Evento cardiovascular en una cohorte de pacientes con artritis reumatoide en Castilla-La Mancha, utilidad de la ecografía carotídea / Cardiovascular event in a cohort of rheumatoid arthritis patients in Castilla-La Mancha: Utility of carotid ultrasound

La artritis reumatoide (AR) presenta una mortalidad de 1,3-3 veces superior a la población general donde destaca la mortalidad de origen cardiovascular con un 40-50%. Actualmente se considera la enfermedad cardiovascular como una manifestación extraarticular de la AR, siendo un factor de riesgo independiente de los tradicionales, con un riesgo elevado de enfermedad cardiovascular (OR: 1,5-4,0). La medición ecográfica del grosor íntimo medial (GIM) de la arteria carótida común y la presencia de placas ateromatosas es un método no invasivo y marcador subrogado de arterioesclerosis subclínica. Objetivo: Establecer si los hallazgos de arterioesclerosis subclínica por ecografía carotídea pueden ser un buen predictor del desarrollo de eventos cardiovasculares (ECV) en una cohorte de pacientes con AR a 10 años. Metodología: Se evaluó una cohorte de pacientes con AR atendidos en consulta externa de Reumatología de una hospital de Castilla-La Mancha durante el año 2013. Se realizó una evaluación para el desarrollo de ECV a los 10 años siguientes de comenzado el estudio y se analizó su correlación con los hallazgos ecográficos previos de GIM y placas ateromatosas. Resultados: Ocho (24%) pacientes presentaron un ECV. Tres (9%), episodio de fallo cardiaco; 3 (9%) accidente cerebrovascular y 2 (6%) episodio de infarto agudo al miocardio. Los pacientes con AR que desarrollaron un ECV habían presentado un GIM mayor (0,97±0,08mm) en comparación con los pacientes con AR que no tuvieron complicaciones cardiovasculares (0,74±0,15mm) (p=0,003). La presencia de un GIM≥0,9mm y placas ateromatosas representó un riesgo relativo de 12,25 (p=0,012) y 18,66 (p=0,003), respectivamente, para el desarrollo de un ECV. Conclusiones: La ecografía carotídea en pacientes con AR nos podría permitir la detección precoz de aterosclerosis subclínica antes del desarrollo de ECV, siendo fundamentalmente el GIM≥0,9mm el hallazgo más asociado a ECV y no influenciado por la edad.(AU)

Rheumatoid arthritis (RA) has a mortality rate 1.3–3 times higher than the general population, with cardiovascular mortality accounting for 40%–50% of cases. Currently, cardiovascular disease is considered an extra-articular manifestation of RA (OR: 1.5–4.0). Ultrasound measurement of the intima-media thickness (IMT) of the common carotid artery and the presence of atherosclerotic plaques is a non-invasive method and a surrogate marker of subclinical arteriosclerosis. Objective: To determine if subclinical arteriosclerosis findings through carotid ultrasound can serve as a good predictor of cardiovascular events (CVE) development in a cohort of RA patients over a 10-year period. Methodology: A cohort of RA patients seen in the rheumatology outpatient clinic of a hospital in Castilla-La Mancha in 2013 was evaluated. A prospective evaluation for the development of CVE over the following 10 years was conducted, and its correlation with previous ultrasound findings of IMT and atherosclerotic plaques was analyzed. Results: Eight (24%) patients experienced a CVE. Three (9%) had heart failure, three (9%) had a stroke, and two (6%) experienced acute myocardial infarction. RA patients who developed a CVE had a higher IMT (0.97±0.08mm) compared to the RA patients without cardiovascular complications (0.74±0.15mm) (P=.003). The presence of IMT≥0.9mm and atherosclerotic plaques had a relative risk of 12.25 (P=.012) and 18.66 (P=.003), respectively, for the development of a CVE. Conclusions: Carotid ultrasound in RA patients may allow for early detection of subclinical atherosclerosis before the development of CVE, with IMT≥0.9mm being the most closely associated finding with CVE, unaffected by age.(AU)

Cardiovascular event in a cohort of rheumatoid arthritis patients in Castilla-La Mancha: Utility of carotid ultrasound.

Rheumatoid Arthritis (RA) has a mortality rate 1,3 to 3 times higher than the general population, with cardiovascular mortality accounting for 40-50% of cases. Currently, cardiovascular disease is considered an extraarticular manifestation of RA (OR: 1,5-4,0). Ultrasound measurement of the intima-media thickness (IMT) of the common carotid artery and the presence of atherosclerotic plaques (AP) is a non-invasive method and a surrogate marker of subclinical arteriosclerosis. OBJECTIVE: To determine if subclinical arteriosclerosis findings through carotid ultrasound can serve as a good predictor of cardiovascular events (CVE) development in a cohort of RA patients over a 10-year period. METHODOLOGY: A cohort of RA patients seen in the Rheumatology outpatient clinic of a hospital in Castilla La Mancha in 2013 was evaluated. A prospective evaluation for the development of CVE over the following 10 years was conducted, and its correlation with previous ultrasound findings of IMT and AP was analyzed. RESULTS: Eight (24%) patients experienced a CVE. Three (9%) had heart failure, three (9%) had a stroke, and two (6%) experienced acute myocardial infarction. RA patients who developed a CVE had a higher IMT (0,97 +/- 0.08 mm) compared to the RA patients without CV complications (0,74 +/- 0.15 mm) (p = 0,003). The presence of IMT ≥ 0.9 mm and AP had a relative risk of 12,25 (p = 0,012) and 18,66 (p = 0,003), respectively, for the development of a CVE. CONCLUSIONS: Carotid ultrasound in RA patients may allow for early detection of subclinical atherosclerosis before the development of CVE, with IMT ≥ 0.9 mm being the most closely associated finding with CVE, unaffected by age.

