Efficacy of Anakinra in Refractory Adult-Onset Still's Disease: Multicenter Study of 41 Patients and Literature Review.

Adult-onset Still's disease (AOSD) is often refractory to standard therapy. Anakinra (ANK), an interleukin-1 receptor antagonist, has demonstrated efficacy in single cases and small series of AOSD. We assessed the efficacy of ANK in a series of AOSD patients. Multicenter retrospective open-label study. ANK was used due to lack of efficacy to standard synthetic immunosuppressive drugs and in some cases also to at least 1 biologic agent. Forty-one patients (26 women/15 men) were recruited. They had a mean age of 34.4 ± 14 years and a median [interquartile range (IQR)] AOSD duration of 3.5 [2-6] years before ANK onset. At that time the most common clinical features were joint manifestations 87.8%, fever 78%, and cutaneous rash 58.5%. ANK yielded rapid and maintained clinical and laboratory improvement. After 1 year of therapy, the frequency of joint and cutaneous manifestations had decreased to 41.5% and to 7.3% respectively, fever from 78% to 14.6%, anemia from 56.1% to 9.8%, and lymphadenopathy from 26.8% to 4.9%. A dramatic improvement of laboratory parameters was also achieved. The median [IQR] prednisone dose was also reduced from 20 [11.3-47.5] mg/day at ANK onset to 5 [0-10] at 12 months. After a median [IQR] follow-up of 16 [5-50] months, the most important side effects were cutaneous manifestations (n = 8), mild leukopenia (n = 3), myopathy (n = 1), and infections (n = 5). ANK is associated with rapid and maintained clinical and laboratory improvement, even in nonresponders to other biologic agents. However, joint manifestations are more refractory than the systemic manifestations.

Influence of the BsmI polymorphism of the vitamin D receptor gene on rheumatoid arthritis clinical activity.

OBJECTIVE: The etiopathogenesis of rheumatoid arthritis (RA) is not fully known; vitamin D has been shown to have immunomodulatory effects and could be implicated in it. BsmI polymorphism of vitamin D receptor (VDR) gene is involved in the pathogenesis of osteoporosis in RA. We analyzed the effect of this polymorphism on clinical activity in 123 Spanish postmenopausal women with RA. METHODS: Patients with RA were enrolled consecutively during outpatient clinic visits. RA severity and activity measures were recorded and a blood sample was extracted. Genetic analysis was made by DNA extraction techniques, amplification by polymerase chain reaction, and restriction using endonuclease BsmI. RESULTS: Mean age of the patients was 62.9 +/- 8.4 years. The mean time of the evolution of RA was 12.5 +/- 7.3 years and mean time since menopause was 15.2 +/- 9.4 years. Seventy-six percent of the patients were rheumatoid factor-positive; mean Health Assessment Questionnaire (HAQ) score was 1.3 +/- 0.7; 92% of the patients had been treated with low-dose glucocorticoids. Twenty-eight patients (23%) had genotype BB, 48 (39%) Bb, and 47 (38%) bb. Patients with BB or Bb genotype had statistically significantly higher HAQ scores, erythrocyte sedimentation rate, current and accumulated dose of glucocorticoids, and number of disease modifying antirheumatic drugs taken, and lower serum hemoglobin and albumin than patients with bb genotype (p < 0.05). CONCLUSION: Among patients with RA, the bb genotype of the BsmI polymorphism of the VDR gene is associated with less severe disease.

Spontaneous pyogenic vertebral osteomyelitis in nondrug users.

