse subtype of SSc (45 vs. 24%; p = 0.004) than patients without DUs. Patients with DUs showed significantly higher scores in the Cochin Hand Function Scale overall (p < 0.002) and for each of its five dimensions. They also showed higher scores in the Systemic Sclerosis Health Assessment Questionnaire items related to hand function such as, dress and self-care (p < 0.013), eat (p < 0.013) and grip (p < 0.03), and higher Visual Analogic Scale scores for pain (p < 0.013), trouble related with Raynaud's Phenomenon (p < 0.001) and sense of severity (p < 0.004). Impact on daily activities was significantly higher in patients with DUs (p = 0.002), with a non-significant trend to experience higher impact on work productivity (p = 0.07). A high correlation was found between DUs patients and physicians opinion on the impact of DUs (daily life: Pearson R = 0.86; work productivity: Pearson R = 0.87). Study findings show an impaired hand function and increased disability for daily life activities and work productivity in SSc patients with DUs compared with patients without DUs in Spanish population.

Cardiac tamponade and severe pericardial effusion in systemic sclerosis: report of nine patients and review of the literature.

AIM: To describe the clinical characteristics, treatment and outcome of patients with systemic sclerosis (SSc) developing severe pericardial effusion or cardiac tamponade. METHODS: SSc patients with severe pericardial effusion or cardiac tamponade from three Spanish hospitals were collected. In addition, a computer-assisted (PubMed, MEDLINE) search of the literature to identify all cases of cardiac tamponade or severe pericardial effusion associated with SSc reported in English, French and Spanish from 1987 through September 2015 was performed. RESULTS: We included 40 patients (nine cases from the Spanish hospitals and 31 cases from the literature review). Most patients (87%) were female with a mean age at pericardial involvement of 49.3 ± 15.2 years (range: 18-80 years), and 22 (55%) patients had the diffuse cutaneous subtype. Twenty-five (63%) patients presented with cardiac tamponade and the remaining 15 (37%) as severe or massive pericardial effusion. Pericardial involvement was previous or simultaneous to SSc diagnosis in 13 (32.5%) cases. In most cases (88.9%) pericardial fluid analysis disclosed an exudate. Half the patients received steroids and 35% needed surgical treatment. Five (12.5%) patients died due to cardiac tamponade, three of them during the acute phase and the remaining two, 2 and 9 months later, respectively. CONCLUSIONS: Although cardiac tamponade or severe pericardial effusion is an infrequent complication in SSc patients, it can be the first manifestation of disease associated with the diffuse cutaneous subset. No specific treatment for this complication is known.

[Selective cholesterol absorption inhibition as a new prospect in treatment of hypercholesterolemia]. / Inhibición selectiva de la absorción de colesterol: una nueva perspectiva en el tratamiento de la hipercolesterolemia.

Ezetimibe is the first of a new class of lipid-lowering drugs, the 2-azetidinones, which selectively inhibits the absorption of intestinal cholesterol. Ezetimibe's mechanism of action complements that of cholesterol synthesis inhibitors. Ezetimibe as monotherapy or in combination with statins significantly decreases plasma cLDL levels. As monotherapy, ezetimibe is well tolerated with a side-effect profile similar to placebo, whereas in combination with statins no differences in the incidence of myopathy, rhabdomyolysis or elevated liver enzymes are reported.

Mortality and survival in systemic sclerosis: systematic review and meta-analysis.

OBJECTIVE: To determine the mortality, survival, and causes of death in patients with systemic sclerosis (SSc) through a meta-analysis of the observational studies published up to 2013. METHODS: We performed a systematic review and meta-analysis of the observational studies in patients with SSc and mortality data from entire cohorts published in MEDLINE and SCOPUS up to July 2013. RESULTS: A total of 17 studies were included in the mortality meta-analysis from 1964 to 2005 (mid-cohort years), with data from 9239 patients. The overall SMR was 2.72 (95% CI: 1.93-3.83). A total of 43 studies have been included in the survival meta-analysis, reporting data from 13,529 patients. Cumulative survival from onset (first Raynaud's symptom) has been estimated at 87.6% at 5 years and 74.2% at 10 years, from onset (non-Raynaud's first symptom) 84.1% at 5 years and 75.5% at 10 years, and from diagnosis 74.9% at 5 years and 62.5% at 10 years. Pulmonary involvement represented the main cause of death. CONCLUSIONS: SSc presents a larger mortality than general population (SMR = 2.72). Cumulative survival from diagnosis has been estimated at 74.9% at 5 years and 62.5% at 10 years. Pulmonary involvement represented the main cause of death.