«Banderas rojas» de amiloidosis cardiaca en pacientes con estenosis de canal lumbar e hipertrofia de ligamento amarillo / Red flags of cardiac amyloidosis in patients with spinal stenosis and yellow ligament hypertrophy

Introducción Carecemos de estudios que evalúen la presencia de amiloidosis cardiaca (AC) en pacientes con estenosis de canal lumbar (ECL). La identificación de banderas rojas (BR) asociadas a la enfermedad podría identificar casos de AC. Nuestro objetivo principal fue determinar la prevalencia de BR de AC. Métodos Estudio transversal de casos consecutivos que presentaban ECL e hipertrofia del ligamento amarillo (HLA). Se realizó una valoración que incluía electrocardiograma, ecocardiograma y análisis de sangre y orina. Se definió como sospecha de AC la presencia de hipertrofia ventricular y alguna BR. Resultados Se evaluaron 103 pacientes con ECL y HLA. La prevalencia de BR de AC fue elevada: insuficiencia cardiaca, 18,4%; estenosis aórtica, 1,9%; síndrome del túnel carpiano, 7,8%; rotura tendinosa bicipital, 1,9%; hipotensión arterial, 17,4%; clínica de neuropatía, 51,5%; patrón de pseudoinfarto, 3,9%; bajos voltajes, 15,5%; trastorno de la conducción, 15,5%; disminución del strain longitudinal, 25,3%; preservación apical del strain, 3,9%. El 57,3% de los pacientes presentaron sospecha de AC. Conclusión La prevalencia de BR de AC en pacientes con ECL es alta. Un elevado número de pacientes presentaron criterios de sospecha de AC. (AU)

Introduction Studies addressing the prevalence of cardiac amyloidosis (CA) among patients with spinal stenosis (SS) are lacking. The identification of the red flags (RF) of CA could lead to early detection of cases of CA. The primary objective of this study was to address the prevalence of RF of CA among patients with SS. Methods Transversal study including consecutive cases with SS and yellow ligament hypertrophy (YLH). A clinical assessment that included electrocardiogram, echocardiogram and urine and blood test was performed. A clinical suspicion of CA was defined by the presence of left ventricular hypertrophy plus any RF. Results One hundred and three patients with SS and YLH were assessed. The prevalence of RF was high: heart failure: 18.4%; aortic stenosis: 1.9%; carpal tunnel syndrome: 7.8%; bicipital tendon rupture: 1.9%; arterial hypotension: 17.4%; polyneuropathy symptoms: 51.5%; pseudoinfarction pattern: 3.9%; low voltages: 15.5%; conduction abnormalities: 15.5%; decreased longitudinal strain: 25.3%; apical sparing pattern: 3.9%. The 57.3% of the cohort met the CA suspicion criteria. Conclusion The prevalence of RF of CA is high among patients with SS and YLH. A high proportion of patients met the CA suspicion criteria. (AU)

«Banderas rojas» de amiloidosis cardiaca en pacientes con estenosis de canal lumbar e hipertrofia de ligamento amarillo / Red flags of cardiac amyloidosis in patients with spinal stenosis and yellow ligament hypertrophy

Introducción Carecemos de estudios que evalúen la presencia de amiloidosis cardiaca (AC) en pacientes con estenosis de canal lumbar (ECL). La identificación de banderas rojas (BR) asociadas a la enfermedad podría identificar casos de AC. Nuestro objetivo principal fue determinar la prevalencia de BR de AC. Métodos Estudio transversal de casos consecutivos que presentaban ECL e hipertrofia del ligamento amarillo (HLA). Se realizó una valoración que incluía electrocardiograma, ecocardiograma y análisis de sangre y orina. Se definió como sospecha de AC la presencia de hipertrofia ventricular y alguna BR. Resultados Se evaluaron 103 pacientes con ECL y HLA. La prevalencia de BR de AC fue elevada: insuficiencia cardiaca, 18,4%; estenosis aórtica, 1,9%; síndrome del túnel carpiano, 7,8%; rotura tendinosa bicipital, 1,9%; hipotensión arterial, 17,4%; clínica de neuropatía, 51,5%; patrón de pseudoinfarto, 3,9%; bajos voltajes, 15,5%; trastorno de la conducción, 15,5%; disminución del strain longitudinal, 25,3%; preservación apical del strain, 3,9%. El 57,3% de los pacientes presentaron sospecha de AC. Conclusión La prevalencia de BR de AC en pacientes con ECL es alta. Un elevado número de pacientes presentaron criterios de sospecha de AC. (AU)

Introduction Studies addressing the prevalence of cardiac amyloidosis (CA) among patients with spinal stenosis (SS) are lacking. The identification of the red flags (RF) of CA could lead to early detection of cases of CA. The primary objective of this study was to address the prevalence of RF of CA among patients with SS. Methods Transversal study including consecutive cases with SS and yellow ligament hypertrophy (YLH). A clinical assessment that included electrocardiogram, echocardiogram and urine and blood test was performed. A clinical suspicion of CA was defined by the presence of left ventricular hypertrophy plus any RF. Results One hundred and three patients with SS and YLH were assessed. The prevalence of RF was high: heart failure: 18.4%; aortic stenosis: 1.9%; carpal tunnel syndrome: 7.8%; bicipital tendon rupture: 1.9%; arterial hypotension: 17.4%; polyneuropathy symptoms: 51.5%; pseudoinfarction pattern: 3.9%; low voltages: 15.5%; conduction abnormalities: 15.5%; decreased longitudinal strain: 25.3%; apical sparing pattern: 3.9%. The 57.3% of the cohort met the CA suspicion criteria. Conclusion The prevalence of RF of CA is high among patients with SS and YLH. A high proportion of patients met the CA suspicion criteria. (AU)

[Red flags of cardiac amyloidosis in patients with spinal stenosis and yellow ligament hypertrophy]. / «Banderas rojas¼ de amiloidosis cardiaca en pacientes con estenosis de canal lumbar e hipertrofia de ligamento amarillo.

