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1.
Reumatol. clín. (Barc.) ; 15(2): 102-108, mar.-abr. 2019. tab, graf
Artigo em Inglês | LILACS-Express | ID: ibc-ET1-3371

RESUMO

Objectives: To describe the prevalence of comorbidities in patients with RA in Spain and discuss their management and implications using data from the Spanish cohort of the multinational study on COMOrbidities in Rheumatoid Arthritis (COMORA). Methods: This is a national sub-analysis of the COMORA study. We studied the demographics and disease characteristics of 200 adults patients diagnosed with RA (1987 ACR), and routine practices for screening and preventing the following selected comorbidities: cardiovascular, infections, cancer, gastrointestinal, pulmonary, osteoporosis and depression. Results: Patients had a mean age of 58 years and a mean RA duration of 10 years. Mean DAS28 score was 3.3 and approximately 25% of patients were in remission (DAS28 <2.6). Forty-four (22%) patients had ≥1 comorbidity, the most frequent being depression (27%) and obesity (26%). A history of myocardial infarction or stroke was observed in 5% and 1% of patients, respectively, and any solid tumor in 6%. Having a Framingham Risk Score >20% (51%), hypercholesterolemia (46%) or hypertension (41%) and smoking (25%) were the most common CV risk factors. For prostate, colon and skin cancers, only 9%, 10% and 18% of patients, respectively, were optimally monitored. Infections were also inadequately managed, with 7% and 17% of patients vaccinated against influenza and pneumococcal, respectively, as was osteoporosis, with 47% of patients supplemented with vitamin D and 56% with a bone densitometry performed. Conclusions: In Spain, the prevalence of comorbidities and CV risk factors in RA patients with established and advanced disease is relatively high, and their management in clinical daily practice remains suboptimal


Objetivos: Describir la prevalencia de comorbilidades en pacientes con AR en España y discutir sobre su manejo en la clínica diaria utilizando los datos de la cohorte española del estudio internacional COMORA. Métodos: Subanálisis nacional del estudio COMORA en el que se analizaron las características demográficas y clínicas de 200 pacientes con AR (1987 ACR) y las prácticas rutinarias para el cribado y la prevención de eventos cardiovasculares (CV), gastrointestinales y pulmonares, infecciones, cáncer, osteoporosis y depresión. Resultados: Los pacientes tenían una edad media de 58 años, una duración media de la enfermedad de 10 años, un DAS28 de 3,3 y el 25% estaba en remisión (DAS28 <2,6). El 22% de los pacientes presentaba al menos una comorbilidad, principalmente depresión (27%) y obesidad (26%). El 5% tenía historia de infarto de miocardio, el 1% de ictus y el 6% de tumor sólido. Una puntuación de Framingham >20% (51%), tener hipercolesterolemia (46%), hipertensión (41%) y fumar (25%) fueron los factores de riesgo CV más comunes. En relación con el cáncer de próstata, colon y piel, solo el 9, 10 y el 18% de los pacientes, respectivamente, estaban óptimamente controlados. Las infecciones tampoco se manejaban de forma óptima, con solo el 7 y el 17% de los pacientes vacunados contra la influenza y neumococo, respectivamente, al igual que la osteoporosis, con el 47% suplementados con la vitamina D y el 56% con una densitometría realizada. Conclusiones: En España, la prevalencia de comorbilidades y factores de riesgo CV en pacientes con AR establecida y avanzada es relativamente alta, y su manejo en la clínica diaria continúa siendo subóptimo

2.
Semin Arthritis Rheum ; 49(1): 162-170, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30580885

RESUMO

OBJECTIVE: To investigate the prevalence, clinical characteristics and prognosis of pulmonary arterial hypertension (PAH) in adult onset Still's disease (AOSD). METHODS: We retrospectively reviewed all patients with AOSD diagnosed during a 33-year period in 2 referral tertiary care hospitals, selecting for analysis those who presented PAH confirmed as by right heart catheterization. A systematic review of the literature (PubMed 1990 to July 2018) was also performed, in order to determine the prognosis and the most appropriate treatment strategy for this complication. RESULTS: The overall prevalence of PAH in our AOSD population was 4.8% (2/41). Including our 2 cases, 20 well-documented patients have been reported. PAH may complicate AOSD at any time during its course, and usually occurs in patients who have persistent and severe disease, with a considerable frequency (35%) of previous or concomitant severe clinical complications. In all cases, the etiology of pulmonary hypertension was a group 1 PAH based on the 2015 ESC/ERS guidelines. Most patients in this series had advanced WHO functional classes III-IV at the time of PAH diagnosis, reflecting an important diagnostic delay. Thirty-three percent of patients had a poor outcome despite the therapy, with a mortality rate that reached 22%. The therapeutic strategy that achieved the best results was the use of glucocorticoids, immunosuppression and PAH-specific vasodilator therapy. CONCLUSION: HAP is an under-recognized complication of AOSD that should be kept in mind in the differential diagnosis of those patients who experience dyspnea on exertion or a decrease in exercise tolerance.

