Depression Is a Major Determinant of Functional Capacity in Rheumatoid Arthritis.

OBJECTIVE: The aim of this study was to determine the prevalence of depression among rheumatoid arthritis (RA) Argentinean patients and its association with sociodemographic and clinical factors. METHODS: We performed a cross-sectional study of consecutive adults with RA. Sociodemographic data, comorbidities, RA disease activity, and current treatment were assessed. The following instruments were used to evaluate quality of life (EQ-5D-3 L [EURO Quality 5-dimension 3 lines], QOL-RA [Quality of Life-Rheumatoid Arthritis]), functional capacity (HAQ-A [Health Assessment Questionnaire-Argentinean version]), and depression (PHQ-9 [Patient Health Questionnaire 9]; scores 5-9: mild, 10-14: moderate, 15-19: moderate-severe, and ≥20: severe depression, a cutoff value ≥10 is diagnostic of major depression). RESULTS: Two hundred fifty-eight patients were included, with a median disease duration of 9 years (interquartile range, 3.6-16.7 years). The m PHQ-9 score was 6 (interquartile range, 2-12.3 years). The prevalence of major depression was 33.8%. The frequency of mild, moderate, moderate/severe, and severe depression was 66 (25.6%), 42 (16.3%), 27 (10.5%), and 18 (7%), respectively. Patients with major depression had worse functional capacity (HAQ-A: mean ± SD, 1.6 ± 0.8 vs. 0.7 ± 0.7; p < 0.0001), poorer quality of life (QOL-RA: mean ± SD, 5.4 ± 1.8 vs. 7.3 ± 1.6; p < 0.0001), greater pain (visual analog scale: mean ± SD, 56.2 ± 27.5 mm vs. 33.4 ± 25.7 mm; p < 0.0001), higher disease activity (Disease Activity Score in 28 joints: mean ± SD, 4.3 ± 1.4 vs. 3.3 ± 1.3; p < 0.0001), higher frequency of comorbidities (67% vs. 33%; p = 0.017), and lower frequency of physical activity (22% vs. 35%; p = 0.032). In the multivariate analysis, patients with moderate and severe depression had worse functional capacity (odds ratio, 2.1; 95% confidence interval, 1.6-4.3; p < 0.0001) and quality of life (odds ratio, 0.7; 95% confidence interval, 0.5-0.8; p < 0.0001), independently of disease activity. CONCLUSIONS: A third of RA patients in this Argentinean cohort had major depression. In those patients, depression was associated with worst functional capacity and quality of life.

Evaluación de las necesidades educacionales de los pacientes con artritis reumatoide mediante el cuestionario SpENAT / Evaluation of the educational needs in Argentine patients with rheumatoid arthritis using the SpENAT questionnaire

INTRODUCCIÓN: El Educational Needs Assessment Tool-versión española (SpENAT) es un cuestionario autorreportado que evalúa las necesidades educacionales (NEd) con el fin de dar información adaptada y centrada en el paciente con artritis reumatoide (AR). Comprende 39 preguntas agrupadas en 7 dominios: Manejo del dolor, Movimiento, Sentimientos, Proceso de artritis, Tratamientos, Medidas de autoayuda y Sistemas de apoyo. OBJETIVOS: Evaluar las NEd en pacientes con AR mediante el SpENAT y determinar cuáles son las principales fuentes de información a las que consultan. MATERIAL Y MÉTODOS: Estudio multicéntrico, observacional, analítico, de corte transversal. Se incluyeron pacientes consecutivos≥18 años con diagnóstico de AR (ACR 87 y/o ACR-EULAR 2010). Se consignaron datos demográficos, nivel educativo, características de la enfermedad y medidas clinimétricas. Todos los pacientes completaron el SpENAT y fueron interrogados acerca de las fuentes a las que acuden para obtener información de su enfermedad. ANÁLISIS ESTADÍSTICO: Se describieron las características poblacionales. Se determinaron las NEd como porcentajes del puntaje máximo posible de cada dominio. Se compararon las necesidades por dominio según sexo, años de educación, tiempo de evolución, uso de biológico y capacidad funcional mediante test de Anova y las comparaciones de a pares con prueba t de Student y corrección de Bonferroni. Se determinó correlación entre los dominios con test de Spearman. Se comparó la edad según la fuente de información con la prueba t de Student. RESULTADOS: Se incluyeron 496 pacientes de 20 centros de todo el país. Se observaron mayores NEd en los dominios Movimiento, Sentimientos y Proceso de artritis. Los pacientes de mayor nivel educacional (>7 años) refirieron mayores NEd en los dominios Proceso de artritis y Medidas de autoayuda. Un mayor deterioro funcional (HAQ≥0,87) se asoció con unas mayores NEd en todos los dominios. Los pacientes con alta actividad mostraron mayores NEd que los pacientes en remisión en los dominios Manejo del dolor, Movimiento, Sentimientos, Tratamientos y Sistemas de apoyo, y que los pacientes con baja actividad en los dominios Medidas de autoayuda y Sistemas de apoyo. Todos los dominios del SpENAT mostraron correlaciones positivas entre sí (p < 0,0001), siendo las más importantes Manejo del dolor/Movimiento y Tratamientos/Proceso de artritis (r≥0,7). La fuente de información más consultada fue el reumatólogo (93,95%); quienes recurrían a Internet tenían una menor edad en promedio (p = 0,0004). CONCLUSIÓN: Los pacientes con AR manifestaron un gran interés por conocer más sobre su enfermedad. Un elevado deterioro funcional se asocia con mayores NEd. Los pacientes con alta actividad de la enfermedad presentan mayores NEd en casi todos los dominios. El médico reumatólogo es la principal fuente de información del paciente con AR

