[Evaluation of the collaboration between Primary and Hospital Care in order to improve inappropriate prescription]. / Evaluación de la colaboración entre atención primaria y hospitalaria para mejorar la polimedicación inapropiada.

INTRODUCTION AND OBJECTIVES: To evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy. MATERIALS AND METHODS: Collaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service. Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria. The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back. The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated. RESULTS: A total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services. CONCLUSIONS: PC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.

A double-blind placebo controlled trial of etanercept in patients with giant cell arteritis and corticosteroid side effects.

OBJECTIVE: Open label studies have suggested that tumour necrosis factor (TNF) antagonists led to sustained improvement and corticosteroid sparing effect in patients with giant cell arteritis (GCA). To confirm these observations, we conducted a randomised, double-blind, placebo controlled trial with etanercept in patients with biopsy-proven GCA with side effects secondary to corticosteroids. METHODS: We randomly assigned patients with GCA to receive etanercept (n = 8) or placebo (n = 9) over 1 year together with corticosteroids that were reduced according to a predefined schedule. The primary outcome was the ability to withdraw the corticosteroid therapy and control the disease activity at 12 months. RESULTS: Baseline characteristics were similar in the two groups, although patients in the etanercept group showed higher levels of basal glycaemia (p = 0.02) and a higher erythrocyte sedimentation rate (ESR) (p = 0.01). After 12 months, 50% of the patients in the etanercept group and 22.2% in the placebo group were able to control the disease without corticosteroid therapy (p value not significant). Patients in the etanercept group had a significant lower dose of accumulated prednisone during the first year of treatment (p = 0.03). There were no differences in the number and type of adverse events. CONCLUSION: The limited number of patients included in this study does not allow us to draw definitive conclusions. Etanercept therapy was well tolerated in this aged population. The therapeutic role of etanercept in patients with GCA should be evaluated in studies with a larger number of patients.

Influence of reduction conditions on H2 adsorption in high-surface Rh/CeO2 catalysts as deduced by volumetry, calorimetry, and 1H NMR techniques.

1H NMR spectra corresponding to H2 adsorption on high-surface Rh/CeO2 catalysts (S(BET) approximately 55 m2/g) are formed by two lines, attributed to hydrogen adsorbed on ceria (resonance line A) and rhodium-metal particles (upfield-shifted line B). The evolution of 1H NMR spectra as a function of temperature, time, and type of reduction (static or dynamic) allows the study of the progressive establishment of the strong metal-support interaction (SMSI) in Rh/CeO2 catalysts. As the reduction progresses, the mean adsorption heat and the amount of hydrogen adsorbed on the metal, deduced from volumetry, NMR, and calorimetry techniques, decrease considerably. As a consequence of the decrease in metal activity, the amount of hydrogen transferred to the support CeO2 is also reduced (spill-over processes). Outgassing of samples at 773 K eliminates hydrogen species retained at the metal-support surface, and oxidation treatments at 473 and 673 K eliminate the electronic effect and physical blocking of metal particles. The oxidation at 673 K recuperates the total adsorption capacity of metal particles. On the basis of these treatments, the contribution of different processes to the SMSI effect is analyzed. Electronic perturbation of rhodium particles is higher when reductions are performed in dynamic conditions; however, the importance of physical blocking of metal particles increases in static reductions. High reducibility of ceria strengthens electronic effects in Rh/CeO2 compared to those observed in Rh/TiO2 catalysts.

HLA-A*2402 and a microsatellite (D6S248) are secondary independent susceptibility markers to ankylosing spondylitis in Basque patients.

Ankylosing spondylitis (AS) is universally associated with human leukocyte antigen B27 (HLA-B27), although other genes could determine the development and clinical expression of the disease. HLA-A9 (A*2402) allele was previously found to be associated in Basque patients. The objective of this study is to perform a more precise analysis of microsatellite polymorphisms in HLA-A*2402 and B27 haplotypes to elucidate the significance of this association. A group of 50 unrelated AS patients and 113 controls of Basque origin were studied. Eight microsatellites in the class I major histocompatibility complex region with vicinity to HLA-A and -B were analyzed and the strength of allelic associations to AS and linkage disequilibrium (LD) between alleles were evaluated. Allele 15 at the microsatellite locus D6S248, 1000 Kb telomeric to HLA-A showed a strong positive association with the disease (OR:6; pc=4.7x10(-4)) and it could not be explained by LD to HLA-B27, HLA-A*2402 or any other loci. We found that D6S248-15 allele together with HLA-A*2402 could be B27-independent markers of additional susceptibility gene/s localised in the region telomeric to HLA-A in Basque AS patients.