3.
Arthritis Res Ther ; 20(1): 100, 2018 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-29848360

RESUMO

BACKGROUND: Systemic lupus erythematosus (SLE) is a common systemic autoimmune disease with a complex genetic inheritance. Genome-wide association studies (GWAS) have significantly increased the number of significant loci associated with SLE risk. To date, however, established loci account for less than 30% of the disease heritability and additional risk variants have yet to be identified. Here we performed a GWAS followed by a meta-analysis to identify new genome-wide significant loci for SLE. METHODS: We genotyped a cohort of 907 patients with SLE (cases) and 1524 healthy controls from Spain and performed imputation using the 1000 Genomes reference data. We tested for association using logistic regression with correction for the principal components of variation. Meta-analysis of the association results was subsequently performed on 7,110,321 variants using genetic data from a large cohort of 4036 patients with SLE and 6959 controls of Northern European ancestry. Genetic association was also tested at the pathway level after removing the effect of known risk loci using PASCAL software. RESULTS: We identified five new loci associated with SLE at the genome-wide level of significance (p < 5 × 10- 8): GRB2, SMYD3, ST8SIA4, LAT2 and ARHGAP27. Pathway analysis revealed several biological processes significantly associated with SLE risk: B cell receptor signaling (p = 5.28 × 10- 6), CTLA4 co-stimulation during T cell activation (p = 3.06 × 10- 5), interleukin-4 signaling (p = 3.97 × 10- 5) and cell surface interactions at the vascular wall (p = 4.63 × 10- 5). CONCLUSIONS: Our results identify five novel loci for SLE susceptibility, and biologic pathways associated via multiple low-effect-size loci.

4.
Int J Endocrinol ; 2018: 1897058, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29853876

RESUMO

Objective: To assess the evolution of joint mobility over a period of 15 years in type 1 diabetic patients and healthy controls and to determine whether microalbuminuria is associated with a different evolution of joint mobility. Methods: Joint mobility of hand and wrist was determined in 63 patients with type 1 diabetes and 63 healthy subjects. Fifteen years later, 37 (58.7%) diabetic patients and 16 (25.4%) healthy subjects were studied again. Joint mobility was assessed with the Prayer sign and by measuring the angle of maximal flexion of the fifth and third metacarpophalangeal (MCP) joints and wrist. Patients with diabetes were visited 2-4 times every year with regular assessment of glycated hemoglobin (HbA1c), urinary albumin excretion (UAE), and ophthalmoscopy. Results: Fifteen years after the initial exam, diabetic patients showed reduced flexion of the fifth MCP joint (82.6 ± 5.8 versus 76.0 ± 6.4 degrees, p < 0.001) and wrist (75.9 ± 8.1 versus 73.2 ± 7.4 degrees, p = 0.015) compared to baseline examination. Joint mobility did not change significantly in healthy subjects. Patients with microalbuminuria showed greater reduction in hand joint mobility than diabetic patients with normal UAE or than healthy subjects (p < 0.001). Conclusions: In type 1 diabetic patients, the severity of LJM progresses with time, and the progression is enhanced in patients with microalbuminuria.

5.
Reumatol. clín. (Barc.) ; 14(3): 142-149, mayo-jun. 2018. tab
Artigo em Espanhol | IBECS | ID: ibc-174098

RESUMO

Objetivos. Desarrollar recomendaciones sobre el uso de metrotexato (MTX) parenteral en pacientes con enfermedades reumáticas, fundamentalmente en la artritis reumatoide, basadas en la mejor evidencia y experiencia. Métodos. Se seleccionó un grupo de 21 expertos reumatólogos en el manejo de MTX. El coordinador generó 13 preguntas sobre el uso de MTX parenteral (perfiles de indicación, eficacia, seguridad, costo-eficacia y biodisponibilidad) para ser contestadas mediante una revisión sistemática de la literatura. Con base en las preguntas se definieron los criterios de inclusión y exclusión, y las estrategias de búsqueda (en Medline, EMBASE y la Cochrane Library). Tres revisores seleccionaron los artículos resultantes de la búsqueda. Se generaron tablas de evidencia. Paralelamente se evaluaron abstracts de congresos de la European League Against Rheumatism (EULAR) y del American College of Rheumatology (ACR). Con toda esta evidencia el coordinador generó 13 recomendaciones preliminares que se evaluaron, discutieron y votaron en una reunión del grupo nominal con los expertos. Para cada recomendación se estableció el nivel de evidencia y grado de recomendación, y el grado de acuerdo mediante un Delphi. Se definió acuerdo si al menos el 80% de los participantes contestaron sí a la recomendación (sí o no). Resultados. La mayoría de la evidencia proviene de la artritis reumatoide. De las 13 recomendaciones preliminares se aceptaron 11 recomendaciones sobre el uso de MTX parenteral en reumatología. Dos no se llegaron a votar y se decidió no incluirlas, pero se comentan en el texto final. Conclusiones. Este documento pretende resolver algunos interrogantes clínicos habituales y facilitar la toma de decisiones con el uso de MTX parenteral


