Consensus statement on a framework for the management of comorbidity and extra-articular manifestations in rheumatoid arthritis.

The objective of the study was to develop evidence-based and practical recommendations for the detection and management of comorbidity in patients with rheumatoid arthritis (RA) in daily practice. We used a modified RAND/UCLA methodology and systematic review (SR). The process map and specific recommendations, based on the SR, were established in discussion groups. A two round Delphi survey permitted (1) to prioritize the recommendations, (2) to refine them, and (3) to evaluate their agreement by a large group of users. The recommendations cover: (1) which comorbidities should be investigated in clinical practice at the first and following visits (including treatments, risk factors and patient's features that might interfere with RA management); (2) how and when should comorbidities and risk factors be investigated; (3) how to manage specific comorbidities, related or non-related to RA, including major adverse events of RA treatment, and to promote health (general and musculoskeletal health); and (4) specific recommendations to assure an integral care approach for RA patients with any comorbidity, such as health care models for chronic inflammatory patients, early arthritis units, relationships with primary care, specialized nursing care, and self-management. These recommendations are intended to guide rheumatologists, patients, and other stakeholders, on the early diagnosis and management of comorbidity in RA, in order to improve disease outcomes.

El bloqueo terapéutico del factor de necrosis tumoral disminuye la concentración sérica de interleucina 15 en pacientes con artritis reumatoide / The therapeutic blockade of TNF reduces serum levels of interleukin 15 in patients with rheumatoid arthritis

Objetivo: Analizar el efecto de la terapia con agentes inhibidores del factor de necrosis tumoral (TNF) en la concentración sérica de interleucina 15 (IL-15) y determinar si los valores basales de ésta o su variación con el tratamiento predicen la respuesta clínica a los anti-TNF. Pacientes y método: Se estudió a 75 pacientes con artritis reumatoide que iban a iniciar tratamiento con anti-TNF. Se recogieron muestras de suero previas y a los 3 meses de tratamiento. La concentración de IL-15 se cuantificó mediante enzimoinmunoanálisis. Tanto en la visita basal como en la final se recogieron parámetros clínicos y analíticos que permitieran calcular el DAS28. También se recogieron variables sociodemográficas y otras relacionadas con la enfermedad, como factor reumatoide, número de fármacos previos, etc. Se definió remisión como un DAS28 < 2,6 y respuesta clínica relevante, como una disminución del DAS28 > 1,2. Resultados: La concentración de IL-15 se relacionó de forma significativa con un mayor uso de fármacos modificadores de la enfermedad durante el seguimiento de los pacientes. También se observó una disminución significativa de la IL-15 a los 3 meses de tratamiento con anti-TNF. Sin embargo, los valores basales de IL-15 y su disminución con el tratamiento no se relacionaron con la respuesta a los anti-TNF o la consecución de remisión clínica. Conclusiones: Nuestros datos parecen confirmar los obtenidos in vitro, que indican que el TNF está implicado en la modulación de la expresión de IL-15. No obstante, la medición de la concentración sérica de IL-15 no parece ser de utilidad para seleccionar a los pacientes candidatos a terapia anti-TNF (AU)

Objective: To analyze the effect of the TNF blocking agents (aTNF) on the serum levels of interleukin 15 (IL-15). To determine whether baseline IL15 serum levels or their response to aTNF therapy can predict the clinical response to this treatment. Patients and method: We studied 75 patients suffering from rheumatoid arthritis that were selected to start aTNF therapy. Serum samples were obtained at baseline visit and after three months of aTNF treatment. Measurement of IL-15 serum concentration was performed through immune-enzyme assay. We collected the clinical and analytical parameters needed to calculate DAS28 both at baseline and final visit, as well as sociodemographic variables and other such as rheumatoid factor, previous disease modifying anti-rheumatic drugs (DMARD), etc. We defined remission as a DAS28 < 2.6 and clinical response when the decrease in DAS28 value was higher than 1.2. Results: There was a significant correlation between IL-15 serum level and the number of previous DMARD. We also detected a significant decrease in the concentration of serum IL-15 after three months of treatment with aTNF. However, neither the baseline IL-15 serum level nor the decrease in the concentration of IL-15 were associated with a specific pattern of response to aTNF. Conclusions: Our data seem to support previous in vitro findings suggesting that TNF is involved in the regulation of IL-15 expression. Nevertheless, the measurement of IL-15 serum levels does not seem to be a useful tool to select those patients that should be treated with aTNF therapy (AU)

[The therapeutic blockade of TNF reduces serum levels of interleukin 15 in patients with rheumatoid arthritis]. / El bloqueo terapéutico del factor de necrosis tumoral disminuye la concentración sérica de interleucina 15 en pacientes con artritis reumatoide.

OBJECTIVE: To analyze the effect of the TNF blocking agents (aTNF) on the serum levels of interleukin 15 (IL-15). To determine whether baseline IL15 serum levels or their response to aTNF therapy can predict the clinical response to this treatment. PATIENTS AND METHOD: We studied 75 patients suffering from rheumatoid arthritis that were selected to start aTNF therapy. Serum samples were obtained at baseline visit and after three months of aTNF treatment. Measurement of IL-15 serum concentration was performed through immune-enzyme assay. We collected the clinical and analytical parameters needed to calculate DAS28 both at baseline and final visit, as well as sociodemographic variables and other such as rheumatoid factor, previous disease modifying anti-rheumatic drugs (DMARD), etc. We defined remission as a DAS28 < 2.6 and clinical response when the decrease in DAS28 value was higher than 1.2. RESULTS: There was a significant correlation between IL-15 serum level and the number of previous DMARD. We also detected a significant decrease in the concentration of serum IL-15 after three months of treatment with aTNF. However, neither the baseline IL-15 serum level nor the decrease in the concentration of IL-15 were associated with a specific pattern of response to aTNF. CONCLUSIONS: Our data seem to support previous in vitro findings suggesting that TNF is involved in the regulation of IL-15 expression. Nevertheless, the measurement of IL-15 serum levels does not seem to be a useful tool to select those patients that should be treated with aTNF therapy.