Early- versus late-onset systemic sclerosis: differences in clinical presentation and outcome in 1037 patients.

Peak age at onset of systemic sclerosis (SSc) is between 20 and 50 years, although SSc is also described in both young and elderly patients. We conducted the present study to determine if age at disease onset modulates the clinical characteristics and outcome of SSc patients. The Spanish Scleroderma Study Group recruited 1037 patients with a mean follow-up of 5.2 ± 6.8 years. Based on the mean ± 1 standard deviation (SD) of age at disease onset (45 ± 15 yr) of the whole series, patients were classified into 3 groups: age ≤ 30 years (early onset), age between 31 and 59 years (standard onset), and age ≥ 60 years (late onset). We compared initial and cumulative manifestations, immunologic features, and death rates. The early-onset group included 195 patients; standard-onset group, 651; and late-onset, 191 patients. The early-onset group had a higher prevalence of esophageal involvement (72% in early-onset compared with 67% in standard-onset and 56% in late-onset; p = 0.004), and myositis (11%, 7.2%, and 2.9%, respectively; p = 0.009), but a lower prevalence of centromere antibodies (33%, 46%, and 47%, respectively; p = 0.007). In contrast, late-onset SSc was characterized by a lower prevalence of digital ulcers (54%, 41%, and 34%, respectively; p < 0.001) but higher rates of heart conduction system abnormalities (9%, 13%, and 21%, respectively; p = 0.004). Pulmonary hypertension was found in 25% of elderly patients and in 12% of the youngest patients (p = 0.010). After correction for the population effects of age and sex, standardized mortality ratio was shown to be higher in younger patients. The results of the present study confirm that age at disease onset is associated with differences in clinical presentation and outcome in SSc patients.

Polymorphisms in the interleukin 4, interleukin 13, and corresponding receptor genes are not associated with systemic sclerosis and do not influence gene expression.

OBJECTIVE: Polymorphisms in the genes encoding interleukin 4 (IL4), interleukin 13 (IL13), and their corresponding receptors have been associated with multiple immune-mediated diseases. Our aim was to validate these previous observations in patients with systemic sclerosis (SSc) and scrutinize the effect of the polymorphisms on gene expression in various populations of peripheral blood leukocytes. METHODS: We genotyped a cohort of 2488 patients with SSc and 2246 healthy controls from The Netherlands, Spain, United Kingdom, Italy, Germany, and France. Taqman assays were used to genotype single-nucleotide polymorphisms (SNP) in the following genes: (1) IL4 (-590C>T/rs2243250); (2) IL4 receptor alpha (IL4RA) (Q576R/rs1801275); (3) IL13 (R130Q/rs20541 and -1112C>T/rs1800925); and (4) IL13RA1 (43163G>A/rs6646259). The effect of these polymorphisms on expression of the corresponding genes was assessed using quantitative RT-PCR on RNA derived from peripheral blood B cells, T cells, plasmacytoid dendritic cells, monocytes, and myeloid dendritic cells. We investigated whether these polymorphisms influenced development of pulmonary complications over 15 years in patients with SSc. RESULTS: None of the investigated polymorphisms was associated with SSc or any SSc clinical subtype. We did not observe any effect on transcript levels in the cell subtypes or on development of pulmonary complications. CONCLUSION: Our data showed that polymorphisms in IL4, IL13, and their receptors do not play a role in SSc and do not influence the expression of their corresponding transcript in peripheral blood cells.

Bosentan in clinical practice for treating digital and other ischemic ulcers in Spanish patients with systemic sclerosis: IBER-DU cohort study.