Objective. To develop recommendations for the use of parenteral methotrexate (MTX) in rheumatic diseases, mainly rheumatoid arthritis, based on best evidence and experience. Methods. A group of 21 experts on parenteral MTX use was selected. The coordinator formulated 13 questions about parenteral MTX (indications, efficacy, safety and cost-effectiveness). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (involving Medline, EMBASE and the Cochrane Library). Three different reviewers selected the articles. Evidence tables were created. Abstracts from the European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) were evaluated. Based on this evidence, the coordinator proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Center for Evidence-Based Medicine and the level of agreement with the Delphi technique (2 rounds). Agreement was established if at least 80% of the experts voted yes (yes/no). Results. Most of the evidence involved rheumatoid arthritis. A total of 13 preliminary recommendations on the use of parenteral MTX were proposed; 11 of them were accepted. Two of the 13 were not voted and are commented on in the main text. Conclusions. The manuscript aims to solve frequent questions and help in decision-making strategies when treating patients with parenteral MTX


Assuntos
Humanos , Doenças Reumáticas/tratamento farmacológico , Artrite Reumatoide/tratamento farmacológico , Metotrexato/uso terapêutico , Resultado do Tratamento , Consenso , Conferências de Consenso como Assunto , Infusões Parenterais , Técnica Delfos , Adesão à Medicação , Automedicação/normas
6.
Ophthalmology ; 125(9): 1444-1451, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29602570

RESUMO

PURPOSE: To assess efficacy, safety, and cost-effectiveness of adalimumab (ADA) therapy optimization in a large series of patients with uveitis due to Behçet disease (BD) who achieved remission after the use of this biologic agent. DESIGN: Open-label multicenter study of ADA-treated patients with BD uveitis refractory to conventional immunosuppressants. SUBJECTS: Sixty-five of 74 patients with uveitis due to BD, who achieved remission after a median ADA duration of 6 (range, 3-12) months. ADA was optimized in 23 (35.4%) of them. This biologic agent was maintained at a dose of 40 mg/subcutaneously/2 weeks in the remaining 42 patients. METHODS: After remission, based on a shared decision between the patient and the treating physician, ADA was optimized. When agreement between patient and physician was reached, optimization was performed by prolonging the ADA dosing interval progressively. Comparison between optimized and nonoptimized patients was performed. MAIN OUTCOME MEASURES: Efficacy, safety, and cost-effectiveness in optimized and nonoptimized groups. To determine efficacy, intraocular inflammation (anterior chamber cells, vitritis, and retinal vasculitis), macular thickness, visual acuity, and the sparing effect of glucocorticoids were assessed. RESULTS: No demographic or ocular differences were found at the time of ADA onset between the optimized and the nonoptimized groups. Most ocular outcomes were similar after a mean ± standard deviation follow-up of 34.7±13.3 and 26±21.3 months in the optimized and nonoptimized groups, respectively. However, relevant adverse effects were only seen in the nonoptimized group (lymphoma, pneumonia, severe local reaction at the injection site, and bacteremia by Escherichia coli, 1 each). Moreover, the mean ADA treatment costs were lower in the optimized group than in the nonoptimized group (6101.25 euros/patient/year vs. 12 339.48; P < 0.01). CONCLUSION: ADA optimization in BD uveitis refractory to conventional therapy is effective, safe, and cost-effective.

7.
Curr Rheumatol Rev ; 14(1): 78-83, 2018 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-29057725

RESUMO

Objetive: Patients with Rheumatoid Arthritis (RA) and nasal carriers of Staphylococcus aureus have an increased risk of developing infections caused by S. aureus. Our objective was to determine the prevalence of S. aureus nasal colonization in patients with RA and its relationship to RA treatments. METHODS: Two hundred and seven patients with RA and 37 healthy controls were prospectively included in a cross-sectional study. A nasal secretion sample was collected by swab from both anterior nostrils and was referred to the hospital's microbiology department for culturing. RESULTS: The mean age of the patients (168 women, 78%) was 61 ± 12 years old. The mean disease duration was 13 ± 10 years. Seventy-six percent of the patients were positive for Rheumatoid Factor (RF), and 71% were positive for Anti-citrullinated Peptides Antibodies (ACPA). Seventy percent had joint erosions. The mean DAS28 was 3.1 ± 2.2. S. aureus nasal colonization was found in 36% of the RA patients and 35% of the controls. Three patients and no controls were resistant to oxacilin/ mupirocin. The patients who were positive for ACPA had a higher prevalence of S. aureus colonization (43% vs. 17%; p < 0.05). The colonization prevalence in the patients treated with glucocorticoids was 32% (n: 133); methotrexate and/or leflunomide, 37% (n: 167); anti-TNF agents, 46% (n: 54), p < 0.05 versus patients not treated with anti-TNF agents; rituximab, 22% (n: 18); tocilizumab, 39% (n: 18). CONCLUSION: The prevalence of S. aureus nasal colonization in patients with RA does not appear to be greater than that of the general population. Anti-TNF agents might confer a higher prevalence of colonization.


