Effectiveness of the use of an algorithm in the diagnostic approach of joint pain patients by primary care physicians.

There is a high percentage of error in the approach of patients with joint pain by primary care physicians. An algorithm can help improve this misdiagnosis problem. Our study seeks to determine the effectiveness of an algorithm when used by primary care physicians for the diagnosis of cases of joint pain patients. A randomized clinical experiment was carried out. Primary care physicians from five cities in Colombia developed a series of clinical cases, which were presented to them through a website on their personal cell phones. Half of the doctors developed the cases using the diagnostic algorithm, and the other half developed the cases without the use of the algorithm. Main measures were proportion of correct diagnosis, number, type of laboratory and diagnostic images requested for the diagnostic approach of clinical cases. Two hundred and twenty-four primary care physicians participated. The overall proportion of cases correctly diagnosed was 37.3% higher in the intervention group; we found a greater difference in cases of spondyloarthritis (60.8%), followed by systemic lupus erythematosus with joint involvement (32.2%), rheumatoid arthritis (30.3%) and osteoarthritis (25.9%). The average number of tests requested to develop clinical cases was lower in the intervention group than in the control group, both globally and for each of the four diseases, with statistically significant differences for each of the comparisons. The diagnostic algorithm proved to be an effective tool when used by primary care physicians; the proportion of correct diagnoses increased, and the number of tests requested in the development of the cases decreased.

Are we treating women patients with real axial spondyloarthritis?

INTRODUCTION: During the last years, regulatory agencies raised some relevant concerns with regard to the possibility of administrating biological therapy (BT) to non-SpA patients. Especially, the possibility of treating women with fibromyalgia as non-radiographic axSpA (nr-axSpA) was mentioned. OBJECTIVES: To evaluate if the gender distribution and clinical pattern of patients with axSpA initiating biological therapy (BT) was modified in clinical practice after its approval for non radiographic-axSpA (nr-axSpA). METHODS: Baseline dataset from a prospective ongoing cohort including all patients with axSpA treated with BT at the Rheumatology Department of University Hospital La Paz, Madrid, Spain, was analysed. Patient's characteristics and disease activity parameters were collected. Based on the approval indication date of BT for nr-axSpA, patients were classified in two periods according to the starting date for the first BT: period 1 (before 2013) and period 2 (during or after 2013). Gender distribution and disease' characteristics were compared between both groups using Chi-square and Student-t tests. RESULTS: In total, 385 patients initiated BT: 266 (69%) in period 1 and 119 (31%) in period 2. No significant differences between both periods were observed regarding gender distribution (38% and 39% of women; p = 0.8). Out of those patients with nr-axSpA initiating BT in period 2, the majority (60%) were men. Women starting BT in period 2 had significantly higher systemic inflammation and mobility restriction compared with women in period 1 [median (interquartile range) CRP 10.2 mg/l (3.0-24.9) vs 3.2 mg/l (2.0-9.4); p = 0.02 and BASMI 2.7 (1.8-3.5) vs. 2.0 (1.2-2.6); p = 0.01, respectively]. In addition, they also presented significantly higher disease activity [BASDAI 6.5 (5.4-8.0) vs. 5.8 (4.6-6.8); p = 0.02; ASDAS, mean (SD) 3.6 ± 3.4 vs. 3.2 ± 1.0; p = 0.02, respectively] and more functional limitation [BASFI 5.7 (3.8-6.7) vs. 4.3 (2.0-6.1); p = 0.01, respectively] than men treated in period 2. CONCLUSIONS: In our clinical practice, the frequency of women who started BT did not increase since their approval for nr-axSpA. Women treated with BT after 2012 had more objective disease activity parameters than before their approval for nr-axSpA treatment.