INTRODUCTION: Studies addressing the prevalence of cardiac amyloidosis (CA) among patients with spinal stenosis (SS) are lacking. The identification of the red flags (RF) of CA could lead to early detection of cases of CA. The primary objective of this study was to address the prevalence of RF of CA among patients with SS. METHODS: Transversal study including consecutive cases with SS and yellow ligament hypertrophy (YLH). A clinical assessment that included electrocardiogram, echocardiogram and urine and blood test was performed. A clinical suspicion of CA was defined by the presence of left ventricular hypertrophy plus any RF. RESULTS: One hundred and three patients with SS and YLH were assessed. The prevalence of RF was high: heart failure: 18.4%; aortic stenosis: 1.9%; carpal tunnel syndrome: 7.8%; bicipital tendon rupture: 1.9%; arterial hypotension: 17.4%; polyneuropathy symptoms: 51.5%; pseudoinfarction pattern: 3.9%; low voltages: 15.5%; conduction abnormalities: 15.5%; decreased longitudinal strain: 25.3%; apical sparing pattern: 3.9%. The 57.3% of the cohort met the CA suspicion criteria. CONCLUSION: The prevalence of RF of CA is high among patients with SS and YLH. A high proportion of patients met the CA suspicion criteria.

Imbalanced machine learning classification models for removal biosimilar drugs and increased activity in patients with rheumatic diseases.

OBJECTIVE: Predict long-term disease worsening and the removal of biosimilar medication in patients with rheumatic diseases. METHODOLOGY: Observational, retrospective descriptive study. Review of a database of patients with immune-mediated inflammatory rheumatic diseases who switched from a biological drug (biosimilar or non-biosimilar) to a biosimilar drug for at least 6 months. We selected the most important variables, from 18 variables, using mutual information tests. As patients with disease worsening are a minority, it is very difficult to make models with conventional machine learning techniques, where the best models would always be trivial. For this reason, we computed different types of imbalanced machine learning models, choosing those with better f1-score and mean ROC AUC. RESULTS: We computed the best-imbalanced machine learning models to predict disease worsening and the removal of the biosimilar, with f1-scores of 0.52 and 0.63, respectively. Both models are decision trees. In the first one, two important factors are switching of biosimilar and age, and in the second, the relevant variables are optimization and the value of the initial PCR. CONCLUSIONS: Biosimilar drugs do not always work well for rheumatic diseases. We obtain two imbalanced machine learning models to detect those cases, where the drug should be removed or where the activity of the disease increases from low to high. In our decision trees appear not previously studied variables, such as age, switching, or optimization.

Ultrasonography in rheumatology: time to learn from patient views.

OBJECTIVE: The objective of this observational, descriptive, cross-sectional, multicentre study was to assess the perceived quality and grade of satisfaction expressed by patients with chronic arthropathies regarding the use of musculoskeletal (MSK) ultrasonography by rheumatologists as an integrated clinical care tool. METHODS: All Spanish rheumatology departments with MSK ultrasonography incorporated in their healthcare services were invited to participate in the study. A Spanish-language survey was offered to fill out anonymously to all consecutive patients with chronic arthropathies under follow-up in the rheumatology outpatient clinics who attended their centre for a period of 3 months. The survey consisted of three sections. The first section contained patients' demographics, disease data, frequency of performing rheumatological ultrasound and information about who performed their ultrasound assessments. The second section consisted of 14 questions about patient's experience and opinion on different aspects of the management, performance and perceived usefulness of performing ultrasound, to be answered on a Likert scale 1-5. The third section of the survey was addressed to the rheumatologist ultrasonographers. RESULTS: Nine hundred and four patients from 16 university hospital rheumatology departments completed the survey. All questions reached an overall favourable response ≥ 80%. Patients who reported usual ultrasound examinations in their rheumatology care and those in which it was their attending rheumatologist who performed the ultrasound assessments responded more favourably. CONCLUSION: Our encouraging patient-centred results may be useful in facilitating the implementation of rheumatological ultrasound in rheumatology care worldwide. Key Points • This is the largest multicentre survey carried out in patients with chronic joint diseases designed to assess their experience and perceived benefits with the use of ultrasonography performed by rheumatologists in daily practice. • Musculoskeletal ultrasound incorporated into rheumatology care was very well accepted and valued by most patients. • The patients perceived that ultrasonography helps not only their rheumatologist but also themselves to better understand their condition. • The patients believed that ultrasonography helps them accept and comply with the proposed treatment.

Cardiac amyloidosis in patients with spinal stenosis and yellow ligament hypertrophy.