Assuntos
Artrite Reumatoide/microbiologia , Infecções Estafilocócicas/epidemiologia , Adulto , Idoso , Artrite Reumatoide/complicações , Estudos de Casos e Controles , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cavidade Nasal/microbiologia , Prevalência , Infecções Estafilocócicas/complicações , Staphylococcus aureus
8.
Reumatol Clin ; 14(3): 142-149, 2018 May - Jun.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-28082032

RESUMO

OBJECTIVE: To develop recommendations for the use of parenteral methotrexate (MTX) in rheumatic diseases, mainly rheumatoid arthritis, based on best evidence and experience. METHODS: A group of 21 experts on parenteral MTX use was selected. The coordinator formulated 13 questions about parenteral MTX (indications, efficacy, safety and cost-effectiveness). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (involving Medline, EMBASE and the Cochrane Library). Three different reviewers selected the articles. Evidence tables were created. Abstracts from the European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) were evaluated. Based on this evidence, the coordinator proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Center for Evidence-Based Medicine and the level of agreement with the Delphi technique (2 rounds). Agreement was established if at least 80% of the experts voted yes (yes/no). RESULTS: Most of the evidence involved rheumatoid arthritis. A total of 13 preliminary recommendations on the use of parenteral MTX were proposed; 11 of them were accepted. Two of the 13 were not voted and are commented on in the main text. CONCLUSIONS: The manuscript aims to solve frequent questions and help in decision-making strategies when treating patients with parenteral MTX.

10.
Reumatol Clin ; 2017 Jul 12.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-28711461

RESUMO

OBJECTIVES: To describe the prevalence of comorbidities in patients with RA in Spain and discuss their management and implications using data from the Spanish cohort of the multinational study on COMOrbidities in Rheumatoid Arthritis (COMORA). METHODS: This is a national sub-analysis of the COMORA study. We studied the demographics and disease characteristics of 200 adults patients diagnosed with RA (1987 ACR), and routine practices for screening and preventing the following selected comorbidities: cardiovascular, infections, cancer, gastrointestinal, pulmonary, osteoporosis and depression. RESULTS: Patients had a mean age of 58 years and a mean RA duration of 10 years. Mean DAS28 score was 3.3 and approximately 25% of patients were in remission (DAS28 <2.6). Forty-four (22%) patients had ≥1 comorbidity, the most frequent being depression (27%) and obesity (26%). A history of myocardial infarction or stroke was observed in 5% and 1% of patients, respectively, and any solid tumor in 6%. Having a Framingham Risk Score >20% (51%), hypercholesterolemia (46%) or hypertension (41%) and smoking (25%) were the most common CV risk factors. For prostate, colon and skin cancers, only 9%, 10% and 18% of patients, respectively, were optimally monitored. Infections were also inadequately managed, with 7% and 17% of patients vaccinated against influenza and pneumococcal, respectively, as was osteoporosis, with 47% of patients supplemented with vitamin D and 56% with a bone densitometry performed. CONCLUSIONS: In Spain, the prevalence of comorbidities and CV risk factors in RA patients with established and advanced disease is relatively high, and their management in clinical daily practice remains suboptimal.

11.
Arthritis Res Ther ; 19(1): 138, 2017 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-28619073

RESUMO

BACKGROUND: Systemic lupus erythematosus (SLE) is a genetically complex rheumatic disease characterized by heterogeneous clinical manifestations of unknown etiology. Recent studies have suggested the existence of a genetic basis for SLE heterogeneity. The objective of the present study was to identify new genetic variation associated with the clinically relevant phenotypes in SLE. METHODS: A two-stage pathway-based approach was used to identify the genetic variation associated with the main clinical phenotypes in SLE. In the discovery stage, 482 SLE patients were genotyped using Illumina Human Quad610 microarrays. Association between 798 reference genetic pathways from the Molecular Signatures Database and 11 SLE phenotypes was tested using the set-based method implemented in PLINK software. Pathways significantly associated after multiple test correction were subsequently tested for replication in an independent cohort of 425 SLE patients. Using an in silico approach, we analyzed the functional effects of common SLE therapies on the replicated genetic pathways. The association of known SLE risk variants with the development of the clinical phenotypes was also analyzed. RESULTS: In the discovery stage, we found a significant association between the vascular endothelial growth factor (VEGF) pathway and oral ulceration (P value for false discovery rate (P FDR) < 0.05), and between the negative regulation signaling pathway of retinoic acid inducible gene-I/melanoma differentiation associated gene 5 and the production of antinuclear antibodies (P FDR < 0.05). In the replication stage, we validated the association between the VEGF pathway and oral ulceration. Therapies commonly used to treat mucocutaneous phenotypes in SLE were found to strongly influence VEGF pathway gene expression (P = 4.60e-4 to 5.38e-14). Analysis of known SLE risk loci identified a strong association between PTPN22 and the risk of hematologic disorder and with the development of antinuclear antibodies. CONCLUSIONS: The present study has identified VEGF genetic pathway association with the risk of oral ulceration in SLE. New therapies targeting the VEGF pathway could be more effective in reducing the severity of this phenotype. These findings represent a first step towards the understanding of the genetic basis of phenotype heterogeneity in SLE.