Espondiloartropatía juvenil: una visión desde la pediatría / Juvenile spondyloarthropathy: a view from pediatrics

La espondiloartropatía juvenil (EAPj) representa un grupo de artropatías crónicas que se inician en la infancia y que corresponden a entidades cuyas clasificaciones se han modificado en el transcurso de las décadas. Las clasificaciones actuales las incluyen sólo parcialmente. Las manifestaciones clínicas incluyen compromiso articular periférico asimétrico, entesis, sacroilíaco y menos frecuentemente de columna han permitido agruparlas en cinco categorías entre el que se encuentra la forma anquilosante juvenil relacionada con HLA B27 (+), el prototipo de EAPj y que podría representar a la forma de inicio de espondiloartropatía anquilosante del adulto. Los recientes avances en los estudios genéticos, en la patogenia, el desarrollo de mejores técnicas de imagenología tales como la ecografía musculo-esquelética y resonancia magnética aplicada a la Reumatología pediátrica podrían contribuir a generar criterios de clasificación de manera tal que faciliten la comunicación científica con los Reumatólogos de adultos. Un diagnóstico precoz, la aplicación de medidas de actividad de la enfermedad validadas y el oportuno manejo terapéutico obtendrán un pronóstico más favorable. Los resultados terapéuticos en EAPj presentan evidencia limitada aún requiriéndose mayor tiempo de evolución para obtener resultados a largo plazo.

Juvenile spondyloarthropathy (EAPj) represents a heterogeneous group of juvenile articular inflammatory entities and their classification have been changed during the last decades. The current classifications include only partially. The clinical manifestations of diseases involves peripheral joints, enthesis, sacroiliac and less frequently spine and they are classified in five specific subgroups among which is the juvenile ankylosing HLA B27 (+); the EAPj’s prototype and that may represent one of ankylosing spondyloarthropathy adult diseases. Recently, novel insights into the epidemiology, pathogenesis, and development of the imaging techniques such as muscle-skeletal ultrasound and magnetic resonance applied to pediatric rheumatology could be contributing to new classification criteria in order to facilitate the scientific communication with Rheumatologist of adult patients. An early diagnosis a validated measures of disease activity and treatment can change the course and outcome of disease.

Intestinal Flora Modification of Arthritis Pattern in Spondyloarthropathy.

BACKGROUND: The reactive form of spondyloarthropathy appears inducible by exposure to agents of infectious diarrhea, but do those organisms represent the tip of the iceberg, as indicated by renewed interest in gastrointestinal flora? Prevalence of spondyloarthropathy (20% of chimpanzees [Pan] and 28% of gorillas) is independent of subspecies and species, respectively. However, there are major differences in arthritis patterns, a characteristic shared with humans. OBJECTIVES: Do patterns of arthritis correlate with gastrointestinal flora? Could such associated modifications be in the form of disease induction or represent protective effectors (at least against the extent of peripheral arthritis)? METHODS: The skeletons of 2 chimpanzee subspecies (79 Pan troglodytes troglodytes and 26 Pan troglodytes schweinfurthii) and 2 gorilla species (99 Gorilla gorilla and 38 Gorilla beringei) adults were examined, and arthritis pattern noted. Feces of Eastern (P. schweinfurthii and G. beringei) and Western (great apes collected in their normal ranges) apes were assessed for 16S rRNA c and its character. RESULTS: Patterns of arthritis recognized on examination of skeletons showed geographic variation in skeletal distribution. East African apes (P. troglodytes schweinfurthii and G. beringei) had pauciarticular arthritis and frequent sacroiliac disease, whereas West African apes (P. troglodytes troglodytes and G. gorilla) had polyarticular peripheral joint disease with minimal sacroiliac involvement. DNA evidence revealed that Corynebactericeae were prominently represented in great apes with polyarticular disease, whereas Dietzia and Bifidobacterium exposure correlated with reduced peripheral joint arthritis distribution. CONCLUSIONS: Suggestions of a protective effect (in this case, limiting extent of peripheral arthritis, but not the disease itself) offered by these organisms are well represented by documented effects in other diseases (eg, tuberculosis) in the zoologic record. Perhaps it is this disease-modifying character that reduces the extent of the peripheral erosive disease, while increasing propensity to axial (sacroiliac) disease. A potential role for probiotic organisms in management of arthritis in humans is suggested, as has been documented for tuberculosis, gastrointestinal disorders, and food allergies.