Musculoskeletal infections in intravenous drug addicts: report of 34 cases with analysis of microbiological aspects and pathogenic mechanisms.

OBJECTIVE: To analyse characteristics of musculoskeletal infections in Spanish intravenous (i.v.) drug addicts. METHODS: A retrospective analysis of 34 medical records was carried out and the aetiologic agent was confirmed in all cases. RESULTS: The mean age was 26 years and the sex ratio was 25M/9F. Twenty-four patients were HIV-positive and 10 HIV-negative. There were no differences between the 2 subgroups. Septic arthritis, seen in 27 cases (79%), was the most common type of infection. Axial involvement was present in 23 cases (67%). The organisms isolated included Staphylococcus aureus (25 cases), Candida albicans (3 cases), Mycobacterium tuberculosis (2 cases), and Neisseria gonorrhoeae, Salmonella typhi, Staphylococcus epidermidis and Streptococcus pyogenes in one case each. Candida albicans affected the sternocostal joints. Laboratory data showed non-specific findings. The outcome was mostly good and only one patient died. CONCLUSION: Human immunodeficiency virus does not affect characteristics of musculoskeletal infections in i.v. drug addicts. Staphylococcus aureus is the most frequently isolated pathogen in this population.

Osteoarticular mycobacterial infections in patients with the human immunodeficiency virus.

OBJECTIVE: Data about the characteristics of patients with the human immunodeficiency virus (HIV) and concomitant mycobacterial skeletal infection are scarce. Thus, our aim was to describe this condition in a cohort of 11 patients. METHODS: A review of the records of 11 HIV-positive individuals with microbiological confirmation of mycobacterial osteoarticular infection was conducted. The studied data included: age, sex, risk factor for the HIV days between the onset of symptoms and diagnosis, evidence of previous tuberculosis, location of the infection, isolated organism, diagnostic method, laboratory data (erythrocyte sedimentation rate, haemoglobin, leukocyte count), number of CD4+ lymphocytes, anti-retroviral therapy, treatment and outcome. RESULTS: Eight patients were men and 3 were women. The median age was 34.2 years (range 20-46 years). Previous tuberculosis was present in 5 cases. Mean days between the onset of symptoms and diagnosis was 124 (range 20-365 days). Infections involved the knee (4 cases), spine (3 cases), hip (2 cases), elbow (1 case) and tibia (1 case). ESR was frequently elevated. The CD4 count ranged from 0.03 to 0.779 x 10(9)/l (mean 0.245 x 10(9)/l). M. tuberculosis was the responsible organism in 9 cases, Mycobacerium tuberculosis plus Staphylococcus aureus in one case and M. Kansasii in one case. Patients received specific treatments with good results. Surgery was necessary in 4 cases. No deaths occurred. Four patients were anti-retroviral naive at the moment the diagnosis was made. The remainder 8 were on zidovudine therapy. CONCLUSION: The immunologic status of patients with HIV and concomitant mycobacterial skeletal infections is quite variable. The outcome of this condition seems to be good.

Vertebral osteomyelitis in northern Spain. Report of 62 cases.

