Experiencia con infliximab en el tratamiento de pacientes con artritis reumatoide refractaria en el Hospital Gregorio Marañón (HGUGM) frente a los resultados del estudio ATTRACT / Infliximab therapy in the treatment or refractory rheumatoid arthritis patients: a comparative study between the experience Hospital Gregorio Marañón (HGUGM) and ATTRACT study results

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Survival study of rheumatoid arthritis patients in Madrid (Spain). A 9-year prospective follow-up.

OBJECTIVE: To determine the risk and causes of death in rheumatoid arthritis (RA) patients in Madrid. METHODS: A longitudinal survival analysis was made. 182 RA patients of the rheumatology clinic of a tertiary care hospital were studied. 42 (23%) males and 140 (77%) females. All were followed-up for a 9-year period or to the date of death. Kaplan-Meier survival curves for both male and female cohorts were performed. The logrank test was used to compare both distributions and to determine the statistical significance. RESULTS: The mortality rate for the RA patient cohort was 15.4 deaths/1000 person-years (10.2/1000 for the female and 34.2/1000 for the male cohorts). The mortality rate ratio was 3.3. The logrank test showed a statistical difference (p=0.0023). The standardized mortality ratio was 1.85 for RA patients. The causes of death were: cardiovascular diseases 5 (21%), infections 5 (21%). amyloidosis 4 (17%), malignant diseases 2 (8%). CONCLUSIONS: Mortality is nearly two times higher in our population of RA patients. Male patients have a much lower survival probability than females. Cardiovascular diseases, infections and amyloidosis were the most common causes of death.

Arthritis in patients with chronic hepatitis C virus infection.

OBJECTIVE: To describe the clinical picture of arthritis in patients with chronic infection by hepatitis C virus (HCV). METHODS: Two patient populations were studied. Patients with arthritis and evidence of serum elevation of alanine aminotransferase (ALT) at the consultation were checked for HCV infection. A second group of 303 consecutive patients with rheumatoid arthritis (RA) were also checked for the presence of HCV antibodies. All patients attended the outpatient rheumatology unit of a tertiary care teaching hospital. Chronic HCV infection was determined by the presence of viral RNA in serum. A group of 315 first-time blood donors served as controls. RESULTS: Twenty-eight patients with arthritis and chronic HCV infection were identified. Seven fulfilled criteria for RA, psoriatic arthritis was found in one patient, systemic lupus erythematosus in one, gout in 2, chondrocalcinosis in 2, osteoarthritis in 7, and tenosynovitis in one. In 7 patients with a clinical picture of intermittent arthritis, a definitive diagnosis could not be made. In these patients, mixed cryoglobulinemia was present in 6/7 (86%), whereas mixed cryoglobulinemia was found in 6/21 (28%) of the other patients. Among patients with RA, 23 (7.6%) had HCV antibodies, and active infection by HCV was found in 7 (2.3%) patients. The prevalence of HCV antibodies in a blood donor population was 0.95%, significantly different (p<0.001; 95% CI 0.03, 0.10) compared to patients with RA. The distribution of antibodies determined by recombinant immunoblot analysis was similar (p = NS) between RA patients and blood donors with HCV antibodies. CONCLUSION: There is not a single clinical picture of arthritis in patients with chronic HCV infection. There is a well defined picture of arthritis associated with the presence of mixed cryoglobulinemia that consists of an intermittent, mono or oligoarticular, nondestructive arthritis affecting large and medium size joints. Although a high prevalence of HCV antibodies is suspected in patients with RA, its occurrence may be coincidental and its interpretation is difficult to determine from the data in this study.

Extrahepatic symptoms as presenting manifestations of hepatitis C virus infection.