Espondiloartropatía entérica: presentación de un caso / Enteric spondyloarthropathy: a case presentation

Seronegative arthropathies or spondyloarthropathy belong to a group of diseases that share clinical and genetic characteristics associated strongly with major histocompatibility complex class I HLA-B27. We report a case of a female patient of 39 years old with nightly back pain, morning stiffness and diffuse lumbar pain in the right buttock. In the immunological study observed negative rheumatoid factor and radiographic study observed right sacroiliitis. The final diagnosis is an enteric spondyloarthropathy...

Las artropatías seronegativas o espondiloartropatías corresponden a un grupo de enfermedades que comparten características clínicas y genéticas, asociadas fuertemente con el complejo mayor de histocompatibilidad clase I HLA-B27. Se presenta el caso de una paciente de 39 años con dolor lumbar nocturno, rigidez matutina lumbar y dolor difuso en la región glútea derecha.En el estudio inmunológico se observa factor reumatoídeo negativo, y al estudio radiológico se constata sacroileítis derecha. El diagnóstico final es una espondiloartropatía entérica...

Biomarcadores en espondiloartropatías / Biomarkers for spondyloarthropathies. State of the art

Among rheumatic diseases and specifically spondyloarthropathies (SpA), the study of biomarkers, defined as molecules that reflect either biologic or specific pathological process, is an important and necessary area in basic and clinical research, being a consequence or the response of an intervention. Other markers provide information about the pathogenesis of this disease. Recently, HLA-B27 has been used as diagnostic criteria to detect SpA. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) are clinical scores used to assess disease activity. A new activity index, Ankylosing Spondylitis Disease Activity Score (ASDAS) considers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as biomarkers. This review describes the state of the art of research on SpA biomarkers. There are promising new candidates as biomarkers such as metallopro-teinase 3, Type II collagen neoepitopes (C2C and C1-2C), C-propeptide of Type II collagen (CPII), aggrecan 846 epitope, macrophage colony stimulating factor, serum amyloid A protein and interleukin-6, among others.

[Biomarkers for spondyloarthropathies. State of the art]. / Biomarcadores en espondiloartropatías.

Among rheumatic diseases and specifically spondyloarthropathies (SpA), the study of biomarkers, defined as molecules that reflect either biologic or specific pathological process, is an important and necessary area in basic and clinical research, being a consequence or the response of an intervention. Other markers provide information about the pathogenesis of this disease. Recently, HLA-B27 has been used as diagnostic criteria to detect SpA. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) are clinical scores used to assess disease activity. A new activity index, Ankylosing Spondylitis Disease Activity Score (ASDAS) considers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as biomarkers. This review describes the state of the art of research on SpA biomarkers. There are promising new candidates as biomarkers such as metallopro-teinase 3, Type II collagen neoepitopes (C2C and C1-2C), C-propeptide of Type II collagen (CPII), aggrecan 846 epitope, macrophage colony stimulating factor, serum amyloid A protein and interleukin-6, among others.

A cross-sectional study of 130 Brazilian patients with Crohn's disease and ulcerative colitis: analysis of articular and ophthalmologic manifestations.

This is a cross-sectional study that analyzed the pattern and frequency of articular and ophthalmologic manifestations in patients with Crohn's disease (CD) and ulcerative colitis (UC), with or without signs of active bowel inflammation. One hundred and thirty consecutive patients with CD (n = 71) and UC (n = 59) were examined. Simple X-rays of lumbar spine, sacroiliac joints, and calcaneal bone were performed and human leukocyte antigen (HLA)-B27 was typed. Joint manifestations occurred in 41 (31.5%) patients, 27 (38%) with CD and 14 (23.7%) with UC. Peripheral involvement occurred in 22 patients, axial involvement in five, and mixed involvement in 14. The most frequently involved joints were knees (56.1%), ankles (29.3%), and hips (29.3%), while the predominant pattern was oligoarticular (84.6%) and asymmetrical (65.6%). Enthesitis was identified in seven (5.4%) patients and inflammatory lumbar pain in 13 (10%). Eight of these patients fulfilled the diagnostic criteria for ankylosing spondylitis (6.2%). Radiographic sacroiliitis occurred in 12 patients (9.2%). Ocular abnormalities were present in six patients (6.2%), and HLA-B27 was positive in five (5.8%). In conclusion, the articular manifestations in the present study were predominantly oligoarticular and asymmetric, with a low frequency of ophthalmologic involvement and positive HLA-B27.

