Rheumatoid arthritis-related interstitial lung disease (RA-ILD): a possible association between disease activity and prognosis.

OBJECTIVES: We hypothesized that RA disease activity might be associated with the survival of RA-ILD patients. To evaluate this possibility, we analyzed data on disease activity during follow-up in an RA-ILD cohort and compared disease activity between surviving patients and those who died during follow-up. METHODS: RA-ILD patients referred for medical evaluation and treatment at a single center, with CDAI scores during all follow up were included. We estimated the HR of the mean of the CDAI score during follow-up with survival. Also, we compared the survival function of patients with high disease activity (CDAI scores ≥ 22) during all follow-up with those with moderate and low disease activity. RESULTS: Thirty-seven patients were included. The mean of the CDAI score during follow-up was higher in death patients (median 30.8 ± 18.5 Vs. 16.8 ± 11.3), and a single unit increase in the mean of the CDAI score was associated with non-survival, HR:1.07 (95% CI: 1.02 -1.12). Patients with high disease activity during all follow-up (CDAI scores > 22) had lower survival function in comparison with moderate and low disease activity (P = 0.042). CONCLUSION: The results of the study suggest that higher RA disease activity is associated with a worse prognosis of RA-ILD patients. The hypothesis that high disease activity is associated with worse survival in RA-ILD patients must be evaluated in more extensive cohort studies and clinical trials. KEY POINTS: • RA-ILD patients with high disease activity during follow-up had a worse prognosis than those with moderate or low disease activity. • The study results suggest the hypothesis that patients with RA-ILD must be treated with a treat to target strategy, with the aim of remission or low RA disease activity.

Rheumatoid arthritis-related interstitial lung disease (RA-ILD): methotrexate and the severity of lung disease are associated to prognosis.

Interstitial lung disease (ILD) is a severe rheumatoid arthritis (RA) manifestation. The worst survival has been associated with usual interstitial pneumonia (UIP) definitive pattern in high-resolution chest tomography (HRCT) scans. Moreover, the use of methotrexate in RA-ILD is controversial. Our aim was to evaluate prognostic factors including methotrexate in an RA-ILD cohort and their association with survival. RA-ILD patients referred for medical evaluation and treatment at a single center were included. At the baseline, pulmonary function tests were carried out and a HRCT was obtained. A radiologist evaluated the ILD tomographic pattern and the extent of lung disease. Patients were considered as receiving methotrexate therapy if this drug was specifically prescribed for the treatment of RA-ILD at the beginning of follow up. Seventy-eight patients were included. UIP definite pattern in HRCT was not associated to worse survival. Variables associated with mortality reflected the severity of lung disease. Treatment with methotrexate was associated with survival (HR 0.13, 95% CI 0.02-0.64); older patients had worse prognosis (HR 1.04, 95% CI 1.003-1.09). After adjusting for confounding variables, methotrexate was strongly associated with survival. Methotrexate treatment during follow up was associated with survival. The severity of lung disease and not the tomographic pattern is associated with mortality; older patients had worse prognosis.

Otitis Media Aguda. Un enfoque clínico y terapéutico / Acute otitis media: A clinical and therapeutic approach