BACKGROUND: The SpENAT, a Spanish version of the Educational Needs Assessment Tool, is a self-completed questionnaire that assesses educational needs (ENs) with the purpose of providing tailored and patient-centered information. It consists of 39 questions grouped into the 7 following domains: Pain management, Movement, Feelings, Arthritic process, Treatments, Self-help measures and Support system. OBJECTIVES: The objective of the study was to describe the ENs of rheumatoid arthritis (RA) patients using the SpENAT and to determine the main sources of information consulted by these patients. MATERIAL AND METHODS: Multicenter, observational, cross-sectional study. We included consecutive patients≥18 years with diagnosis of RA (ACR 87/ACR-EULAR 2010). Sociodemographic data, disease characteristics and clinimetric properties were recorded. All patients completed the SpENAT and were asked about the sources employed to obtain information about their disease. STATISTICAL ANALYSIS: Population characteristics were described. ENs were determined as percentages of the highest possible score for each domain. Needs for each domain according to sex, years of education, disease duration, use of biologicals and functional capacity were analyzed by means of ANOVA, and bivariate comparisons were made with Student's t-test and the Bonferroni correction. Correlation between domains was determined with the Spearman correlation coefficient. We compared patients' age by source of information with Student's t-test. RESULTS: We included 496 patients from 20 centers across the country. More ENs were observed in the domains of Movement, Feelings and the Arthritic process. Patients with higher educational level (>7 years) reported more ENs in the Arthritic process and Self-help measure domains. A higher functional impairment (HAQ-A≥0.87) was associated with more ENs in every domain. Patients with high activity showed more ENs than those in remission in the domains of Pain management, Movement, Feelings, Treatments and Support system, as well as those with low activity in Self-help measures and Support system domains. All SpENAT domains showed positive correlations among each other (P<.0001), the most important being Pain management/Movement and Treatments/Arthritic process (r≥0.7). The source of information most frequently consulted was the rheumatologist (93.95%); those who made use of Internet were on average younger (P=.0004). CONCLUSION: RA patients were very interested about knowing more about their disease. High functional impairment was associated with more ENs. Patients with high disease activity had higher EN levels in almost every domain. The rheumatologist was the main source of information for the patient with RA

Asociación entre Artritis Reumatoidea y otras enfermedades autoinmunes / Association between Rheumatoid Arthritis and other autoimmune diseases