BACKGROUND: Spinal stenosis (SS) is a manifestation associated with cardiac amyloidosis (CA). However, there is a lack of studies assessing the prevalence of CA among patients with SS. We aimed to address the prevalence of CA among patients with SS and YLH. METHODS: We performed a cross-sectional study of consecutive patients older than 65 years with SS and yellow ligament hypertrophy (YLH). All the patients were assessed with an electrocardiogram, echocardiogram and biohumoral evaluation. Patients with CA red flags was further studied with cardiac magnetic resonance and 99mTc-DPD scintigraphy. A cohort of patients with confirmed CA and SS was used to assess clinical features associated with CA. RESULTS: 105 patients (75.0 ± 6.6 years old; 45.7% males) with SS and YLH [5.5 [5-7] mm] were screened. Prevalence of red flags of CA was high and 58 patients presented clinical suspicion of CA. One patient (0.95%) was finally diagnosed of CA. Patients with confirmed CA presented a more expressive phenotype than the screened population. Patients with suspected CA had greater YLH than patients without suspicion of CA (6.4 ± 1.3 vs. 5.0 ± 0.8 mm; p < 0.001) and patients with confirmed CA presented greater YLH than the screening population (6.7 ± 1.8 vs. 5.7 ± 1.2 mm; p = 0.018). CONCLUSION: Despite red flags of CA are common among patients with SS, the prevalence of confirmed CA was low in our sample of screened patients.

Sex differences in cardiovascular and disease-related features in axial spondyloarthritis. A multicenter study of 912 patients.

OBJECTIVES: To determine the potential impact of sex-specific disease-related characteristics on cardiovascular (CV) disease in axial spondyloarthritis (axSpA). METHODS: Cross-sectional study of the Spanish AtheSpAin cohort to study CV disease in axSpA. Data on carotid ultrasound and CV disease and disease-related features were collected. RESULTS: 611 men and 301 women were recruited. Classic CV risk factors were significantly less prevalent in women, who also showed a lower frequency of carotid plaques (p = 0.001), lower carotid intima-media thickness (IMT) values ​​(p<0.001) and CV events (p = 0.008). However, after adjustment for classic CV risk factors, only the differences with respect to carotid IMT remained statistically significant. Women showed higher ESR at diagnosis (p = 0.038), and more active disease (ASDAS, p = 0.012, and BASDAI, p<0.001). They had shorter disease duration (p<0.001), lower prevalence of psoriasis (p = 0.008), less structural damage (mSASSS, p<0.001), and less mobility limitation (BASMI, p = 0.033). To establish whether these findings could lead to sex differences in CV disease burden, we compared the prevalence of carotid plaques in men and women with the same level of CV risk stratified according to the Systematic Coronary Risk Evaluation (SCORE). Men included in the low-moderate CV risk SCORE category had more carotid plaques (p = 0.050), along with longer disease duration (p = 0.004), higher mSASSS (p = 0.001) and psoriasis (p = 0.023). In contrast, in the high-very high-risk SCORE category, carotid plaques were observed more frequently in women (p = 0.028), who were characterized as having worse BASFI (p = 0.011), BASDAI (p<0.001) and ASDAS (p = 0.027). CONCLUSION: Disease-related features may influence the expression of atherosclerosis in patients with axSpA. This may be especially applicable to women at high CV risk, characterized by greater disease severity and more severe subclinical atherosclerosis than men, suggesting a stronger interaction between disease activity and atherosclerosis in women with axSpA.

Cardiovascular and disease-related features associated with extra-articular manifestations in axial spondyloarthritis. A multicenter study of 888 patients.

OBJECTIVES: To determine the potential impact of extra-articular manifestations (EAMs) on disease characteristics and cardiovascular (CV) risk in patients with axial spondylarthritis (axSpA). METHODS: This is a cross-sectional study from the AtheSpAin cohort, a Spanish multicenter cohort to study atherosclerosis in axSpA. Data on the history of CV events, subclinical carotid atherosclerosis, and disease-related features, including EAMs, were collected. RESULTS: 888 axSpA patients were recruited. Concomitant acute anterior uveitis (AAU), psoriasis (PSO), and inflammatory bowel disease (IBD) were present in 177 (19.9%), 96 (10.8%), and 57 (6.4%) patients, respectively. When compared with axSpA patients without EAMs, a significant increase in past CV events was observed in patients with PSO (9% versus 4%, p = 0.048) and in those with at least one EAM (7% versus 4%, p = 0.032) or with more than one EAM (11% versus 4%, p = 0.022). The frequency of carotid plaques and the values of cIMT were higher in patients with EAMs than in those without EAMs, although only the univariable analysis for carotid plaques in patients with PSO (39% versus 30%, p = 0.038) and for cIMT in patients with AAU (665 ± 156 µm versus 637 ± 139 µm, p = 0.042) and those with at least one EAM (661 ± 155 µm versus 637 ± 139 µm, p = 0.024) showed significant results. In addition, patients with PSO or IBD were found to have specific disease-related features, such as higher ESR at diagnosis, and more frequent use of glucocorticoids and TNF inhibitors than those without EAMs. Also, PSO patients had more commonly peripheral involvement and those with AAU more severe radiographic damage than those without EAMs. The frequency of HLA B27 was higher in patients with AAU and lower in those with PSO or IBD compared to those without EAMs. CONCLUSION: Patients with axSpA and EAMs, in addition to displaying their own disease-related features, are likely to have an increased CV risk that appears proportional to the number of EAMs and could be related to proatherogenic factors other than traditional CV risk factors, such as the inflammatory load and the use of glucocorticoids.

Irisin as a Novel Biomarker of Subclinical Atherosclerosis, Cardiovascular Risk and Severe Disease in Axial Spondyloarthritis.