Resumen La otitis media aguda (OMA) es una enfermedad con alta prevalencia a nivel mundial principalmente en pacientes en edad pediátrica, debido a factores de riesgo propios del grupo etario, como los factores anatómicos y condiciones ambientales (asistencia a guardería, ausencia de lactancia materna y exposición al humo del tabaco, entre otros). El diagnóstico de certeza de la OMA es clínico y se basa en el inicio súbito del padecimiento, signos y síntomas de otitis media y líquido en el oído medio. El método más certero para evaluar la integridad de la membrana timpánica es la otoscopia simple, aunque la variante neumática es la más efectiva para establecer el compromiso en la movilidad de la membrana timpánica. Para la elección del tratamiento adecuado de la OMA se deben considerar diversos factores, entre ellos la edad del paciente, el estadio clínico, si existen tratamientos previos y el tiempo de evolución. La estrategia "esperar y ver" acompañada de analgésicos sistémicos por 48 a 72 horas disminuye la tasa de prescripción innecesaria de antibióticos en los casos de enfermedad no grave. El tratamiento antibiótico de primera línea, en el caso de que no haya mejoría con la primera estrategia o en forma directa es la amoxicilina a dosis de 80-90 mg/kg, y la combinación de amoxicilina con ácido clavulánico es el siguiente escalón cuando hay falla terapéutica con el primero, y una cefalosporina como la ceftriaxona, cuando se ha tenido falla terapéutica con amoxicilina y otro antimicrobiano previo. El tratamiento recomendado en pacientes alérgicos a la penicilina es claritromicina. La incidencia de complicaciones de la OMA es baja, éstas pueden ser: otitis media recurrente, hipoacusia conductiva, mastoiditis, parálisis del nervio facial, meningitis y absceso cerebral. Se recomienda realizar un seguimiento 3 a 6 meses después de un episodio sin complicaciones.

Abstract Acute otitis media (AOM) is a highly prevalent disease worldwide, primarily in pediatric patients due to the inherent risk factors in their age group, anatomical and environmental conditions such as day care attendance, lack of breastfeeding and exposure to cigarette smoke, among others. The definitive diagnosis of AOM is clinical and is based on a sudden onset of the disease, signs and symptoms of otitis media and fluid in middle ear. The most accurate method to evaluate the integrity of the patient's tympanic membrane is a simple otoscopy, although its pneumatic variant is the most effective tool to determinate loss of tympanic membrane mobility. Several factors, including the patient's age, clinical stage, previous treatment and time evolution should be considered in order to choose the right treatment for AOM. The "wait-and-see prescription" in addition to systemic analgesics for 48-72 hours reduces unnecessary antibiotic prescription in non-severe cases. Amoxicillin 80-90 mg/kg is the first-line antibiotic in case of no improvement with the first strategy. A combination of amoxicillin and clavulanate is the next step when first antibiotic therapy fails. A cephalosporin like Ceftriaxone is indicated in treatment failure with amoxicillin in addition to other previous antimicrobial. The recommended treatment in patients allergic to penicillin is clarithromycin. The incidence of complications of AOM is low, these include: recurrent otitis media, conductive hearing loss, mastoiditis, facial nerve paralysis, meningitis and brain abscess. Monitoring 3-6 months after an episode without complications is recommended.

Rheumatoid arthritis-associated interstitial lung disease: lung inflammation evaluated with high resolution computed tomography scan is correlated to rheumatoid arthritis disease activity / Enfermedad intersticial pulmonar asociada a Artritis Reumatoide: La inflamación pulmonar evaluada mediante tomografía computarizada de alta resolución correlaciona con la actividad de la enfermedad de Artritis Reumatoide

Objective. To describe the association between rheumatoid arthritis disease activity (RA) and interstitial lung damage (inflammation and fibrosis), in a group of patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). Methods. A retrospective study of RA patients with interstitial lung disease (restrictive pattern in lung function tests and evidence of interstitial lung disease in high resolution computed tomography (HRCT)). Patients were evaluated to exclude other causes of pulmonary disease. RA disease activity was measured with the CDAI index. Interstitial lung inflammation and fibrosis were determined by Kazerooni scale. We compared Kazerooni ground-glass score with the nearest CDAI score to HRCT date scan of the first medical evaluation at our institution. In nine patients, we compared the first ground-glass score with a second one after treatment with DMARDs and corticosteroids. Spearman's rank correlation coefficient was used to evaluate association between RA disease activity and the Kazerooni ground-glass and fibrosis scores. Results. Thirty-four patients were included. A positive correlation between CDAI and ground-glass scores was found (rs = 0.3767, P < 0.028). Fibrosis and CDAI scores were not associated (rs = −0.0747, P < 0.6745). After treatment, a downward tendency in the ground-glass score was observed (median [IQR]): (2.33 [2,3] vs. 2 [1.33–2.16]), P < 0.056, along with a lesser CDAI score (27 [8–43] vs. 9 [5–12]), P < 0.063. Conclusion. There is a correlation between RA disease activity and ground-glass appearance in the HRCT of RA-ILD patients. These results suggest a positive association between RA disease activity and lung inflammation in RA-ILD (AU)

