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.

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.

Síndromes reumáticos y tumor oculto, experiencia de 10 años en un hospital universitario / Rheumatic syndromes and occult tumor: 10-year experience in a teaching hospital

OBJETIVO: Describir las diferentes características clínicas de los pacientes ingresados en el Servicio de Reumatología por manifestaciones reumáticas como primera expresión de un proceso tumoral no conocido. PACIENTES Y MÉTODOS: Estudio observacional retrospectivo y descriptivo protocolizado por la revisión de las historias clínicas de los ingresados en Reumatología del Hospital Universitario de Ciudad Real desde enero de 2007 hasta agosto de 2017 por manifestaciones iniciales reumáticas, con sospecha al alta de un tumor no conocido. RESULTADOS: De más de 500 ingresos, se obtuvieron 64 casos. Las manifestaciones reumáticas más frecuentes fueron lumbalgia inflamatoria, poliartralgias, síndrome de cadera, dorsalgia, cervicalgia, poliartritis y polimialgia reumática. Un 44% presentaban anemia, un 70% elevación de los reactantes de fase aguda, un 62% alteración en los marcadores tumorales y un 76% lesiones metastásicas. En el 20%, el tumor primario fue de origen pulmonar y solo el 26,56% recibió tratamiento paliativo. El 64% fallecieron. DISCUSIÓN: Es importante plantearse en el diagnóstico diferencial la posibilidad de un proceso tumoral subyacente, dado que su diagnóstico temprano puede ser determinante para el pronóstico

OBJECTIVE: To describe the different clinical characteristics of patients admitted to the Rheumatology Department due to rheumatic manifestations as the first expression of an unknown malignant process. PATIENTS AND METHODS: Retrospective and descriptive observational study involving the review of the medical records of those admitted to rheumatology in the University Hospital of Ciudad Real between January 2007 and August 2017 for initial rheumatic manifestations with a suspicion at discharge of an unknown tumor. RESULTS: In all, 64 patients were identified from more than 500 admissions. The most common rheumatic manifestations were inflammatory low back pain, polyarthralgia, hip pain, thoracic spine pain, cervical pain, polyarthritis and polymyalgia rheumatica. Forty-four percent had low hemoglobin, 70% had elevation of acute-phase reactants, 62% had abnormal tumor markers, 76% had metastatic lesions. In 20% the primary tumor was of pulmonary origin and only 26.56% received palliative treatment; 64% died. DISCUSSION: It is important to consider the possibility of an underlying malignant process in the differential diagnosis since its early identification can be determinant for prognosis

Radioisotope Synoviorthesis in the Control of Refractory Synovitis in Castilla-La Mancha. A 10-year Experience. / La sinoviortesis radioisotópica en el control de la sinovitis refractaria en Castilla La-Mancha. Una experiencia de 10 años.

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%.

Rheumatic syndromes and occult tumor: 10-year experience in a teaching hospital. / Síndromes reumáticos y tumor oculto, experiencia de 10 años en un hospital universitario.

OBJECTIVE: To describe the different clinical characteristics of patients admitted to the Rheumatology Department due to rheumatic manifestations as the first expression of an unknown malignant process. PATIENTS AND METHODS: Retrospective and descriptive observational study involving the review of the medical records of those admitted to rheumatology in the University Hospital of Ciudad Real between January 2007 and August 2017 for initial rheumatic manifestations with a suspicion at discharge of an unknown tumor. RESULTS: In all, 64 patients were identified from more than 500 admissions. The most common rheumatic manifestations were inflammatory low back pain, polyarthralgia, hip pain, thoracic spine pain, cervical pain, polyarthritis and polymyalgia rheumatica. Forty-four percent had low hemoglobin, 70% had elevation of acute-phase reactants, 62% had abnormal tumor markers, 76% had metastatic lesions. In 20% the primary tumor was of pulmonary origin and only 26.56% received palliative treatment; 64% died. DISCUSSION: It is important to consider the possibility of an underlying malignant process in the differential diagnosis since its early identification can be determinant for prognosis.