Introduction: Patients with axial spondyloarthritis (axSpA) have a high disease burden mainly due to the rheumatic disease itself, and also exhibit accelerated atherosclerosis, that leads to a higher incidence of cardiovascular (CV) disease. Accordingly, the identification of biomarkers of CV risk and inflammation in axSpA patients is clinically relevant. In this sense, given the beneficial functions exerted by the adipomyokine irisin in processes related to CV disease and inflammation, our aim was to assess, for the first time, the role of irisin as a genetic and serological biomarker of subclinical atherosclerosis, CV risk and disease severity in axSpA patients. Methods: A large cohort of 725 Spanish patients with axSpA was included. Subclinical atherosclerosis (presence of plaques and abnormal carotid intima-media thickness values) was evaluated by carotid ultrasound. Four irisin polymorphisms (rs16835198 G/T, rs3480 A/G, rs726344 G/A, and rs1570569 G/T) were genotyped by TaqMan probes. Additionally, serum irisin levels were determined by ELISA. Results: Low irisin levels were linked to the presence of plaques (p=0.002) and atherogenic index values ≥4 (p=0.01). Serum irisin were positively correlated with C-peptide levels (p<0.001) and negatively correlated with visual analogue scale and Bath Ankylosing Spondylitis Metrology Index (p<0.05 in all the cases). Moreover, lower irisin levels were observed in patients with sacroiliitis and in those with a negative HLA-B27 status (p<0.001 and p=0.006, respectively), as well as in those treated with non-steroidal anti-inflammatory drugs and conventional disease-modifying antirheumatic drugs (p<0.001 and p=0.002, respectively). Interestingly, the TT genotype and the T allele of rs16835198 were less frequent in axSpA patients with ASDAS >2.1 (Odds Ratio (OR): 0.48 [0.28-0.83] and OR: 0.73 [0.57-0.92], respectively, p=0.01 in both cases). Additionally, the frequency of rs1570569 T allele was higher in these patients (OR: 1.46 [1.08-1.97], p=0.01). Furthermore, the GGGT haplotype was more frequent in patients with ASDAS values >2.1 (OR: 1.73 [1.13-2.66], p=0.01). Conclusions: Our results indicate that low serum irisin levels could be indicators of the presence of subclinical atherosclerosis, high CV risk and more severe disease in axSpA patients. In addition, irisin may also constitute a genetic biomarker of disease activity in axSpA.

First Spanish study on the effectiveness of ultrasound-guided sacroiliac joint injection in patients with spondyloarthritis.

Objective: The aim was to assess clinical improvement after US-guided injection of CSs into the SI joint of patients with SpA. Methods: This was an observational, descriptive, retrospective study of patients with SpA and sacroiliitis who received an US-guided injection into the SI joint between 1 June 2020 and 31 May 2021. Means were compared using Student's paired t-test for the variables visual analog scale (VAS), BASDAI, ASDAS, CRP and ESR before and after the procedure. We evaluated the association between these variables and the clinical response using the odds ratio. Results: We analysed 32 patients with SpA [age 42.69 (8.19) years; female sex, 56.25%], with a VAS score of 7.88 (0.79), BASDAI of 5.43 (1.48) and ASDAS of 3.27 (0.86) before the procedure. At 2-3 months, 75% of patients had improved: VAS 3.81 (2.33) (-4.07, P < 0.0001) and BASDAI 3.24 (1.6) (-2.19, P < 0.0001). At 5-6 months, 59.37% had improved: VAS 4.63 (2.31) (-3.25, P < 0.0001), BASDAI 3.57 (1.67) (-1.86, P < 0.0001) and ASDAS 2.27 (0.71) (-1.0, P < 0.0001). Bone marrow oedema resolved in 87.5% of cases compared with the previous MRI scan. No significant association was identified with the clinical response to the injection. Conclusion: US-guided injection of CSs into the SI joint of patients with SpA and active sacroiliitis leads to an improvement in symptoms that is maintained at 5-6 months. The procedure is effective, safe, inexpensive and easy to apply.

Factors associated with atherosclerosis in radiographic and non-radiographic axial spondyloarthritis. A multicenter study on 838 patients.

OBJECTIVES: To identify disease-related factors associated with subclinical atherosclerosis and cardiovascular (CV) events in a large series of patients with axial spondyloarthritis (axSpA) and to identify possible differences in the effect of the potential pro-atherogenic factors between ankylosing spondylitis (AS) non-radiographic axSpA (nr-axSpA). METHODS: This is a cross-sectional observational study of the AtheSpAin cohort, a Spanish multicenter cohort to study atherosclerosis in axSpA. Subclinical atherosclerosis determined by carotid ultrasound included assessment of carotid intima-media thickness (cIMT) and plaque detection. RESULTS: 639 AS and 167 nr-axSpA patients were recruited. CV risk factors (CRF) and several disease-related factors showed a statistically significant association with subclinical atherosclerosis in the crude analysis. After adjustment for age, sex, and smoking (model 1), associations remained statistically significant for spinal mobility, inflammatory bowel disease, use of prednisone, and Disease-modifying antirheumatic drugs (DMARD) when assessing carotid plaques and for acute phase reactants (APR) at diagnosis, use of prednisone, DMARD, and TNF-inhibitors when measuring cIMT. In model 2, which also included classic CRF as confounding factors to identify axSpA features with a potential independent pro-atherogenic effect, the functional status was the only variable significantly associated with plaques and the use of prednisone and APR at diagnosis with cIMT. No association differences were found between both subtypes of patients. Besides, APR at diagnosis were also associated with subsequent development of CV events that had occurred in 33 patients. CONCLUSION: Apart from CRF, atherosclerotic disease in AxSpA is associated with disease-related factors such as inflammatory response and disease severity, with no differences between AS and nr-axSpA.