OBJECTIVE: To describe treatment outcomes and safety experience with bosentan in patients with systemic sclerosis (SSc) and digital ulcers (DU), in a clinical setting in Spain. METHODS: This was a multicenter, noninterventional retrospective cohort study. Data were collected retrospectively from patients with DU, with or without pulmonary arterial hypertension (PAH), who were initiating bosentan therapy in 2003 (n = 26) or 2004 (n = 41) and followed until May 2005. Data were obtained from centers prescribing bosentan. Relevant measures included number of DU, occurrence of new DU, overall DU clinical status (improved, stabilized, worsened), and bosentan-associated adverse events. RESULTS: Sixty-seven patients with SSc and DU or other ulcers were included. PAH was also present in 12 patients (18%). At the start of bosentan treatment, the median number of DU per patient was 3.0. The median change in number of DU was -3.6 and -5.0 at 12 and 24 months, respectively. Sixty-eight percent of the patients did not develop any new DU at 12 months. DU clinical status was reported at 12 months for 22 patients: 18 patients (81.8%) improved and 4 (18.2%) stabilized. The median treatment duration was 13.0 months. The main adverse event was increase of aminotransferase, observed in 5 patients (7%), leading to discontinuation of treatment in 3 patients (4.4%). CONCLUSION: Previously reported results of bosentan efficacy in DU management are reproducible in clinical practice. This efficacy is maintained in the longterm followup. Bosentan treatment was well tolerated and adverse events were comparable with those observed in previous reports.

Efficacy of cyclophospamide in the treatment of interstitial lung disease associated with systemic sclerosis.

BACKGROUND: Cyclophosphamide (CYC) stabilizes the parameters of lung function tests (LFT) of patients with (SSc) and interstitial lung disease (ILD) treated for 12 months. There is little information about long-term treatment (24 months). The aim of this study is to analyze the effect of intravenous CYC in LFT parameters in patients with SSc and ILD treated for 24 months. PATIENTS AND METHOD: Retrospective study of 37 patients with ILD associated with scleroderma treated with intravenous CYC for 24 months and regularly assessed by LFT (at baseline, 6, 12 and 24 months) including forced vital capacity (FVC) and transfer capacity of carbon monoxide (DL(CO)). To evaluate response to treatment the recommendations of the ATS and SEPAR were considered. RESULTS: The difference between FVC and DL(CO) values performed at baseline and those performed at 6, 12, and 24 months were less than 10%, which meant that CYC stabilized LFT. There were no differences in LFT when patients treated for 6 months were evaluated according to the type of skin involvement of the SSc (diffuse or limited) and the duration of the ILD. Although patients with severe restriction (FVC<70%) showed more improvement, it was less than 10% in all cases. CONCLUSION: In this series of patients with ILD associated with SSc intravenous CYC was effective in stabilizing LFT in long-term treatment.

Association of HLA class II genes with systemic sclerosis in Spanish patients.

OBJECTIVE: To examine the role of HLA-DRB1 and HLA-DQB1 alleles in the susceptibility to systemic sclerosis (SSc) and its clinical expression in a Spanish population. METHODS: One hundred Spanish Caucasian patients with SSc and 130 controls were studied. Molecular HLA-DRB1 and HLA-DQB1 typing was performed by polymerase chain reaction (PCR) sequence-based typing and PCR sequence-specific oligonucleotide. RESULTS: HLA-DRB1*11 was associated with genetic susceptibility to SSc, whereas HLA-DRB1*07 (HLA-DRB1*0701) showed a protective effect. A significant increase in the frequency of the DRB1*1104 allele was observed in patients with anti-topoisomerase I autoantibodies (anti-Topo I) while HLA-DRB1*01 and HLA-DQB1*05 alleles were significantly increased in patients with anti-centromere antibodies (ACA). The HLA-DRB1*11 allele was more frequent in patients with pulmonary fibrosis; however, no significant association with any HLA-DRB1 or DQB1 alleles was identified in patients with pulmonary arterial hypertension. CONCLUSION: HLA alleles play a role in genetic susceptibility to SSc in Spanish patients. Some alleles are more prevalent in patients with pulmonary fibrosis and in patients with certain SSc-specific autoantibodies (anti-Topo I and ACA).