El modelo de autogestión en la agenda de consultas sucesivas en reumatología / Self-management model in the scheduling of successive appointments in rheumatology

INTRODUCCIÓN: El Servicio de Reumatología del Hospital de Ciudad Real tiene implementado un modelo de autogestión de citaciones de consultas sucesivas desde hace más de 10 años, en el que son los facultativos del propio servicio los que gestionan las citas de revisión de los pacientes en función de su enfermedad, evolución, pruebas complementaria. El propósito del presente estudio es valorar y comparar el modelo de autogestión de citas sucesivas del Servicio de Reumatología del Hospital de Ciudad Real frente al modelo de gestión externa de citas implantado en 8 de los 15 servicios médicos del hospital. MATERIAL Y MÉTODOS: Se realizó un análisis comparativo y multivariante para la identificación de variables con diferencias estadísticamente significativas, en términos de indicadores de actividad/rendimiento y de calidad percibida por los usuarios, entre el modelo de autogestión de citas sucesivas del Servicio de Reumatología del Hospital de Ciudad Real, y el modelo de gestión externa de citas de 8 servicios médicos del hospital, entre el 1 de enero y el 31 de mayo de 2016. RESULTADOS: En una base de datos con más de 100.000 registros de las citaciones del conjunto de servicios incluidos en el estudio, el tiempo medio de espera y los números de incomparecencias y reprogramaciones para consultas sucesivas del servicio de reumatología fueron significativamente inferiores al resto de servicios. El número de pacientes atendidos en consultas externas de reumatología fue de 7.768 y, de estos, se le realizó una encuesta a un total de 280 pacientes (tasa de respuesta del 63,21%), donde destaca una gran satisfacción global, además de una tasa de incidencia de reclamaciones baja. CONCLUSIÓN: Nuestros resultados denotan que el modelo de autogestión de citaciones tiene mejores resultados, tanto en indicadores de actividad como en la calidad percibida por los usuarios, a pesar de la intensa actividad, por lo que este estudio puede ser fundamental para la toma de decisiones en la mesogestión de organizaciones sanitarias

INTRODUCTION: The rheumatology service of Ciudad Real Hospital, located in an autonomous community of that same name that is nearly in the center of Spain, implemented a self-management model of successive appointments more than 10 years ago. Since then, the physicians of the department schedule follow-up visits for their patients depending on the disease, its course and ancillary tests. The purpose of this study is to evaluate and compare the self-management model for successive appointments in the rheumatology service of Ciudad Real Hospital versus the model of external appointment management implemented in 8 of the hospital's 15 medical services. MATERIAL AND METHODS: A comparative and multivariate analysis was performed to identify variables with statistically significant differences, in terms of activity and/or performance indicators and quality perceived by users. The comparison involved the self-management model for successive appointments employed in the rheumatology service of Ciudad Real Hospital and the model for external appointment management used in 8 hospital medical services between January 1 and May 31, 2016. RESULTS: In a database with more than 100,000 records of appointments involving the set of services included in the study, the mean waiting time and the numbers of non-appearances and rescheduling of follow-up visits in the rheumatology department were significantly lower than in the other services. The number of individuals treated in outpatient rheumatology services was 7,768, and a total of 280 patients were surveyed (response rate 63.21%). They showed great overall satisfaction, and the incidence rate of claims was low. CONCLUSION: Our results show that the self-management model of scheduling appointments has better results in terms of activity indicators and in quality perceived by users, despite the intense activity. Thus, this study could be fundamental for decision making in the management of health care organizations

Self-management model in the scheduling of successive appointments in rheumatology. / El modelo de autogestión en la agenda de consultas sucesivas en reumatología.

INTRODUCTION: The rheumatology service of Ciudad Real Hospital, located in an autonomous community of that same name that is nearly in the center of Spain, implemented a self-management model of successive appointments more than 10 years ago. Since then, the physicians of the department schedule follow-up visits for their patients depending on the disease, its course and ancillary tests. The purpose of this study is to evaluate and compare the self-management model for successive appointments in the rheumatology service of Ciudad Real Hospital versus the model of external appointment management implemented in 8 of the hospital's 15 medical services. MATERIAL AND METHODS: A comparative and multivariate analysis was performed to identify variables with statistically significant differences, in terms of activity and/or performance indicators and quality perceived by users. The comparison involved the self-management model for successive appointments employed in the rheumatology service of Ciudad Real Hospital and the model for external appointment management used in 8 hospital medical services between January 1 and May 31, 2016. RESULTS: In a database with more than 100,000 records of appointments involving the set of services included in the study, the mean waiting time and the numbers of non-appearances and rescheduling of follow-up visits in the rheumatology department were significantly lower than in the other services. The number of individuals treated in outpatient rheumatology services was 7,768, and a total of 280 patients were surveyed (response rate 63.21%). They showed great overall satisfaction, and the incidence rate of claims was low. CONCLUSION: Our results show that the self-management model of scheduling appointments has better results in terms of activity indicators and in quality perceived by users, despite the intense activity. Thus, this study could be fundamental for decision making in the management of health care organizations.

