Clinical factors associated with discontinuation of ts/bDMARDs in rheumatic patients from the BIOBADASER III registry.

Biologic and targeted synthetic disease-modifying antirheumatic drugs (ts/bDMARDs) play a pivotal role in the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS). Persistence of therapy provides an index of a drug's overall effectiveness. The objective of the study was to identify factors associated with discontinuation of ts/bDMARDs in a real-world dataset. The study population comprised patients diagnosed with RA, PsA, and AS included in the BIOBADASER registry for whom follow-up data were available until November 2019. Patient features and treatment data were included in the analysis. The Kaplan-Meier method was used to study survival of the different drugs according to the reason for discontinuation. Factors associated with discontinuation were studied using Cox regression models and bivariate and multivariate analyses. P values of less than 0.05 were regarded as statistically significant. The study population comprised 4,752 patients who received a total of 8,377 drugs, of which 4,411 (52.65%) were discontinued. The Kaplan-Meier curves showed that survival for first-line treatment was greater in all 3 groups (p < 0.001). Patients with RA had a greater risk of discontinuation if they were younger (HR, 0.99; 95% CI 0.99-1.00), if they were receiving anti-TNFα agents (HR, 0.61; 95% CI 0.54-0.70), and if they had more comorbid conditions (HR, 1.09; 95% CI 1.00-1.17). Patients with PsA had a higher risk if they were women (HR, 1.36; 95% CI 1.15-1.62) and if they were receiving other ts/bDMARDs (HR, 1.29; 95% CI 1.05-1.59). In patients with AS, risk increased with age (HR, 1.01; 95% CI 1.00-1.02), as did the number of comorbid conditions (HR, 1.27; 95% CI 1.12-1.45). The factors that most affected discontinuation of ts/bDMARDs were line of treatment, age, type of drug, sex, comorbidity and the year of initiation of treatment. The association with these factors differed with each disease, except for first-line treatment, which was associated with a lower risk of discontinuation in all 3 diseases.

Necrotizing fasciitis and myositis caused by streptococcal flesh-eating bacteria.

Three types of group A streptococcal infections are particularly feared: necrotizing fasciitis, myositis, and streptococcal toxic shock syndrome (TSS). We present 3 cases of necrotizing fasciitis due to Streptococcus pyogenes, one in an immunocompromised patient who had received kidney transplant and 2 healthy patients. Mean age of patients was 52 years (range, 42-67 years), and all 3 were male. One spontaneous case in absence of any obvious portal of entry is reported. The clinical course was initially indolent but quickly destructive. All patients required emergency surgical debridement and intravenous antibiotics. In 2 cases, intravenous immunoglobulin therapy was added. Differential diagnoses include septic arthritis, cellulitis, gout, other causes of tenosynovitis, erysipelas, and deep vein thrombosis.Blood and soft-tissue cultures should be obtained to identify the bacteria, and emergency computed tomography or magnetic resonance imaging scan should be performed to confirm the diagnosis and define the extension of the necrosis. Aggressive surgical debridement in the first 24 to 48 hours and antibiotic treatment, including penicillin and clindamycin, are the cornerstones in the management of these infections. Adjuvant intravenous immunoglobulin therapy might be useful in case of TSS. Diagnostic and treatment delays are the main causes of mortality in these infections.

Utilidad del propéptido amino-terminal del procolágeno tipo 1 (P1NP) como marcador de remodelado óseo en el paciente sometido a trasplante renal / Use of procollagen type 1 n-terminal propeptide (P1NP) as a marker of bone remodelling in renal transplant patients

Introducción y objetivo. El propéptido aminoterminal del procolágeno tipo I (P1NP) es un marcador de formación ósea que se altera en afecciones óseas tales como la osteoporosis. El objetivo de este estudio es ver la utilidad del marcador en el diagnóstico de la osteoporosis en una población de pacientes sometidos a un trasplante renal (TR). Material y métodos. Noventa pacientes sometidos a un TR (60 varones, 30 mujeres) con una edad media±desviación estándar (DE) de 55±15 años. Se determinó en suero P1NP, creatinina, paratirina (PTH) y vitamina D, en situación pretrasplante, a los 3 meses y al año. Se estimó el filtrado glomerular con la fórmula MDRD abreviado y se registró la terapia inmunosupresora. Se realizó una densitometría ósea a los 3 meses del trasplante. Según los criterios de la Organización Mundial de la Salud se clasificó la muestra en población con masa ósea baja (T-score<−1 DE) y población normal (T-score≥−1 DE). Resultados. No se observó correlación entre la concentración de P1NP y la función renal. Un 64% de los pacientes presentaron una masa ósea baja. El paciente con densidad mineral ósea disminuida presentaba unos valores de P1NP en situación pretrasplante mayores, respecto a los pacientes con masa ósea normal. El análisis de regresión logística puso de manifiesto que P1NP (p=0,028; odds ratio=10,755) podría ser un marcador de masa ósea baja independiente de la edad, el sexo, la dosis de glucocorticoides y la PTH (covariables en el estudio). Conclusiones. El P1NP es un buen marcador para estimar el estado óseo en el paciente renal. El valor de P1NP en situación pre-trasplante sería indicativo de un mayor riesgo de presentar una masa ósea disminuida (AU)

Introduction and objective. Type I procollagen N-terminal propeptide (P1NP) is a marker of bone formation which is altered in bone diseases such as osteoporosis. The objective of this study was to evaluate the use of this marker in the diagnosis of osteoporosis in patients who undergo a renal transplant. Material and methods. Ninety RT (renal transplant) patients (60 men, 30 women) with a mean age of 55±15 years were evaluated. Serum P1NP, creatinine, parathyroid hormone (PTH), and vitamin D were measured at baseline and at 3 months and 1 year after transplantation. The glomerular filtration rate was estimated using the Modification of Diet in Renal Disease (MDRD) formula and immunosuppression therapy was recorded. A bone densitometry scan was performed 3 months after transplant. The patients were classified,according to WHO guidelines, into two populations: a group with low bone mass (T-score<−1SD) and a normal group (T-score≥−1SD). Results. No correlation was observed between P1NP conentrations and kidney function. A low bone mass was seen in 64% of the RT patients. Patients in the group with low bone mass had higher pretransplant levels of P1NP compared to those in the normal group. The logistic regression analysis showed that P1NP (P=.028; OR=10.755) could be a marker of low bone mass, regardless of age, sex, glucosteroid dose and PTH (covariables in the study). Conclusions. P1NP is a good marker for estimating bone status in renal transplanted patients. Pretransplant P1NP values could be indicative of a higher risk of having a decreased bone mass (AU)