Assuntos
Lúpus Eritematoso Sistêmico/genética , Lúpus Eritematoso Sistêmico/patologia , Úlceras Orais/genética , Fator A de Crescimento do Endotélio Vascular/genética , Adulto , Feminino , Predisposição Genética para Doença/genética , Variação Genética , Estudo de Associação Genômica Ampla , Genótipo , Humanos , Lúpus Eritematoso Sistêmico/complicações , Masculino , Fenótipo
12.
Medicine (Baltimore) ; 96(11): e6318, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28296747

RESUMO

The diagnosis of adult-onset Still's disease (AOSD) can be very difficult. There are no specific tests available, and diagnosis is usually based on a symptom complex and the well-described typical evanescent rash seen in the majority of patients. However, in recent years, other atypical cutaneous manifestations of AOSD have been reported. These atypical skin eruptions often present in addition to the typical evanescent rash but may also be the only skin manifestation, resulting in delayed diagnosis because of under-recognition.In this study, we present 3 new cases of AOSD with atypical cutaneous manifestations diagnosed during a 30-year period in our department and review 78 additional cases previously reported (PubMed 1990-2016). These 81 patients form the basis of the present analysis.The overall prevalence of atypical cutaneous manifestations in our AOSD population was 14%. These manifestations may appear at any time over the course of the disease, and usually occur in patients who have persistent and severe disease, with a considerable frequency of clinical complications (23%), including serositis, myopericarditis, lung involvement, abdominal pain, neurologic involvement, and reactive hemophagocytic syndrome.The most representative and frequent lesion among the nonclassical skin rashes is the development of persistent pruritic papules and/or plaques. Interestingly, these lesions show a distinctive histological pattern. Other, less frequently observed lesions include urticaria and urticaria-like eruptions, generalized or widespread non-pruritic persistent erythema, vesiculopustular eruptions, a widespread peau d'orange appearance of the skin, and edema of the eyelids mimicking dermatomyositis without any accompanying skin lesion.The great majority of these patients required medium or high doses of glucocorticoids (including intravenous methylprednisolone pulse therapy in some cases) and, in nearly 40%, a more potent or maintenance immunotherapy with immunosuppressant drugs and/or biologic agents (mainly anakinra or tocilizumab) to control or manage symptoms because of a polycyclic or chronic course. The development of atypical cutaneous manifestations seems to be associated with a potentially worse prognosis, with a mortality rate reaching 8% primarily because of infectious complications related to immunosuppressive therapy.In conclusion, the appearance of atypical cutaneous manifestations is not uncommon in AOSD. Recognition of this clinical variant is crucial for the early diagnosis of AOSD, as it might imply persistent disease activity and the need for more aggressive treatment.


Assuntos
Dermatopatias/etiologia , Dermatopatias/patologia , Doença de Still de Início Tardio/complicações , Doença de Still de Início Tardio/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Dermatopatias/tratamento farmacológico , Fatores Socioeconômicos , Doença de Still de Início Tardio/tratamento farmacológico , Adulto Jovem
13.
Medicine (Baltimore) ; 95(48): e5511, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27902617

RESUMO

The cornerstone of therapy in thromboangiitis obliterans (TAO) is complete abstinence from tobacco. In addition to discontinuation of cigarette smoking, very few pharmacological and surgical options of controversial efficacy are available to date. New therapeutic options with greater efficacy are clearly needed to properly manage these patients.In this preliminary study, we assessed the effectiveness and safety of bosentan in a case series of 8 adults with TAO and severe ischemic ulceronecrotic lesions who were treated with bosentan after inadequate response to platelet inhibitors, vasodilators, and intravenous alprostadil. Additionally, we reviewed 18 well-documented patients with refractory TAO treated with bosentan, which was previously reported (PubMed 1965-2015). These 26 patients formed the basis of our present analysis. All were current smokers.The median duration of bosentan treatment (SD) was 4.5 ±â€Š4 months (range 3-16). Eleven patients (42%) were unable to completely abstain from smoking during their follow-up. With bosentan treatment, no new ischemic lesions were observed in the target extremities. A complete therapeutic response was achieved in 80% of patients, whereas a partial response was observed in 12%. Two patients (8%) ultimately required amputation despite treatment.After discontinuation of bosentan, patients were followed for a median of 20 ±â€Š14 months (range 3-60). Two patients whose trophic lesions had healed relapsed.When comparing patients who gave up smoking with those who were unable to completely abstain from smoking during follow-up, no significant differences were found in efficacy outcomes. Four patients (15%) developed adverse events, requiring bosentan discontinuation in 1 case.These preliminary data suggest that bosentan may be considered a therapeutic option for treatment of cases of severe TAO refractory to conventional treatment, and merit further evaluation in larger controlled, randomized clinical studies.