El déficit de vitamina D en pacientes con espondiloartritis en un hospital de Castilla-La Mancha / Vitamin D deficiency in patients with spondylarthritis in a Spanish (Castilla-La Mancha) hospital

RESUMEN Introducción: Las espondiloartritis son un grupo de enfermedades inflamatorias crónicas con afectación principalmente del esqueleto axial y también de articulaciones periféricas. En cuanto al metabolismo óseo de estos pacientes, se ha observado en algunos estudios que existen niveles más bajos de vitamina D en pacientes con espondiloartritis. Objetivo: Estimar la prevalencia de déficit/insuficiencia de vitamina D, el metabolismo fosfocálcico y sus implicaciones en una cohorte de pacientes con espondiloartritis. Metodología: Estudio observacional, descriptivo y transversal. Se llevó a cabo una revisión retrospectiva de la base de datos de pacientes con espondiloartritis que fueron atendidos en las consultas externas del Servicio de Reumatología del Hospital General Universitario de Ciudad Real entre junio del 2018 y junio del 2019. Las variables se describieron usando medidas de frecuencia o medidas de tendencia central/dispersión según correspondiera. Resultados: Se analizaron 115 pacientes, de los cuales 64 fueron hombres y 51 mujeres, con una edad media de 45,97 años (± 13,41 DE). Del total de los pacientes, 59 presentaron espon dilitis anquilosante, 24 artropatía psoriásica, 9 artritis asociada a enfermedad inflamatoria intestinal, 12 espondiloartritis axial no radiográfica y 11 artritis reactiva. Los niveles de vitamina D fueron de 23,81 ng/ml (±10,5 DE), con un 77,4% de los pacientes con cifras de déficit/insuficiencia de vitamina D. Agrupados por el subtipo de espondiloartritis y según las cifras de déficit/insuficiencia de vitamina D, 45 pacientes tenían espondilitis anquilo sante, 19 artropatía psoriásica, 9 artritis asociada a enfermedad inflamatoria intestinal, 7 espondiloartritis axiales no radiográficas y 9 artritis reactivas. Además, el déficit de vita mina D (< 20 ng/ml) se presentaba la mayoría de las veces en las estaciones de primavera e invierno, con 31 y 26 pacientes respectivamente. Conclusiones: Una optimización de los niveles de vitamina D puede implicar una mejoría en la situación clínica del paciente, medida tanto por BASDAI y DAPSA como por PCR y VSG. En consecuencia, se recomienda la monitorización y suplementación de vitamina D en pacientes con hipovitaminosis D.

ABSTRACT Introduction: Spondyloarthritis is a group of chronic inflammatory diseases that mainly affect the axial skeleton, and also the peripheral joints. In bone metabolism studies on these patients, it has been observed that there are lower levels of vitamin D in patients with spondyloarthritis. Objective: To estimate the prevalence of vitamin D deficiency / insufficiency, as well as calcium/ phosphate metabolism and their implications in a cohort of patients with spondyloarthritis. Methodology: Observational, descriptive, and cross-sectional study. A retrospective review of the databases was carried out on patients with spondyloarthritis who were treated in the outpatient clinics of the Rheumatology Department of the General University Hospital of Ciudad Real between June 2018 and June 2019. Variables are described using frequency and central tendency / dispersion measurements as appropriate. Results: The study included 115 patients, of whom 64 were men and 51 women, with a mean age of 45.97 years (± 13.41 SD). They included 59 patients with ankylosing spondylitis, 24 with psoriatic arthropathy, 9 arthritis associated with inflammatory bowel disease, 12 non-radiographic axial spondylarthritis, and 11 reactive arthritis. Vitamin D levels were 23.81 ng/ml (± 10.5 SD), with 77.4% of patients with vitamin D deficiency / insufficiency levels. Grouped by the spondylarthritis subtype, and according to vitamin D deficiency / insufficiency, 45 patients had ankylosing spondylitis, 19 psoriatic arthropathy, 9 arthritis associated with inflammatory bowel disease, 7 non-radiographic axial spondyloarthritis, and 9 reactive arthritis. Furthermore, vitamin D deficiency (< 20 ng/ml) mainly occurred in the spring and winter seasons, with 31 and 26 patients, respectively. Conclusions: An optimization of vitamin D levels may lead to an improvement in the clinical situation of the patients, as measured by both BASDAI and DAPSA, as well as by PCR and ESR. Therefore, vitamin D monitoring and supplementation is recommended in patients with vitamin D deficiency.

Miositis del subescapular. Una evolución infrecuente en la tendinopatía calcificada. Estudio de un caso / Subscapularis myositis: An uncommon complication in calcific tendinopathy. A case study

RESUMEN La tendinopatía calcificada del hombro se caracteriza por el depósito de cristales de hidroxiapatita en uno o varios tendones del hombro. Dentro de los procesos que ocurren en esta entidad está la fase de reabsorción, en la que los depósitos podrían migrar hacia estructuras adyacentes. Una muy rara complicación es la migración hacia la unión miotendinosa del tendón correspondiente, la cual provoca una importante reacción inflamatoria muscular que puede objetivarse en pruebas complementarias específicas. Presentamos un caso clínico de una tendinopatía calcificante del subescapular, con pos terior migración hacia la unión miotendinosa causando una miositis del mismo.