Extrahepatic manifestations are being recognized increasingly in patients with hepatitis C virus (HCV) chronic infection. The objective of this study is to investigate these extrahepatic symptoms as presenting manifestations of HCV chronic infection.We studied 189 patients with HCV chronic infection, demonstrated by the presence of viral RNA in the serum. The presenting symptoms as well as the presence of other extrahepatic manifestations were registered at the first consultation by means of a clinical and laboratory protocol. In 47 patients (24.8%), liver disease was previously undiagnosed and HCV infection manifested itself by extrahepatic symptoms. The mean age was older (p < 0.001), and there were more females (p < 0.001). However, the mean alanine aminotransferase value was lower (p < 0.001) compared with that of the patients who had been seen first for liver disease-related problems. Arthralgias (p < 0.001) and fibromyalgia (p < 0.022) were significantly more common among the patients seen first for extrahepatic manifestations. Other extrahepatic manifestations, such as sicca symptoms, arthritis, and purpura, were also common in these patients. Im-munologic abnormalities were present in 70% of patients.Extrahepatic symptoms were the initial manifestations of HCV chronic infection in 25% of our patients. We point out the importance of extrahepatic manifestations as presenting symptoms of HCV infection.

B-lymphoproliferative disorders in patients with hepatitis C virus infection.

A cohort of 148 consecutive patients with hepatitis C virus infection were studied at the rheumatology out-patient clinic of a tertiary care teaching hospital. The diagnosis of hepatitis C virus infection was supported by detection of HCV RNA in the serum. Cryoglobulin screening was done in all patients and the presence of a monoclonal component was investigated when the cryocrit was higher than 1%. Patients with lymphoproliferative disorders were further investigated. Four patients had a B lymphoproliferative disorder, which represents a prevalence of 2.7% in this cohort of patients with hepatitis C virus infection. Mixed cryoglobulinemia (MC), with cryocrit higher than 1%, was found in 16 of 148 patients (11%). It was type III MC in 13 patients and type II MC in 3. All patients who developed a B lymphoproliferative disorder had mixed cryoglobulinemia, with a monoclonal component (type II MC) in two patients and without a monoclonal component (type III MC) in the other two. The incidence of B-lymphoproliferative disorders among this cohort of patients with hepatitis C virus infection seems to be significantly increased. However, the high frequency of asymptomatic, undiagnosed HCV infection among the apparently healthy general population may decrease the true significance of this association. Systematic screening of cryoglobulin production in patients with hepatitis C virus infection might clarify whether the risk of B lymphoproliferative disorders increases when type II or type III mixed cryoglobulinemia is present.

Fibromyalgia-associated hepatitis C virus infection.

The objective was to determine whether there might be an association between hepatitis C virus (HCV) chronic infection and fibromyalgia (FM). We determined the prevalence of HCV infection in 112 FM patients, in comparison with matched rheumatoid arthritis (RA) patients from the out-patient clinic of a teaching tertiary care general hospital. Furthermore, we looked for evidence of FM in 58 patients diagnosed with chronic hepatitis due to HCV, compared with matched surgery clinic patients, HCV antibodies were determined by enzyme-linked immunosorbent assay (ELISA) and recombinant immunoblot assay (RIBA). Serum RNA of HCV (HCV-RNA) was determined by polymerase chain reaction. In the group of FM patients, HCV antibodies were found by ELISA in 17 (15.2%) patients and in six (5.3%) of the RA controls (P < 0.05). RIBA was positive in 16 and indeterminate in one of the FM patients. Serum HCV-RNA was found in 13 of these FM patients. In eight (47%) FM patients, alanine aminotransferase (ALT) was normal, although HCV-RNA was detected in four (50%) of them. In the group of patients with chronic hepatitis due to HCV, all patients had HCV antibodies and the presence of HCV-RNA in serum. Within these patients, 31 (53%) had diffuse musculoskeletal pain, while six (10%) fulfilled FM diagnostic criteria. In the control group, 13/58 (22%) had diffuse musculoskeletal pain (P < 0.001), whereas only one female patient (1.7%) fulfilled FM criteria (P < 0.05). Serum ALT was 51.7 +/- 38.4 in FM patients, whereas it was 122 +/- 76.3 in patients with HCV chronic hepatitis but without FM (P < 0.001). There were no statistical differences in autoimmune markers between patients with and without FM. These data suggest that there exists an association between FM and active HCV infection in some of our patients. FM is not associated with liver damage or autoimmune markers in these patients. HCV infection should be considered in FM patients even though ALT elevations were absent.