Objetivos: Determinar la frecuencia de enfermedades autoinmunes (EAI) en pacientes con Artritis Reumatoidea (AR) y comparar la frecuencia de EAI entre pacientes con AR y sin AR ni otra EAI reumatológica. Material y Métodos: Estudio multicéntrico, observacional, analítico, retrospectivo. Se incluyeron pacientes consecutivos con AR (ACR/EULAR 2010) y como grupo control pacientes con diagnóstico inicial de Osteoartritis primaria (OA). Resultados: Se incluyeron 1549 pacientes: 831 con AR (84% mujeres, edad media 55.2 años [DE 13.6]) y 718 con OA (82% mujeres, edad media 67 años [DE 11.1]). La frecuencia de EAI en el grupo AR fue del 22% (n=183). Estos presentaron mayor frecuencia de EAI reumatológicas (9.4 vs 3.3%, p< 0.001), y menor frecuencia de EAI no reumatológicas que aquellos con OA (15.3 vs 20.5, p=0.007). La EAI reumatológica más prevalente fue el Síndrome de Sjögren, el cual fue más frecuente en el grupo AR (87.2 vs 29.2%, p< 0,001). La frecuencia de EAI reumatológicas en los pacientes con AR fue mayor en la forma erosiva (11 vs 6.8%, p=0.048). Conclusión: La frecuencia de EAI en los pacientes con AR fue del 22%, en quienes predominaron las de etiología reumatológica mientras que, las no reumatológicas predominaron en pacientes con OA.

Objectives: To determine the frequency of autoimmune diseases (AID) in Rheumatoid Arthritis (RA) patients and to compare this frequency between patients with and without RA or other rheumatologic AID. Methods: Multicenter, observational, analytical, retrospective study. Consecutive patients with diagnosis of RA (ACR/EULAR 2010) were included. Patients with initial diagnosis of primary ostearthritis (OA) were used as control group. Results: A total of 1549 patients were included: 831 RA (84% women, mean age 55.2 [±13.6]) and 718 OA (82% women, mean age 67 [± 11.1]). The frequency of AID in the RA group was 22% (n=183). RA patients showed higher frequency of rheumatologic AID (9.4 vs 3.3%, p< 0.001), and lower frequency of non-rheumatologic AID than OA patients (15.3 vs 20.5%, p= 0.007). The most prevalent rheumatic AID was Sjögren's Syndrome, which was more frequent in the AR group (87.2 vs 29.2%, p<0.001). The frequency of rheumatologic AID in RA patients was higher in those with erosive RA (11 vs 6.8%, p=0.048). Conclusion: The frequency of AID in RA patients was 22%. Rheumatologic AID were more frequent in RA patients, whereas non-rheumatologic AID prevailed in OA patients.

Evaluation of the Educational Needs in Argentine Patients with Rheumatoid Arthritis Using the SpENAT Questionnaire. / Evaluación de las necesidades educacionales de los pacientes con artritis reumatoide mediante el cuestionario SpENAT.

BACKGROUND: The SpENAT, a Spanish version of the Educational Needs Assessment Tool, is a self-completed questionnaire that assesses educational needs (ENs) with the purpose of providing tailored and patient-centered information. It consists of 39 questions grouped into the 7 following domains: Pain management, Movement, Feelings, Arthritic process, Treatments, Self-help measures and Support system. OBJECTIVES: The objective of the study was to describe the ENs of rheumatoid arthritis (RA) patients using the SpENAT and to determine the main sources of information consulted by these patients. MATERIAL AND METHODS: Multicenter, observational, cross-sectional study. We included consecutive patients≥18 years with diagnosis of RA (ACR 87/ACR-EULAR 2010). Sociodemographic data, disease characteristics and clinimetric properties were recorded. All patients completed the SpENAT and were asked about the sources employed to obtain information about their disease. STATISTICAL ANALYSIS: Population characteristics were described. ENs were determined as percentages of the highest possible score for each domain. Needs for each domain according to sex, years of education, disease duration, use of biologicals and functional capacity were analyzed by means of ANOVA, and bivariate comparisons were made with Student's t-test and the Bonferroni correction. Correlation between domains was determined with the Spearman correlation coefficient. We compared patients' age by source of information with Student's t-test. RESULTS: We included 496 patients from 20 centers across the country. More ENs were observed in the domains of Movement, Feelings and the Arthritic process. Patients with higher educational level (>7 years) reported more ENs in the Arthritic process and Self-help measure domains. A higher functional impairment (HAQ-A≥0.87) was associated with more ENs in every domain. Patients with high activity showed more ENs than those in remission in the domains of Pain management, Movement, Feelings, Treatments and Support system, as well as those with low activity in Self-help measures and Support system domains. All SpENAT domains showed positive correlations among each other (P<.0001), the most important being Pain management/Movement and Treatments/Arthritic process (r≥0.7). The source of information most frequently consulted was the rheumatologist (93.95%); those who made use of Internet were on average younger (P=.0004). CONCLUSION: RA patients were very interested about knowing more about their disease. High functional impairment was associated with more ENs. Patients with high disease activity had higher EN levels in almost every domain. The rheumatologist was the main source of information for the patient with RA.