ABSTRACT Calcific tendinopathy of the shoulder is characterised by the deposit of hydroxy apatite crys tals in one or more tendons of the shoulder. Within the processes that occur within this disorder, there is the resorption phase, in which the deposits could migrate towards adjacent structures. A very rare complication is the migration towards the myotendinous junction of the corresponding tendon, which causes a significant muscular inflammatory reaction that can be seen in specific complementary tests. A clinical case is presented of a subscapular calcific tendinopathy, with subsequent migra tion to the myotendinous junction, causing myositis of the same.

Potential relation of cardiovascular risk factors to disease activity in patients with axial spondyloarthritis.

BACKGROUND: Axial spondyloarthritis (axSpA) patients are known to have a higher prevalence of several comorbidities, including, among others, an increased risk of atherosclerosis, hypertension, dyslipidemia, and diabetes. The purpose of the present study was to determine whether the sum of traditional cardiovascular (CV) risk factors is related to disease characteristics, such as disease activity, in patients with axSpA. METHODS: A cross-sectional study that encompassed 804 patients with axSpA was conducted. Patients were assessed for the presence of five traditional CV risk factors (diabetes mellitus, dyslipidemia, hypertension, obesity, and smoking status), and disease activity measurements. A multivariable regression analysis was performed to evaluate whether the number of classic CV risk factors was independently associated with specific features of the disease, to include disease activity. RESULTS: A multivariable analysis showed that Ankylosing Spondylitis Disease Activity Score-C reactive protein (ASDAS-CRP) activity score was significantly higher in patients with 1 [beta coefficient 0.3 (95% confidence interval (CI) 0.1-0.5), p = 0.001] and ⩾2 [beta coefficient 0.5 (95% CI 0.3-0.7), p = 0.000] CV risk factors compared with those without CV risk factors. Similarly, patients with 1 [OR 2.00 (95%CI 0.99-4.02), p = 0.053] and ⩾2 [OR 3.39 (95%CI 1.82-6.31), p = 0.000] CV risk factors had a higher odds ratio for the presence of high disease activity compared with the zero CV category. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) activity score was significantly associated with the number of CV risk factors, being higher in patients with more CV risk factors. These relationships showed a CV risk factor-dependent effect being beta coefficients and ORs higher for the effect of ⩾2 over 1 CV risk factor. CONCLUSION: Among patients with axSpA, as the number of traditional CV risk factors increased, disease activity similarly increases in an independent manner.

Vaspin in atherosclerotic disease and cardiovascular risk in axial spondyloarthritis: a genetic and serological study.

BACKGROUND: Vaspin is a novel anti-inflammatory adipokine associated with cardiovascular (CV) disease and inflammation in chronic inflammatory conditions different from axial spondyloarthritis (axSpA). Given the high incidence of CV disease (mainly due to accelerated atherosclerosis) exhibited by axSpA patients, we wondered if vaspin could also be a key molecule in this process. However, data on the role of vaspin regarding atherosclerotic disease in the context of axSpA is scarce. For this reason, we aimed to evaluate the implication of vaspin, at the genetic and serological level, in subclinical atherosclerosis and CV risk in axSpA. METHODS: This study included 510 patients diagnosed with axSpA. Carotid ultrasound (US) was performed to evaluate the presence of subclinical atherosclerosis. Three vaspin gene variants (rs2236242, rs7159023, and rs35262691) were genotyped by TaqMan probes. Serum vaspin levels were assessed by enzyme-linked immunosorbent assay. Statistical analysis was performed using STATA® v.11.1. RESULTS: Serum vaspin levels were significantly higher in female patients than in males and also in obese patients when compared to those with normal weight (p < 0.05). At the genetic level, we disclosed that the minor allele of rs2236242 (A) was associated with lower serum vaspin levels in axSpA, while the rs7159023 minor allele (A) was linked to higher serum levels (p < 0.05). When the three polymorphisms assessed were combined conforming haplotypes, we disclosed that the TGC haplotype related to high serum levels of vaspin (p = 0.01). However, no statistically significant association was observed between vaspin and markers of subclinical atherosclerosis, both at the genetic and serological level. CONCLUSIONS: Our results revealed that vaspin is linked to CV risk factors that may influence on the atherosclerotic process in axSpA. Additionally, we disclosed that serum vaspin concentration is genetically modulated in a large cohort of patients with axSpA.

Subclinical atherosclerotic disease in ankylosing spondylitis and non-radiographic axial spondyloarthritis. A multicenter study on 806 patients.

OBJECTIVES: To compare the atherosclerosis disease burden between ankylosing spondylitis (AS) and non-radiographic (nr) axial spondyloarthritis (axSpA) and establish a model that allows to identify high-cardiovascular (CV) risk in axial spondyloarthritis patients. METHODS: Cross-sectional study from the AtheSpAin cohort, a Spanish multicenter cohort aimed to study atherosclerosis in axSpA. Carotid ultrasound (US) was performed to determine the carotid intima-media wall thickness (cIMT) and detect the presence of carotid plaques. The European cardiovascular disease risk assessment model, the Systematic COronary Risk Evaluation (SCORE), was also applied. RESULTS: A set of 639 patients with AS and 167 patients with nr-axSpA without history of CV events were recruited. AS patients were older showing more CV risk factors and higher values of C reactive protein and erythrocyte sedimentation rate (ESR) than those with nr-axSpA. However, no difference in the prevalence of carotid plaques or in the cIMT was found between both groups in the adjusted analysis. The percentage of patients reclassified from the low and moderate CV risk categories to the very high-risk category due to the presence of carotid plaques was comparable in AS and nr-axSpA (10.7% versus 10.1% and 40.5% versus 45.5%, respectively). A model containing age, BASFI and ESR applied to moderate risk axSpA patients identified 41% of these patients as having very high-risk patients with high specificity (88%). CONCLUSION: The atherosclerosis burden is similar in nr-axSpA and AS. As occurred for AS, more than 40% of axSpA patients included in the category of moderate CV risk according to the SCORE are reclassified into very high risk after carotid US, and a clinically relevant proportion of them can be detected by applying a model containing age, BASFI and ESR.