OBJECTIVE: To analyze the clinical, microbiological, and radiologic features of patients without drug addiction suffering from spontaneous pyogenic vertebral osteomyelitis. METHODS: We collected all microbiologically proved cases of pyogenic vertebral osteomyelitis seen between January 1980 and December 1999 in a teaching hospital. Patients with prior spinal instrumentation or surgery and injection drug users were excluded. RESULTS: Sixty-four patients, with a mean age of 59 +/- 17 years, were identified. In 29 (45%) patients, 1 or more underlying medical illnesses were found. The mean duration of symptoms before hospital admission was 48 +/- 40 days. Neurologic impairment was present in 18 (28%) patients. Staphylococcus aureus and gram-negative bacilli, mainly Escherichia coli, were the predominant etiologic agents. Blood cultures were positive in 72% (46/64) of cases. The cultures of spinal specimens obtained by x-ray-guided biopsy were positive in 52% (11/21) of cases, and those obtained by open biopsy in 75% (15/20) of cases. Plain radiography showed abnormalities in all but 7 patients. Fifty-one of 53 (96%) technetium Tc 99m diphosphonate bone scans and 40 of 44 (91%) gallium citrate Ga 67 bone scans showed increased uptake of tracers in the involved area. Paraspinal and epidural extension was found on computed tomography and/or magnetic resonance imaging in 74% (39/53) of cases; the presence of an extra-vertebral extension was not associated with the development of neurologic findings in many patients. Two patients died in relation to the infectious process and 3 relapsed; functional sequelae often were found. CONCLUSIONS: Spontaneous pyogenic vertebral osteomyelitis in nondrug users is a disease that affects mainly older patients suffering underlying medical illnesses. S aureus and E coli are the main causative microorganisms. Positive blood cultures frequently aided the diagnosis. Extra-vertebral extension is frequent but does not indicate a worse prognosis. Although life outcome is good, functional sequelae are common. Diagnostic delay before admission is a concern, and the physician should be alert to the possibility of this condition in patients with back or neck pain.

Utilidad de la fórmula de Cockroft-Gault como estimación del aclaramiento de creatinina en la artritis reumatoide / Utility of the Cockroft-Gault formula as an estimation of creatinine clearance in rheumatoid arthritis

Objetivo: Estudiar la utilidad de la fórmula de Cockroft-Gault (CG) para predecir el aclaramiento de creatinina en pacientes con artritis reumatoide.Método: Se ha estudiado a 81 pacientes con artritis reumatoide pertenecientes a todas las clases funcionales. El aclaramiento de creatinina fue calculado mediante la fórmula estándar y estimado a partir de la fórmula de CG. Los resultados del aclaramiento medido y estimado se compararon mediante correlación lineal y el método de BlandAltman. Resultados: El aclaramiento de creatinina medido ñ desviación estándar y el estimado con la fórmula de CG fueron 81,3 ñ 29,3 ml/min y 69 ñ 21,9 ml/min, respectivamente. Se observó una correlación positiva entre ambos aclaramientos con un valor de r de 0,66. La diferencia promedio ñ error estándar entre ambos métodos fue -12,2 ñ 24,8.Conclusiones: Existe una moderada correlación entre el aclaramiento de creatinina medido y el estimado por la fórmula de CG. En este estudio la fórmula de CG estima a la baja el aclaramiento de creatinina medido. Aunque la estimación del aclaramiento de creatinina a partir de la fórmula de CG puede ser inexacta, en la mayoría de pacientes esta inexactitud no es clínicamente relevante (AU)

Estudio densitométrico en mujeres posmenopáusicas con artritis reumatoide tratadas con dosis bajas de glucocorticoides / Prevalence of malnutrition and morphofunctional alterations of the pancreas in asymptomatic chronic alcoholic patients

Fundamento: Evaluar el estado de la densidad mineral ósea (DMO) en un grupo de mujeres posmenopáusicas afectadas de artritis reumatoide (AR) tratadas con dosis bajas de glucocorticoides. Pacientes y método: Se incluyeron 111 pacientes. La edad media (DE) fue de 63,8 (8,8) años, la duración media del período posmenopáusico de 16,4 (10,1) años y la duración media de la enfermedad de 12,5 (8,2) años. Resultados: Se observó una reducción significativa de la DMO, respecto de la población general, tanto en la columna lumbar (p < 0,05) como en el cuello femoral (p < 0,0001). La prevalencia de la osteoporosis fue del 47 por ciento. Conclusiones: El estudio confirma, en población española, que las mujeres posmenopáusicas con AR tratadas con dosis bajas de glucocorticoides presentan una menor DMO que la población general. La prevalencia de la osteoporosis se considera elevada. (AU)

Tratamiento de la amiloidosis secundaria a artritis reumatoide con metotrexato / Treatment of amyloidosis secondary to rheumatoid arthritis with methotrexate

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