La depresión es un determinante mayor de la capacidad funcional en pacientes con artritis reumatoidea, independientemente de la actividad de la enfermedad / Depression is a major driver of functional capacity in patients with rheumatoid arthritis regardless of disease activity

La depresión es una de las comorbilidades más frecuentemente reportadas en pacientes con Artritis Reumatoidea (AR). Su presencia se asocia a mayores costos de salud, mayor mortalidad y reduce las probabilidades de alcanzar una buena respuesta al tratamiento. Objetivo: Evaluar la prevalencia de depresión en pacientes argentinos con AR y establecer su relación con diferentes factores sociodemográficos y clínicos. Material y métodos: Se incluyeron pacientes ≥18 años de edad, con diagnóstico de AR según criterios ACR-EULAR 2010. Se consignaron datos sociodemográficos, comorbilidades, características clínicas, actividad de la enfermedad y tratamiento actual. Se administraron los cuestionarios EQ-5D-3L, QOL-RA, HAQ-A y PHQ-9. Los valores de PHQ-9 de 5-9, 10-14, 15-19 y ≥20 determinan la presencia de depresión leve, moderada, moderada/severa y severa, respectivamente y un valor de corte ≥10, depresión mayor. Análisis estadístico: Test T de Student, ANOVA y Chi². Regresión lineal múltiple. Resultados: Se incluyeron 258 pacientes, con un tiempo mediano (m) de evolución de la enfermedad de 9 años (RIC 3,6-16,7). La m de depresión valorada por PHQ-9 de 6 (RIC 2-12,5). La prevalencia de depresión mayor fue de 33,8%. Sesenta y seis (25,6%), 42 (16,3%), 27 (10,5%) y 18 (7%) pacientes presentaron depresión leve, moderada, moderada/severa y severa, respectivamente. Los pacientes con depresión mayor mostraron menor capacidad funcional (HAQ-A X1,6±0,8 vs X0,7±0,7, p <0,0001), peor calidad de vida (QOL-RA X5,4±1,8 vs X7,3±1,6, p <0,0001), más dolor (EVN X56,2±27,5 mm vs X33,4±25,7 mm, p <0,0001), mayor actividad de la enfermedad (DAS28-ERS X4,3±1,4 vs X3,3±1,3, p <0,0001), mayor frecuencia de desempleo (71% vs 29%, p=0,015 ) y de comorbilidades (67% vs 33%, p=0,017) y menor frecuencia de actividad física (22% vs 35%, p=0,032). En el análisis multivariado, peor capacidad funcional (OR: 2,1, IC 95%: 1,6-4,3, p <0,0001) y calidad de vida (OR: 0,7, IC 95%: 0,5-0,8, p <0,0001) se asociaron independientemente a la presencia de depresión mayor. Conclusiones: La prevalencia de depresión mayor medida por PHQ-9 en esta cohorte argentina de pacientes con AR fue de 33,8%. La presencia de depresión tiene un impacto negativo sobre la capacidad funcional y la calidad de vida de estos pacientes, independientemente de la actividad de la enfermedad.