Assuntos
Anti-Hipertensivos/uso terapêutico , Sulfonamidas/uso terapêutico , Tromboangiite Obliterante/tratamento farmacológico , Adulto , Bosentana , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
14.
Medicine (Baltimore) ; 95(33): e4626, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27537601

RESUMO

Shrinking lung syndrome (SLS) is a rare and less known complication mainly associated with systemic lupus erythematosus (SLE). In this study, we analyze the clinical features, investigation findings, approaches to management, and outcome in a case series of 9 adult patients with SLE and SLS diagnosed during a 35-year period in 3 referral tertiary care hospitals in Spain. Additionally, we reviewed 80 additional cases previously reported (PubMed 1965-2015). These 80 cases, together with our 9 patients, form the basis of the present analysis.The overall SLS prevalence in our SLE population was 1.1% (9/829). SLS may complicate SLE at any time over its course, and it usually occurs in patients without previous or concomitant major organ involvement. More than half of the patients had inactive lupus according to SELENA-systemic lupus erythematosus disease activity index (SLEDAI) scores. Typically, it presents with progressive exertional dyspnea of variable severity, accompanied by pleuritic chest pain in 76% of the cases.An important diagnostic delay is common. The diagnostic tools that showed better yield for SLS detection are the imaging techniques (chest x-ray and high-resolution computed tomography) along with pulmonary and diaphragmatic function tests. Evaluation of diaphragm dome motion by M-mode ultrasonography and phrenic nerve conduction studies are less useful.There are no standardized guidelines for the treatment of SLS in SLE. The majority of patients were treated with medium or high doses of glucocorticoids. Several immunosuppressive agents have been used in conjunction with steroids either if the patient fails to improve or since the beginning of the treatment. Theophylline and beta-agonists, alone or in combination with glucocorticoids, have been suggested with the intent to increase diaphragmatic strength.The overall long-term prognosis was good. The great majority of patients had significant clinical improvement and stabilization, or mild to moderate improvement on pulmonary function tests. The mortality rate was very low.


Assuntos
Pneumopatias/etiologia , Lúpus Eritematoso Sistêmico/complicações , Adulto , Idoso , Feminino , Humanos , Pneumopatias/patologia , Lúpus Eritematoso Sistêmico/patologia , Masculino , Pessoa de Meia-Idade , Síndrome
15.
Med. clín (Ed. impr.) ; 147(3): 109-112, ago. 2016. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-154572

RESUMO

Objetivos: Evaluar la efectividad de una intervención sobre los factores de riesgo cardiovascular (FRCV) en pacientes con artritis reumatoide. Métodos: Tras determinar sus FRCV y su riesgo cardiovascular (RCV) mediante SCORE modificado, se entregó a los pacientes una carta dirigida a su médico de familia, en la que se solicitaba su colaboración en el control de los FRCV y se especificaba el objetivo respecto al colesterol LDL. Tres meses después se registraron las intervenciones terapéuticas realizadas y su resultado. Resultados: Se incluyeron 211 pacientes, el 29% con un alto RCV. Se realizaron nuevos diagnósticos de FRCV en 100 (47%) casos. El médico de familia cambió el tratamiento en 2/12 diabetes, 30/84 HTA, 74/167 con elevación del colesterol LDL y 21/51 hipertrigliceridemias. El porcentaje de pacientes con buen control de cada FRCV pasó: a) en HTA, del 25 al 73%; b) en elevación del colesterol LDL, del 10 al 17%; y c) en hipertrigliceridemia, del 25 al 38%. Conclusiones: Mediante esta intervención se diagnosticaron nuevos FRCV en casi la mitad de los pacientes. Su efectividad sobre el control de los FRCV fue baja (AU)


Objectives: To evaluate the effectiveness of an intervention on cardiovascular risk factors (CVRF) in patients with rheumatoid arthritis. Methods: After determining their CVRF and cardiovascular risk (CVR) by modified SCORE, we gave the patients a letter for their general practitioners in which they were requested for their cooperation in controlling CVRF and where the therapeutic goal for LDL cholesterol was specified. Three months later, any therapeutic intervention was recorded as well as the results. Results: We included 211 patients, 29% with a high CVR. There were new diagnoses of CVRF in 100 patients (47%). The general practitioner changed the treatment in 2/12 diabetes, 30/84 HBP, 74/167 with elevation of LDL cholesterol and 21/51 with hypertriglyceridemia. The percentage of patients with good control over CVRF was: a) in HBP, 25 to 73%; b) elevation of LDL cholesterol from 10 to 17%; and c) in hypertriglyceridemia, 25 to 38%. Conclusions: Through this intervention, a new CVRF was diagnosed in nearly half of the patients. The effectiveness of the intervention on CVRF was low (AU)