Diagnóstico temprano de las espondiloartropatías / Early diagnosis of spondylarthropathies

Las espondiloartropatías son un grupo de enfermedades inflamatorias crónicas, de las cuales se destacan especialmente la espondilitis anquilosante, artritis reactiva, artritis psoriásica, artritis asociada con la enfermedad inflamatoria intestinal y las espondiloartropatías indiferenciadas. Los subgrupos más comunes de espondiloartropatías son la espondilitis anquilosante y la espondiloartropatía indiferenciada. El diagnóstico de la espondilitis anquilosante se basa especialmente en los hallazgos radiológicos inequívocos de sacroiliítis de grado 2 bilateralmente o grado 3 unilateralmente. Sin embargo en la fase temprana de la enfermedad, los estudios radiológicos no son lo suficientemente sensibles como para mostrar la presencia de sacroiliítis y por lo general pueden tardar varios años para detectar la presencia de sacroiliitis radiológica; de esta manera el diagnóstico de espondilitis anquilosante puede tardar hasta 8 a 11 años luego del inicio de los síntomas; como consecuencia de ello, el diagnóstico de espondiloartropatía con compromiso axial en ausencia de sacroiliítis radiológica es de gran dificultad para el reumatólogo. En los estadíos tempranos, el test de HLA B27 y la resonancia magnética de articulaciones sacroiliacas son útiles en el diagnóstico temprano. En presencia de dolor crónico de espalda la probabilidad de espondiloartropatía axial es de un 5 por ciento y aumenta a un 14 por ciento en presencia de dolor de espalda inflamatorio; la probabilidad de espondiloartropatía axial aumenta a un 90 por ciento en presencia de = 3 hallazgos de espondiloartropatías (talagia, uveítis, dactilitis, historia familiar positiva, dolor glúteo alternante, psoriasis, enfermedad inflamatoria intestinal, artritis asimétrica, respuesta favorable a los antiinflamatorios no esteroideos). De otra parte, la positividad del HLA B27 y la resonancia magnética aumentan la probabilidad de la enfermedad, en especial en aquellos casos que no presentan otros hallazgos de espondiloartropatías o que presentan 1 a 2 manifestaciones de espondiloartropatías. En pacientes con espondiloartropatía psoriásica o asociada con la enfermedad inflamatoria intestinal el uso del HLA B27 es de valor limitado, ya que estas entidades por lo general tienen una asociación negativa con el HLA B27

Recomendaciones del Comité de Expertos de la Asociación Colombiana de Reumatología para el empleo de terapia biológica en las espondiloartropatías / Recommendations of the expert committee of the rheumatology Colombian association for the use of biologic therapy in the spondyloarthropathies

Las espondiloartropatías son un grupo de enfermedades que comparten ciertas características clínicas, radiológicas y de laboratorio. Estudios recientes resaltan la importancia de estas que pueden como grupo llegar a tener una prevalencia mayor que patologías frecuentes como la artritis reumatoide, con implicaciones de los aspectos sociales, laborales y fármacoeconómicos. El manejo tradicional de estas patologías no presentó avances significativos hasta hace cinco años cuando con la aparición de los inhibidores del factor de necrosis tumoral (TNF), la llamada terapia biológica se cambió las perspectivas del tratamiento de este grupo de enfermedades convirtiéndose en el día de hoy en una gran herramienta terapéutica. La Asociación Colombiana de Reumatología teniendo en cuenta el conocimiento de este gran avance y el alto impacto de éste en la parte de costos ha desarrollado unas recomendaciones para la utilización de la terapia biológica en las espondiloartropatías mediante la modalidad de consenso con la participación de especialistas expertos en esta área de la reumatología