Depression is one of the most frequent comorbidity in patients with Rheumatoid Arthritis (RA). It's presence is associated with higher healthcare costs, mortality rate and reduced odds of achieving a good treatment response. Objective: To determine the prevalence of depression in Argentinean patients with RA and to establish its relationship with different sociodemographic and clinical factors. Material and methods: Consecutive patients ≥18 years old, with a diagnosis of RA according to ACR-EULAR 2010 criteria were included. Sociodemographic data, comorbidities, RA characteristics, disease activity and current treatment were registered. Questionnaires were administered: EQ-5D-3L, QOL-RA, HAQ-A and PHQ-9. PHQ-9 scores of 5-9, 10-14, 15-19, ≥20 represent mild, moderate, moderate/severe and severe depression, respectively and a cut-off value ≥10, major depression. Statistical analysis: Student's T, ANOVA and Chi² tests. Multiple logistic regression. Results: 258 patients were included, with a median (m) disease duration of 9 years (IQR 3.6-16.7). The m PHQ-9 score was 6 (IQR 2-12.3). The prevalence of major depression was 33.8%. 66 (25.6%), 42 (16.3%), 27 (10.5%) and 18 (7%) patients presented mild, moderate, moderate/severe and severe depression, respectively. Patients with mayor depression had worse functional capacity (HAQ-A X 1.6±0.8 vs X 0.7±0.7, p <0.0001), poorer quality of life (QOL-RA X 5.4±1.8 vs X 7.3±1.6, p <0.0001), greater pain (NVS X 56.2±27.5 mm vs X 33.4±25.7 mm, p <0.0001), higher disease activity (DAS28-ESR X 4.3±1.4 vs X 3.3±1.3, p <0.0001), higher frequency of unemployment (71% vs 29%, p=0.015 ) and comorbidities (67% vs 33%, p=0.017) and lower frequency of physical activity (22% vs 35%, p=0.032). In the multivariate analysis, patients with moderate and severe depression had worse functional capacity (OR: 2.1, 95% CI: 1.6-4.3, p <0.0001) and quality of life (OR: 0.7, 95% CI: 0.5-0.8, p <0.0001), independently of disease activity. Conclusion: The prevalence of mayor depression in this Argentinean cohort of patients with RA was 33.8%. The presence of depression had a negative impact on functional capacity and quality of life regardless of disease activity.

Validación del índice QOL-RA (Quality of Life-RheumatoidArthritis) en una cohorte argentina de pacientes con artritis reumatoidea / Validation of the Quality of Life-Rheumatoid Arthritis Scale (QOL-RA) in argentinean cohort of patients with rheumatoid arthritis

El autocuestionario QOL-RA es una herramienta diseñada para valorar la calidad de vida de los pacientes con Artritis Reumatoidea (AR). No requiere licencia para su uso. Objetivo: Validar el cuestionario QOL-RA en una cohorte de pacientes con AR en Argentina. Material y métodos: Estudio de corte transversal. Se incluyeron pacientes ≥18 años de edad con diagnóstico de AR según criterios ACR-EuLAR 2010. Se consignaron datos sociodemográficos, comorbilidades, características de la enfermedad. Se completaron los cuestionarios QOL-RA, EQ 5D-3L, HAQ-A, PHQ-9. Se midió el tiempo para completar y calcular el QOL-RA. Análisis estadístico: Estadística descriptiva. Test T de Student, ANOvA, Chi2. Correlación de Spearman. Alpha de Cronbach. Coeficiente de correlación intraclase. Regresión Logística multinomial con modelo factorial completo. Regresión Lineal múltiple. Resultados: Se incluyeron 258 pacientes, 85,7% eran mujeres, con una edad mediana de 54 años (RIC 45-62). La mediana del QOL-RA fue 6,75 (RIC 5,4-8,1), presentando buena correlación con EQ 5D-3L (Rho: 0,63), HAQ-A (Rho: -0,56), PHQ9 (Rho: -0,54), SDAI (Rho: -0,45) y DAS28-ERS (Rho: -0,44). Peor calidad de vida se asoció con la presencia de comorbilidades (x6,4 ± 2 vs 7 ± 1,7, p=0,01) y no realizar actividad física (x6,7 ± 1,9 vs 7,1 ± 1,7, p=0,004). El tiempo para completar el cuestionario fue de x1,7 ± 0,42 minutos y para calcularlo de x12± 2,1 segundos. La confiabilidad y la reproducibilidad fueron buenas. Sin embargo, 4,3% de los cuestionarios presentaban alguna pregunta faltante y se observó redundancia entre las preguntas 3 y 6. En el análisis de regresión lineal múltiple usando QOL-RA como variable dependiente y ajustando para edad y tiempo de evolución, las variables que se asociaron independientemente a peor calidad de vida fueron: la discapacidad funcional, la actividad de la enfermedad y la presencia de depresión y comorbilidades. Conclusión: El cuestionario QOL-RA demostró buena validez de constructo, reproducibilidad y confiabilidad. Es fácil de completar y calcular. Sin embargo, dada la redundancia entre dos preguntas proyectamos cambiar una de ellas y re-testearlo

Controversies in the Management of Low-Risk Differentiated Thyroid Cancer.