Assuntos
Humanos , Artrite Reumatoide/complicações , Doenças Cardiovasculares/epidemiologia , Fatores de Risco , Avaliação de Resultado de Ações Preventivas , Hipercolesterolemia/prevenção & controle , Atenção Primária à Saúde
16.
Patient Prefer Adherence ; 10: 1101-13, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27382258

RESUMO

PURPOSE: To define importance values assigned to attributes of biological agents (BAs) by Spanish patients with rheumatic diseases (rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis) and rheumatologists. PATIENTS AND METHODS: This was an observational, cross-sectional design based upon a rank-based full-profile conjoint analysis. A literature review and four focus groups were undertaken to identify attributes and levels. An orthogonal matrix, combining the selected levels of attributes, was used to define scenarios. Participants ranked eight scenarios from 1 (most preferred) to 8 (least preferred). The relative importance (RI) of attributes was calculated. Multivariate regression analysis was performed to identify the characteristics that influenced the values of RI. A total of 488 patients (male 50.9%, mean age 50.6 [standard deviation {SD} 12.06] years, rheumatoid arthritis 33.8%, ankylosing spondylitis 32.4%, psoriatic arthritis 33.8%; mean time since diagnosis 12.6 [SD 8.2] years) and 136 rheumatologists (male 50.4%, mean age 46.4 [SD 9.1] years, mean time of practice 16.7 [SD 8.8] years) participated. RESULTS: The ideal BAs for patients and physicians, respectively, should allow pain relief and improvement of functional capacity (RI 39% and 44.7%), with low risk of adverse events (RI 24.9% and 30.5%), a long time prior to perceiving the need for a new dose (RI 16.4% and 12.4%), and self-administration at home (RI 19.7% and 12.5%), as identified through their preferences. CONCLUSION: Although efficacy and safety are paramount for patients and rheumatologists to make a choice regarding BAs, the need for a low frequency of administration and the administration method also play a role as preference attributes for BAs.

17.
Medicine (Baltimore) ; 95(25): e3962, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27336895

RESUMO

Pyogenic arthritis of native joints due to Bacteroides fragilis seems to be an infrequent disease. We analyzed the cases diagnosed in a tertiary hospital during a 22-year period and reviewed the literature to summarize the experience with this infectious entity.In our institution, of 308 patients with pyogenic arthritis of native joints, B fragilis was the causative organism in 2 (0.6%) cases. A MEDLINE search (1981-2015) identified 19 additional cases.Of the 21 patients available for review (13 men and 8 women, with a mean age, of 54.4 ±â€Š17 years), 19 (90%) presented a systemic predisposing factor for infection; the most common associated illness was rheumatoid arthritis (8 patients). Bacteremia was documented in 65% (13/20) of cases. In 5 patients (24%), 1 or more concomitant infectious process was found. Metronidazole was the most frequently used antibiotic. Surgical drainage was performed in 11 cases (52%). The overall mortality rate was 5%.Pyogenic arthritis of native joints due to B fragilis is an infrequent disease that mainly affects elderly patients with underlying medical illnesses and in whom bacteremia and the presence of a concomitant infectious process are frequent conditions.


Assuntos
Artrite Infecciosa/diagnóstico , Infecções por Bacteroides/diagnóstico , Bacteroides fragilis/isolamento & purificação , Adulto , Idoso , Artrite Infecciosa/microbiologia , Infecções por Bacteroides/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
18.
Med Clin (Barc) ; 147(3): 109-12, 2016 Aug 05.
Artigo em Espanhol | MEDLINE | ID: mdl-27143527

RESUMO

OBJECTIVES: To evaluate the effectiveness of an intervention on cardiovascular risk factors (CVRF) in patients with rheumatoid arthritis. METHODS: After determining their CVRF and cardiovascular risk (CVR) by modified SCORE, we gave the patients a letter for their general practitioners in which they were requested for their cooperation in controlling CVRF and where the therapeutic goal for LDL cholesterol was specified. Three months later, any therapeutic intervention was recorded as well as the results. RESULTS: We included 211 patients, 29% with a high CVR. There were new diagnoses of CVRF in 100 patients (47%). The general practitioner changed the treatment in 2/12 diabetes, 30/84 HBP, 74/167 with elevation of LDL cholesterol and 21/51 with hypertriglyceridemia. The percentage of patients with good control over CVRF was: a) in HBP, 25 to 73%; b) elevation of LDL cholesterol from 10 to 17%; and c) in hypertriglyceridemia, 25 to 38%. CONCLUSIONS: Through this intervention, a new CVRF was diagnosed in nearly half of the patients. The effectiveness of the intervention on CVRF was low.