Artritis reumatoide, una enfermedad sistémica con un riesgo cardiovascular subestimado / Rheumatoid arthritis; a systemic disease with an under-estimated cardiovascular risk

RESUMEN Objetivo: Determinar el riesgo cardiovascular y la prevalencia de factores de riesgo cardiovascular (RCV) en los pacientes con artritis reumatoide. Materiales y métodos: Estudio observacional, descriptivo y transversal, realizado en el Hospital General de Ciudad Real, entre junio de 2013 y mayo de 2014. Se realizó una analítica completa, se elaboró un perfil clínico, se calculó el SCOREm y se estratificó el RCV. Finalmente, se determinó la presencia de aterosclerosis subclínica mediante la realización de una ecografía carotídea. Resultados: 119 pacientes aceptaron participar en el estudio. Hubo una prevalencia del 73,1% de los factores de riesgo tradicionales, 6,72% había presentado un evento cardiovascular al momento del estudio, 22,68% poseía un infradiagnóstico de diabetes mellitus o nefropatía. La distribución final del RCV fue: riesgo bajo 46 (38,7%), riesgo intermedio 33 (27,7%), riesgo alto 2 (1,7%), riesgo muy alto 38 (31,9%). Conclusiones: Existe una alta prevalencia de factores de RCV y riesgo elevado infradiagnosticado en esta población. Por lo que si bien la artritis reumatoide se manifiesta de forma más aparente a nivel articular, ha de considerarse una enfermedad sistémica asociada a una mayor incidencia de eventos cardiovasculares.

ABSTRACT Objective: To determine the cardiovascular risk and the prevalence of cardiovascular risk (CVR) factors in patients with rheumatoid arthritis. Material and methods: Observational, descriptive and cross-sectional study performed in the General Hospital of Ciudad Real from June 2013 to May 2014. A complete laboratory analysis was performed, a clinical profile was prepared, the Systematic Coronary Risk Evaluation (SCOREm) was calculated, and the CVR was stratified. Finally, the presence of sub-clinical atherosclerosis was determined by performing a carotid ultrasound. Results: 119 patients accepted to participate in the study. There was a prevalence of 73.1% of traditional risk factors; 6.72% having had a cardiovascular event at the time of the study, and 22.68% had an underdiagnosis of diabetes mellitus and/or nephropathy. The final distribution of the CVR was: Low risk 46 (38.7%), intermediate risk 33 (27.7%), high risk 2 (1.7%), very high risk 38 (31.9%). Conclusions: There is a high prevalence of CVR factors and an elevated risk of underdiagnosis in the rheumatoid arthritis population. Therefore, although rheumatoid arthritis manifests itself more in the joints, it should be considered a systemic disease associated with a higher incidence of cardiovascular events.

Neumonitis por citomegalovirus durante el tratamiento crónico con metotrexato / Pneumonitis due to cytomegalovirus during chronic methotrexate treatment

Si bien la neumonitis por hipersensibilidad es la complicación pulmonar más frecuentemente descrita durante el tratamiento con metotrexato, existen otras complicaciones de tipo linfoproliferativo e infeccioso que hay que tener en cuenta dentro del diagnóstico diferencial ante una neumopatía en el contexto de dicho tratamiento. La existencia de un riesgo incrementado de desarrollar procesos infecciosos o reactivaciones de microorganismos latentes puede ser similar al observado a lo largo del tratamiento con antagonistas del factor de necrosis tumoral y corticoides. Dentro de ellas, la neumonía por citomegalovirus es una complicación muy severa a tener en cuenta, ya que el diagnóstico acertado y el tratamiento oportuno evitarán un desenlace potencialmente mortal (AU)

Although hypersensitivity pneumonitis is the most common pulmonary complication described during treatment with methotrexate, other complications like lymphoproliferative and infectious disease may be considered in the study of respiratory disease associated to methotrexate. The existence of an increased risk to developing infectious diseases may be similar to that observed during treatment with antagonists of tumor necrosis factor and corticosteroids, where Cytomegalovirus pneumonia is a serious complication; early diagnosis and treatment will prevent a potentially fatal outcome (AU)

Pneumonitis due to cytomegalovirus during chronic methotrexate treatment.

Although hypersensitivity pneumonitis is the most common pulmonary complication described during treatment with methotrexate, other complications like lymphoproliferative and infectious disease may be considered in the study of respiratory disease associated to methotrexate. The existence of an increased risk to developing infectious diseases may be similar to that observed during treatment with antagonists of tumor necrosis factor and corticosteroids, where Cytomegalovirus pneumonia is a serious complication; early diagnosis and treatment will prevent a potentially fatal outcome.