Controversy exists over optimal management of low-risk differentiated thyroid cancer. This controversy occurs in all aspects of management, including surgery, use of radioactive iodine for remnant ablation, thyroid hormone supplementation, and long-term surveillance. Limited and conflicting data, treatment paradigm shifts, and differences in physician perceptions contribute to the controversy. This lack of physician consensus results in wide variation in patient care, with some patients at risk for over- or undertreatment. To reduce patient harm and unnecessary worry, there is a need to design and implement studies to address current knowledge gaps.

Genome stability of Lyme disease spirochetes: comparative genomics of Borrelia burgdorferi plasmids.

Lyme disease is the most common tick-borne human illness in North America. In order to understand the molecular pathogenesis, natural diversity, population structure and epizootic spread of the North American Lyme agent, Borrelia burgdorferi sensu stricto, a much better understanding of the natural diversity of its genome will be required. Towards this end we present a comparative analysis of the nucleotide sequences of the numerous plasmids of B. burgdorferi isolates B31, N40, JD1 and 297. These strains were chosen because they include the three most commonly studied laboratory strains, and because they represent different major genetic lineages and so are informative regarding the genetic diversity and evolution of this organism. A unique feature of Borrelia genomes is that they carry a large number of linear and circular plasmids, and this work shows that strains N40, JD1, 297 and B31 carry related but non-identical sets of 16, 20, 19 and 21 plasmids, respectively, that comprise 33-40% of their genomes. We deduce that there are at least 28 plasmid compatibility types among the four strains. The B. burgdorferi ∼900 Kbp linear chromosomes are evolutionarily exceptionally stable, except for a short ≤20 Kbp plasmid-like section at the right end. A few of the plasmids, including the linear lp54 and circular cp26, are also very stable. We show here that the other plasmids, especially the linear ones, are considerably more variable. Nearly all of the linear plasmids have undergone one or more substantial inter-plasmid rearrangements since their last common ancestor. In spite of these rearrangements and differences in plasmid contents, the overall gene complement of the different isolates has remained relatively constant.

Inhibidor adquirido del Factor VIII y medicina transfusional / Acquired inhibitor anti-factor VIII antibodies and transfusion therapy

La presencia del Inhibidor Adquirido de Factor VIII, con una frecuencia poblacional de 1 caso por millón al año, es una patología que puede presentar episodios de sangrados muy graves. Cerca del 50 por ciento de los casos son idiopáticos. En esta presentación se reportan dos casos internaados en nuestra institución entre 2006 y 2007.

Comparative genomic evidence for a close relationship between the dimorphic prosthecate bacteria Hyphomonas neptunium and Caulobacter crescentus.

The dimorphic prosthecate bacteria (DPB) are alpha-proteobacteria that reproduce in an asymmetric manner rather than by binary fission and are of interest as simple models of development. Prior to this work, the only member of this group for which genome sequence was available was the model freshwater organism Caulobacter crescentus. Here we describe the genome sequence of Hyphomonas neptunium, a marine member of the DPB that differs from C. crescentus in that H. neptunium uses its stalk as a reproductive structure. Genome analysis indicates that this organism shares more genes with C. crescentus than it does with Silicibacter pomeroyi (a closer relative according to 16S rRNA phylogeny), that it relies upon a heterotrophic strategy utilizing a wide range of substrates, that its cell cycle is likely to be regulated in a similar manner to that of C. crescentus, and that the outer membrane complements of H. neptunium and C. crescentus are remarkably similar. H. neptunium swarmer cells are highly motile via a single polar flagellum. With the exception of cheY and cheR, genes required for chemotaxis were absent in the H. neptunium genome. Consistent with this observation, H. neptunium swarmer cells did not respond to any chemotactic stimuli that were tested, which suggests that H. neptunium motility is a random dispersal mechanism for swarmer cells rather than a stimulus-controlled navigation system for locating specific environments. In addition to providing insights into bacterial development, the H. neptunium genome will provide an important resource for the study of other interesting biological processes including chromosome segregation, polar growth, and cell aging.