Rheumatologic and autoimmune manifestations in patients with chronic hepatitis C virus infection.

Hepatitis C virus (HCV) has been associated with several autoimmune and rheumatologic disorders. The aim of this study was to determine the incidence of these abnormalities in patients with chronic HCV. We studied 56 patients, 29 of whom (52%) had biochemical abnormalities that suggested immunological disorders. Cryoglobulinemia was detected in nine patients (22%), antinuclear antibodies in eleven (20%), rheumatoid factor in seven (19.27%) and hypocomplementemia in fourteen (29.16%). The most common clinical manifestations were: arthralgias (52%), myalgias (16%), xerostomia (28.5%) and xerophthalmia (14%). These results indicate the existence of a relationship between HCV and rheumatologic disorders. We conclude that HCV may play a role in the pathogenesis of these autoimmune phenomena, but more studies are required to define the extent of this role.

[Variation in the number of diagnostic analyses and tests in a hospital outpatient consulting clinic]. / Variación en el número de análisis y pruebas diagnósticas en una consulta externa hospitalaria.

OBJECTIVE: To analyze the variation in the number of diagnostic test orders after physicians have been made aware of the need to order only the necessary tests for adequate patient diagnosis. MATERIAL AND METHODS: The study was done in a prospective manner in 3 successive steps during which 750 first-visit patients attending in an outpatient rheumatology clinic at a general hospital were analyzed. In the first step (baseline) data were collected without the physicians' knowledge. The results of the study were later presented at a grand round. In the second step (intervention) data were collected again, this time with the physicians' knowledge. A final data collection (control) was carried out 6 months later without physicians' knowledge again. RESULTS: In the baseline step 2.355 orders with a mean of 9.42 +/- 5.5 order/patient were done. In the intervention step, there was a reduction of 1,946 orders with a mean of 7.78 +/- 4.48 (p < 0.001). Six months later, in the control step, the number of orders was reduced to 1.806 with a mean of 7.22 +/- 5.16 orders/patient, with a 23.3% saving compared with the baseline step (p < 0.001). Also, significant differences were found in the number or orders among physicians at each step. Reduction was observed in every kind of diagnostic test. CONCLUSIONS: A considerable reduction of 23.3% in the number of analysis and diagnostic tests can be obtained if physicians are made aware of the need to order only the necessary tests for patients' diagnostic. This strategy may result in a significant containment in the growing health care cost we suffer nowadays.

AIDS and rheumatic manifestations in patients addicted to drugs. An analysis of 106 cases.

We evaluated the rheumatic manifestations in 106 patients with AIDS whose risk factor is intravenous drug addiction. All were intravenous drug addicts and carriers of the human immunodeficiency virus (HIV). Their average age was 28.36 years; 83 were men and 23 were women; 73 were in stage IV of the HIV infection; 12 were in stage III and 21 in stage II. Rheumatic manifestations were found in 21 patients (20%). Specifically, 13 had arthralgias/myalgias, 2 demonstrated oligoarthritis, 1 had tuberculous arthritis of the knee, and 1 patient showed systemic necrotizing vasculitis. Finally, 6 patients had a history of septic arthritis. There was an absence of the Reiter syndrome/reactive arthritis, a low frequency of symptoms of articular swelling, and the marked presence of histories of septic arthritis. The practices that lead to HIV infection may play a decisive role in the appearance of rheumatic manifestations in patients with AIDS, even more than the presence of the virus itself or the immunological alterations thereby produced.