Assuntos
Artrite Reumatoide/complicações , Doenças Cardiovasculares/prevenção & controle , Serviços Preventivos de Saúde/métodos , Adulto , Idoso , Biomarcadores/sangue , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etiologia , LDL-Colesterol/sangue , Estudos Transversais , Feminino , Medicina Geral , Indicadores Básicos de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
19.
Reumatol Clin ; 12(5): 248-55, 2016 Sep-Oct.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-26775226

RESUMO

INTRODUCTION: In recent years, outpatient clinics have undergone extensive development. At present, patients with rheumatic diseases are mainly assisted in this area. However, the quality standards of care are poorly documented. OBJECTIVE: To develop specific quality criteria and standards for an outpatient rheumatology clinic. METHOD: The project was based on the two-round Delphi method. The following groups of participants took part: scientific committee (13 rheumatologists), five nominal groups (45 rheumatologists and 12 nurses) and a group of discussion formed by 9 patients. Different drafts were consecutively generated until a final document was obtained that included the standards that received a punctuation equal or over 7 in at least 70% of the participants. RESULTS: 148 standards were developed, grouped into the following 9 dimensions: a) structure (22), b) clinical activity and relationship with the patients (34), c) planning (7), d) levels of priority (5), e) relations with primary care physicians, with Emergency Department and with other clinical departments, f) process (26), g) nursing (13), h) teaching and research (13) and i) activity measures (8). CONCLUSION: This study established specific quality standards for rheumatology outpatient clinic. It can be a useful tool for organising this area in the Rheumatology Department and as a reference when proposing improvement measures to health administrators.


Assuntos
Instituições de Assistência Ambulatorial/normas , Qualidade da Assistência à Saúde/normas , Doenças Reumáticas , Reumatologia/normas , Técnica Delfos , Humanos , Doenças Reumáticas/diagnóstico , Doenças Reumáticas/terapia , Espanha
20.
Reumatol. clín. (Barc.) ; 11(supl.1): 29-35, ene. 2016. tab
Artigo em Espanhol | IBECS | ID: ibc-153465

RESUMO

El metotrexato, utilizado a dosis bajas semanales, es actualmente el tratamiento de referencia en la artritis reumatoide. No se conoce con exactitud el mecanismo de acción en esta enfermedad, pero se han descrito diversas acciones antiproliferativas, antiinflamatorias e inmunorreguladoras que pueden contribuir a su efecto terapéutico. Diversos ensayos clínicos demostraron en la década de los ochenta del siglo pasado su eficacia clínica, así como su efecto enlentecedor del daño anatómico. En los últimos años se ha visto además que llegar a dosis más altas de las inicialmente utilizadas, entre 25 y 30 mg/semanales, puede maximizar sus efectos. En pacientes resistentes, el metotrexato también puede ser útil en terapia combinada con otros fármacos modificadores de la enfermedad, sintéticos o biológicos. Habitualmente, el metotrexato es bien tolerado, pero puede tener efectos adversos a diversos niveles (hematológico, digestivo, hepático, neurológico o pulmonar), alguno de los cuales pueden ser graves, por lo que requiere una cuidadosa monitorización clínica y analítica (AU)


The aim of this document is to describe the optimal use of: a) methotrexate (MTX) monotherapy in established RA in readministration after a previous effective cycle, and b) MTX combination with synthetic and biological DMARD. Clinical questions were proposed and a systematic literature search was conducted. Recommendations were developed and then discussed and validated in a working session with fifteen experts. After an effective cycle, MTX will be restarted with the same dose and route of administration than previously, following an intensive strategy if the dose were insufficient or the patient had poor prognostic factors. When sustained remission, MTX may be reduced gradually, with a close monitoring of the patient. Before starting a combination therapy with other synthetic or biologic DMARD, full doses of MTX should be reached and the use of the parenteral route evaluated. In established RA, when starting the combination of MTX with a biological DMARD, the same dose and route of administration of MTX than previously used should be maintained. In patients in remission for at least 6 months and in combination therapy with a biological, it is recommended to reduce the dose of the biological agent or increase its administration period before reducing the dose of MTX, unless side effects due to MTX. This document pretends to solve some frequent clinical questions on the use of MTX in monotherapy and/or in combination therapy with other synthetic or biological DMAR (AU)


Assuntos
Humanos , Masculino , Feminino , Artrite Reumatoide/tratamento farmacológico , Metotrexato/uso terapêutico , Quimioterapia Combinada/métodos , Quimioterapia Combinada , Antirreumáticos/metabolismo , Antirreumáticos/uso terapêutico , Conferências de Consenso como Assunto , Resultado do Tratamento , Grupos de Pesquisa , Estudos de Coortes
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