Objetivo. Describir la asociación entre la actividad de la artritis reumatoide (AR) y la afectación intersticial pulmonar (inflamación y fibrosis), en un grupo de pacientes con enfermedad pulmonar intersticial asociada a la artritis reumatoide. Métodos. Estudio retrospectivo de pacientes con AR y enfermedad pulmonar intersticial (patrón restrictivo en las pruebas de la mecánica pulmonar y evidencia de enfermedad pulmonar intersticial en la tomografía de alta resolución (TCAR)). Los pacientes fueron evaluados para excluir otras causas de enfermedad pulmonar. La actividad de la AR fue medida con el índice clínico de actividad de la enfermedad (CDAI). La inflamación y la fibrosis pulmonar fueron evaluadas con el método de Kazerooni. Se realizó una correlación entre las puntuaciones de vidrio deslustrado del método de Kazerooni con la puntuación más cercano del índice de CDAI. En 9 pacientes se comparó la primera puntuación del vidrio deslustrado con la segunda puntuación después del tratamiento con corticosteroides y fármacos modificadores de la enfermedad (FARME). El coeficiente de correlación de Spearman fue utilizado para evaluar la correlación del índice de CDAI y la puntuación de Kazerooni de vidrio despulido y fibrosis. Resultados. Se incluyeron 34 pacientes. Se encontró una correlación de rs= 0.3767 (P < 0.028) entre las puntuaciones del CDAI y las del vidrio deslustrado. El índice de CDAI y las puntuaciones de fibrosis no estaban asociadas (rs= -0.0747, p < 0.6745). En los 9 pacientes con una segunda TCAR, después del tratamiento, se encontró una tendencia a una menor puntuación de la escala de vidrio deslustrado (mediana [IIC]): (2.33 [2,3] vs. 2 [1.33-2.16]), p < 0.056, además de una tendencia a una menor puntuación del CDAI (mediana [IIC]): (2.33 [2,3] vs. 2 [1.33-2.16]), p < 0.056. Conclusiones. Existe una correlación entre la actividad de la AR y la presencia de vidrio despulido en la TCAR en los pacientes con EPI-AR. Este resultado sugiere una asociación positiva entre la actividad de la AR y el daño pulmonar (AU)

Rheumatoid arthritis-associated interstitial lung disease: lung inflammation evaluated with high resolution computed tomography scan is correlated to rheumatoid arthritis disease activity.

OBJECTIVE: To describe the association between rheumatoid arthritis disease activity (RA) and interstitial lung damage (inflammation and fibrosis), in a group of patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). METHODS: A retrospective study of RA patients with interstitial lung disease (restrictive pattern in lung function tests and evidence of interstitial lung disease in high resolution computed tomography (HRCT)). Patients were evaluated to exclude other causes of pulmonary disease. RA disease activity was measured with the CDAI index. Interstitial lung inflammation and fibrosis were determined by Kazerooni scale. We compared Kazerooni ground-glass score with the nearest CDAI score to HRCT date scan of the first medical evaluation at our institution. In nine patients, we compared the first ground-glass score with a second one after treatment with DMARDs and corticosteroids. Spearman's rank correlation coefficient was used to evaluate association between RA disease activity and the Kazerooni ground-glass and fibrosis scores. RESULTS: Thirty-four patients were included. A positive correlation between CDAI and ground-glass scores was found (rs=0.3767, P<0.028). Fibrosis and CDAI scores were not associated (rs=-0.0747, P<0.6745). After treatment, a downward tendency in the ground-glass score was observed (median [IQR]): (2.33 [2,3] vs. 2 [1.33-2.16]), P<0.056, along with a lesser CDAI score (27 [8-43] vs. 9 [5-12]), P<0.063. CONCLUSION: There is a correlation between RA disease activity and ground-glass appearance in the HRCT of RA-ILD patients. These results suggest a positive association between RA disease activity and lung inflammation in RA-ILD.