Espondiloartropatía y uveítis / Spondyloarthropathies and uveitis

El presente estudio presenta una revisión del tema de la espondiloartropatía. Los autores relatan las características clínicas de la enfermedad, las manifestaciones oftalmológicas, discuten los estudios experimentales y clínicos relacionados con su patogénesis, su asociación con el antígeno HLA-B27, y presentan las alternativas de tratamiento y pronóstico, basados en la pesquisa bibliográfica. A pesar de que la literatura es abundante sobre la espondiloartropatía, existen pocos relatos nacionales de esta patología en revistas oftalmológicas.

[Clinical features of spondyloarthropaties in childhood: analysis of 26 patients]. / Características clínicas das espondiloartropatias na infância: análise de 26 pacientes.

OBJECTIVE: To evaluate retrospectively the clinical features of children and adolescents with spondiloarthropathies (Sps). METHODS: The charts of all Sps patients followed up in the outpatient Pediatric Rheumatology unit of UNIFESP-EPM, were analyzed from June 1982 to April 2000. The following demographic data were evaluated: age of onset, disease duration, clinical features, laboratory data, radiological findings, treatment and outcome. RESULTS: 10 out of 26 patients (38.4%) presented SEA, 1 patient (3.8%) undifferentiated spondiloarthrophaty, 10 (38.4%) JAS, 2 (7.7%) arthropathy related to inflammatory bowel disease, 2 (7.7%) Reiter's syndrome and 1 (3.8%) psoriatic arthritis. The average age at disease onset was 9.2 years (1 to 15 years). The patients with Reiter's syndrome presented lower age at onset (average age 6.5 years). Twenty-five out of 26 were males and 15 out of 26 were caucasians. Most patients presented peripheral arthritis in lower limbs (96.1%), enthesitis (61.5%) and positive HLA-B27 (14/23 - 60.9%). Ten patients (38.4%) presented axial involvement. Fifteen patients had JRA or RF as diagnosis in the beginning of the disease. CONCLUSION: Although less frequent than JRA, the spondiloarthropathies must be considered in the differential diagnosis of children and adolescents, mainly among male patients with chronic arthritis.

Características clínicas das espondiloartropatias na infância: análise de 26 pacientes / Clinical features of spondyloarthropaties in childhood: analysis of 26 patients

OBJETIVO: Avaliar retrospectivamente as características clínicas dos pacientes com diagnóstico de espondiloartropatia. MÉTODOS: Foram analisados os prontuários de todos os pacientes com diagnóstico de espondiloartropatia seguidos no ambulatório de reumatologia pediátrica da UNIFESP-EPM no período de junho de 1982 a abril de 2000. Foram avaliados a idade de início e tempo de evoluçäo da doença, manifestaçöes clínicas, dados laboratoriais, achados radiológicos, tratamento e evoluçäo. RESULTADOS: Dos 26 pacientes estudados, 10 (38,4 por cento) apresentavam SEA, um (3,8 por cento) espondiloartropatia indiferenciada (EAI), 10 (38,4 por cento) EAJ, dois (7,7 por cento) artropatia da DIIC, dois (7,7 por cento) síndrome de Reiter e um (3,8 por cento) artrite psoriásica. O início da doença variou de 1 a 15 anos (média de 9,2 anos). Os pacientes com síndrome de Reiter tiveram menor idade de início (média de 6,5 anos). Houve predomínio do sexo masculino (25 pacientes) e da raça caucasóide (15 pacientes). A maioria dos pacientes apresentou artrite periférica em membros inferiores (96,1 por cento), entesite (61,5 por cento) e HLA B27 positivo (14/23 - 60,9 por cento). Dez pacientes (38,4 por cento) apresentaram comprometimento axial. Quinze pacientes receberam diagnóstico de ARJ ou FR no início do quadro. CONCLUSÄO: Embora menos freqüentes do que a ARJ, as espondiloartropatias devem ser consideradas no diagnóstico diferencial das crianças e adolescentes, principalmente do sexo masculino, com artrite crônica