Eficacia de la ciclofosfamida endovenosa en el tratamiento de la enfermedad pulmonar intersticial asociada a la esclerosis sistémica / Efficacy of Cyclophospamide in the Treatment of Interstitial Lung Disease Associated with Systemic Sclerosis

Introducción: La ciclofosfamida (CFM) estabiliza los parámetros del estudio funcional respiratorio (EFR)de los pacientes con esclerosis sistémica (ES) y enfermedad pulmonar intersticial (EPI) tratados durante12 meses. Existe poca información acerca del tratamiento a largo plazo (24 meses). El objetivo del estudioes analizar el efecto de la CFM endovenosa en los parámetros del EFR de los pacientes con ES y EPI tratadosdurante 24 meses.Pacientes y método: Estudio retrospectivo de 37 pacientes con EPI asociada a esclerodermia, tratados conCFM endovenosa durante 24 meses y evaluados de forma periódica mediante EFR (basal, a los 6, 12 y 24meses). En este se evaluó la capacidad vital forzada (FVC) y la capacidad de transferencia de monóxidode carbono (DLCO).Resultados: Las diferencias entre los valores de FVC y DLCO basales y los realizados a los 6, 12 y 24 mesesfueron menores del 10%, lo que significa que la CFM estabilizó los parámetros funcionales. Tampoco sedetectaron diferencias en la FVC ni en la DLCO cuando se valoró a los pacientes tratados durante 6 mesesde acuerdo al tipo de afectación cutánea de la ES (difusa o limitada), o según el tiempo de evolución dela EPI antes del inicio del tratamiento. Si bien los pacientes con restricción grave (FVC < 70%) al iniciomostraron mayor mejoría, esta fue en todos los casos inferior al 10%.Conclusión: En esta serie de pacientes con EPI asociada a ES, la CFM endovenosa estabilizó los parámetrosfuncionales respiratorios en el tratamiento a largo plazo(AU)

Background: Cyclophosphamide (CYC) stabilizes the parameters of lung function tests (LFT) of patientswith (SSc) and interstitial lung disease (ILD) treated for 12 months. There is little information aboutlong-term treatment (24 months). The aim of this study is to analyze the effect of intravenous CYC in LFTparameters in patients with SSc and ILD treated for 24 months.Patients and method: Retrospective study of 37 patients with ILD associated with scleroderma treated withintravenous CYC for 24 months and regularly assessed by LFT (at baseline, 6, 12 and 24 months) includingforced vital capacity (FVC) and transfer capacity of carbon monoxide (DLCO). To evaluate response totreatment the recommendations of the ATS and SEPAR were considered.Results: The difference between FVC and DLCO values performed at baseline and those performed at 6,12, and 24 months were less than 10%, which meant that CYC stabilized LFT. There were no differences in LFT when patients treated for 6 months were evaluated according to the type of skin involvement of theSSc (diffuse or limited) and the duration of the ILD. Although patients with severe restriction (FVC<70%)showed more improvement, it was less than 10% in all cases.Conclusion: In this series of patients with ILD associated with SSc intravenous CYC was effective instabilizing LFT in long-term treatment(AU)

Inhibición selectiva de la absorción de colesterol: una nueva perspectiva en el tratamiento de la hipercolesterolemia / Selective cholesterol absorption inhibition as a new prospect in treatment of hypercholesterolemia

La ezetimiba es el primer fármaco de una nueva clase de agentes hipolipemiantes, las 2-azetidionas, que actúan selectivamente inhibiendo la absorción intestinal de colesterol. Este mecanismo es complementario al de los inhibidores de la síntesis de colesterol. Tanto en monoterapia como coadministrada con estatinas, contribuye de forma eficaz a la reducción de la concentración plasmática de colesterol unido a lipoproteínas de baja densidad. En monoterapia, la ezetimiba ha demostrado una buena tolerancia con un porcentaje de reacciones adversas similar a placebo, mientras que coadministrada con estatinas no se observó un aumento de la incidencia de miopatía, rabdomiólisis ni elevación de las enzimas hepáticas

Ezetimibe is the first of a new class of lipid-lowering drugs, the 2-azetidinones, which selectively inhibits the absorption of intestinal cholesterol. Ezetimibe's mechanism of action complements that of cholesterol synthesis inhibitors. Ezetimibe as monotherapy or in combination with statins significantly decreases plasma cLDL levels. As monotherapy, ezetimibe is well tolerated with a side-effect profile similar to placebo, whereas in combination with statins no differences in the incidence of myopathy, rhabdomyolysis or elevated liver enzymes are reported