Baseline serum RANKL levels may serve to predict remission in rheumatoid arthritis patients treated with TNF antagonists.

AIMS: The objective of this study was to investigate whether baseline receptor activator for nuclear factor kappaB ligand (RANKL) and osteoprotegerin (OPG) serum (s) levels can predict the therapeutic response to TNF antagonists (a-TNF). METHODS: We studied 75 rheumatoid arthritis patients (81% female) with a longstanding refractory disease. The variables of disease activity, physical function and sRANKL and sOPG levels were determined before and after both 12-14 and 28-30 weeks of a-TNF therapy (65 adalimumab, 10 infliximab). Remission was defined by a 28 joint count disease activity score (DAS28) /=1.2 at both 3- and 7-month follow-up visits. RESULTS: In most patients, disease activity was severe, as reflected by a baseline DAS28 score of 5.9+/-1 (mean+/-SD), an HAQ of 1.6 (1.1 to 2.1) (median (interquartile range (IQR))) and a CRP 15 mg/l (IQR: 9 to 24). The sRANKL levels and RANKL/OPG ratio in patients that achieved remission were significantly lower at baseline than in the remaining patients at both 3 and 7 months of follow-up. The sOPG levels correlated with the HAQ and the physician's disease assessment and diminished significantly after a-TNF treatment. However, no significant association was detected between the therapeutic response profile and sOPG levels. CONCLUSIONS: These data suggest that in patients receiving a-TNF treatment, lower serum levels of RANKL and RANKL/OPG ratio may serve to predict remission.

[Spondylodiscitis and sacroiliitis due to Streptococcus agalactiae in adults: clinical case and literature review]. / Espondilodiscitis y sacroileítis por Streptococcus agalactiae en adultos: caso clínico y revisión de la literatura.

INTRODUCTION: Streptococcus agalactiae is a well-known pathogen related with infection in newborns, and in women during pregnancy and the puerperium. In recent years it has been described as a causal agent in invasive disease in immunodepressed adults and those with other severe underlying pathologies. METHODS: We describe a case of S. agalactiae spondylodiscitis and concomitant bilateral sacroiliitis in an adult with no known underlying diseases. A systematic review of the related literature was performed (MEDLINE and EMBASE, up to December 2003). RESULTS: The literature search retrieved only 33 cases of spondylodiscitis (predominance in men, 55-70 years old) and 13 cases of sacroiliitis (higher frequency in women, 30-40 years old) due to S. agalactiae. Simultaneous involvement of both locations of the axial skeleton is unusual. CONCLUSION: Spondylodiscitis and sacroiliitis due to S. agalactiae is uncommon. S. agalactiae is an emerging pathogen in adults outside of the gestational and perinatal period. This micro-organism produces spondylodiscitis in the adult population over 50 years old. In contrast, sacroiliac involvement is described mainly in women in the reproductive age.

Espondilodiscitis y sacroileítis por Streptococcus agalactiae en adultos: caso clínico y revisión de la literatura / Spondylodiscitis and sacroiliitis due to Streptococcus agalactiae in adults: clinical case and literature review

INTRODUCCIÓN. Streptococcus agalactiae es un conocido patógeno relacionado con infecciones en el recién nacido, en la gestación y durante el puerperio. En los últimos años se ha descrito como agente causal de enfermedades invasivas en adultos con inmunodepresión y otras patologías subyacentes graves. MÉTODOS. Descripción de un caso de espondilodiscitis y sacroileítis bilateral concomitante por S. agalactiae en un adulto sin enfermedad de base conocida. Se realizó revisión sistemática de la literatura (MEDLINE; EMBASE hasta diciembre de 2003). RESULTADOS. En la revisión realizada solamente se han comunicado 33 espondilodiscitis (predominio en varones entre 55 y 70 años) y 13 casos de sacroileítis (mayor frecuencia en mujeres de 30 a 40 años) por S. agalactiae. La asociación de afectación en ambas localizaciones del esqueleto axial es un hecho inhabitual. CONCLUSIÓN. La espondilodiscitis y sacroileítis por S. agalactie es infrecuente. S. agalactie es un patógenoemergente en adultos, fuera del período gestacional y perinatal. Este microorganismo produce espondilodiscitis en población adulta mayor de 50 años. Por el contrario, la afectación sacroilíaca se describe fundamentalmente en mujeres en edad reproductiva (AU)

INTRODUCTION. Streptococcus agalactiae is a well-known pathogen related with infection in newborns, and in women during pregnancy and the puerperium. In recent years it has been described as a causal agent in invasive disease in immunodepressed adults and those with other severe underlying pathologies. METHODS. We describe a case of S. agalactiae spondylodiscitis and concomitant bilateral sacroiliitis in an adult with no known underlying diseases. A systematic review of the related literature was performed (MEDLINEand EMBASE, up to December 2003). RESULTS. The literature search retrieved only 33 cases of spondylodiscitis (predominance in men, 55-70 years old)and 13 cases of sacroiliitis (higher frequency in women, 30-40 years old) due to S. agalactiae. Simultaneous involvement of both locations of the axial skeleton isunusual. CONCLUSION. Spondylodiscitis and sacroiliitis due to S. agalactiae is uncommon. S. agalactiae is an emerging pathogen in adults outside of the gestational and perinatalperiod. This micro-organism produces spondylodiscitis in the adult population over 50 years old. In contrast, sacroiliac involvement is described mainly in women in there productive age (AU)