La sinoviortesis radioisotópica en el control de la sinovitis refractaria en Castilla La-Mancha. Una experiencia de 10 años / Radioisotope synoviorthesis in the control of refractory synovitis in Castilla-La Mancha. A 10-year experience

Nuestro hospital es el hospital de referencia en medicina nuclear para la realización de la sinoviortesis radioisotópica para toda Castilla La-Mancha. OBJETIVO: Describir la experiencia en la realización de la sinoviortesis radioisotópica en las artritis refractarias a otros tratamientos en nuestro hospital. METODOLOGÍA: Estudio observacional, descriptivo y transversal protocolizado a través de la revisión de la base de datos de las sinoviortesis radioisotópicas realizadas entre 2007 y 2017. Se recopilaron datos clínicos previos (edad, sexo, proceso patológico, tratamientos previos, infiltración previa y articulación afectada) y evolutivos a los 6 meses tras administrar el isótopo. Se creó una base de datos Excel para un análisis de frecuencias con SPSS 21. RESULTADOS: Se realizaron 30 radiosinoviortesis, siendo las enfermedades más frecuentes, por este orden: sinovitis villonodular pigmentada (40%), artritis reumatoide (23,3%), espondiloartritis (13,3%), osteoartritis (10%) y artritis inespecíficas (6,7%), seguido de lupus eritematoso sistémico y gota. Tras 6 meses un 56,7% de los pacientes mejoraron frente a un 36,7% que seguían igual. Así mismo, ninguno de ellos presentó complicaciones relacionadas con el procedimiento. A un 6,6% de los pacientes se les perdió el seguimiento. DISCUSIÓN Y CONCLUSIONES: En los pacientes con episodios de artritis de repetición con derrame articular asociado en una o 2 articulaciones, refractarias a tratamientos sistémicos, a las infiltraciones locales con corticoides y en aquellos pacientes en los que otros tratamientos puedan estar contraindicados, debemos considerar la posibilidad de realizar una radiosinoviortesis isotópica, pues es una técnica sencilla, segura y con una tasa de éxito superior al 50%

Our hospital is the nuclear medicine referral hospital for radioisotopic synoviorthesis for all of Castilla-La Mancha. OBJECTIVE: To describe the experience in the performance of radioisotopic synoviorthesis for arthritis refractory to other treatments in our hospital. METHODOLOGY: Observational, descriptive and cross-sectional study protocolised through the review of the database of radioisotopic synoviorthesis performed between 2007 and 2017. Previous clinical data were collected (age, sex, pathology, previous treatments, previous infiltration and affected joint), and progress at 6 months after administering the isotope. An Excel database was created for a frequency analysis with SPSS 21. RESULTS: 30 radiosynovitis interventions were performed. The most frequent pathologies in this order were: pigmented villonodular synovitis (40%), rheumatoid arthritis (23.3%), spondyloarthritis (13.3%), osteoarthritis (10%) and nonspecific arthritis (6.7%), followed by systemic lupus erythematosus and gout. After 6 months, 56.7% of the patients improved compared to 36.7% who remained the same. Likewise, none of them presented complications related to the procedure. Six point six percent of the patients were lost to follow-up. DISCUSSION AND CONCLUSIONS: In patients with episodes of recurrent arthritis with associated joint effusion in one or two joints, refractory to systemic treatments, to local infiltrations with corticosteroids and for patients for whom other treatments may be contraindicated, we must consider the possibility of performing an isotope radiosinoviortesis, as it is a simple, safe technique with a success rate of more than 50%

Vitamin D, an inflammatory activity marker for spondyloarthritis?

In this study, a relationship between low levels of vitamin D and other markers of inflammation is observed in patients with spondyloarthritis. Therefore, insufficient levels of vitamin D could be used as a marker of inflammation, so they would help to have a better follow-up of the patient. PURPOSE: The aim of this study is to determine the association between 25-hydroxyvitamin D deficiency and level of disease activity in patients suffering from spondyloarthritis. METHODOLOGY: This study is an observational, descriptive and transversal study. A retrospective review of patients with spondyloarthritis under treatment at the Rheumatology Department of Hospital General Universitario de Ciudad Real between September 2016 and September 2018 is under consideration. The association between 25-hydroxyvitamin D deficiency and levels of disease activity was calculated using odds ratio (OR) with a 95% confidence level. RESULTS: Initial study developments are reported. A group of 147 patients was analyzed. The average disease activity was 4.3 (according to BASDAI) and 11.4 (according to DAPSA). Twenty-eight percent of patients showed increased levels of acute-phase reactants, and 82% exhibited 25-hydroxyvitamin D deficiency/insufficiency. Analysis of the association between vitamin D deficiency/insufficiency and BASDAI/DAPSA activity degree revealed an OR of 7.9 (CI95%: 2.92-21.23, p = < 0.0001). CONCLUSION: In this study, an association was found between those patients with spondyloarthritis who had a 25-hydroxyvitamin D deficiency and disease activity. Despite these results, a 1-year follow-up of these patients using two or more measurements of activity and 25-hydroxyvitamin D levels would be needed to corroborate these data.