OBJECTIVE: The records of 62 patients with clinical and radiographic evidence of vertebral osteomyelitis and positive bacteriological diagnosis, seen between 1979 and 1996, were reviewed in order to gather data on the epidemiology and the clinical pattern displayed by patients with this condition in northern Spain. RESULTS: Staphylococcus aureus (15 cases), Mycobacterium tuberculosis (15 cases) and Brucella melitensis (13 cases) were the microorganisms most frequently found in our patient series. After improvement of the sanitary and hygienic control of food products, the role of Brucella melitensis is decreasing as a causative agent (only 3 cases in the last 6 years). Staphylococcus epidermidis, present in 4 cases (6.6%), should be suspected in elderly patients with previous intravenous cannulations (3 of 4 cases). The most frequent risk factors were alcoholism (7 cases), chronic hepatic disease (7 cases), diabetes (6 cases) and previous surgery (6 cases). Delay in diagnosis was high (the mean number of days between the onset of symptoms and diagnosis was 125). The lumbar region was the most commonly affected site. Neurologic involvement was present in 10 patients on admission (16%). ESR was > 50 mm/hr in a high number of cases. Blood cultures were found to be the most valuable routine test. Plain x-rays were normal in 10 patients (16%); in 6 of them Staphylococcus aureus was the responsible organism. Other imaging modalities showed a high sensitivity. Surgical drainage was necessary in 12 individuals (in 7 due to Mycobacterium tuberculosis). Outcome was good in the majority of cases: only 2 patients with associated endocarditis died. Neurologic sequelae were present in another 3 patients. CONCLUSION: Vertebral osteomyelitis can be caused by a variety of pathogens. Therefore, bacteriological studies are necessary to establish the etiologic diagnosis and determine the specific antimicrobial treatment required.

Absence of pulmonary fibrosis in patients with psoriatic arthritis treated with weekly low-dose methotrexate.

OBJECTIVES: To analyse pulmonary toxicity in psoriatic arthritis patients treated with weekly low-dose methotrexate. METHODS: A transversal study was carried out to analyse the findings on chest x-rays and high resolution computed tomography, and the results of pulmonary function tests in 27 Caucasian psoriatic arthritis patients treated with weekly low-dose methotrexate. None of them had previous recognized interstitial lung disease. RESULTS: The median age of the patient cohort was 50 years (range 24-70 years) and the sex ratio was 20M/7F. 17 patients had previously used other disease-modifying antirheumatic drugs. The mean weekly dose of methotrexate was 8.46 mg (range 5-15 mg), the average treatment period was 52 months (range 3-240 months), and the median cumulative dose was 2241 mg (range 300-6520 mg). High resolution computed tomography failed to show alveolar or interstitial involvement in any patient. Diffusing lung capacity for carbon monoxide was mildly altered only in 2 cases. Pulmonary function tests did not show differences between patients with and without recognized risk factors for developing methotrexate-associated lung toxicity identified in rheumatoid arthritis patients (old age, diabetes, hypoalbuminemia, previous use of disease modifying antirheumatic drugs). CONCLUSION: In this cohort of 27 psoriatic arthritis patients methotrexate was not associated with pulmonary fibrosis evaluated by means of sensitive imaging findings and pulmonary function tests.

Mixed sclerosing bone dystrophy. Report of a case and review of the literature.

A 63-year old woman was admitted because of hip pain. Radiographs showed multiple round and oval sclerotic lesions involving humeral heads, pelvis, vertebral bodies and both femoral bones. Diaphyseal periosteal proliferation was found in metatarsal bones. A diagnosis of mixed sclerosing bone dystrophy was made. We review clinical, epidemiological and radiological findings of this entity.

Subclinical sacroiliitis in inflammatory bowel disease: a clinical and follow-up study.

The aim of this study was to evaluate the clinical features, evolution and reliability of spondyloarthropathy criteria in a subset of patients with subclinical sacroiliitis and inflammatory bowel disease (IBD). All patients with IBD (n 62) attending a gastroenterology clinic from a referral centre were included to assess the prevalence of articular involvement. Patients were evaluated according to a specific protocol designed for the study, which included epidemiological and clinical variables, physical examination and radiological assessment. Only those with subclinical sacroiliitis were followed prospectively for 4 years. This group was visited every 6 months with the same initial protocol. Sacroiliac joints were studied using frontal and oblique X-ray views and graded according to New York criteria. HLA B27 typing was performed by serological methods in all patients and in 80 healthy controls. The reliability of Amor and ESSG criteria for spondyloarthropathy was evaluated. Fifteen patients (24%) presented with isolated subclinical sacroiliitis. In this group a higher frequency of peripheral arthritis and erythema nodosum was observed (p = NS compared to those without sacroiliitis). Most cases (60%) were grade II unilateral sacroiliitis. Three patients were HLA B27+ (p>0.05 compared to healthy controls). The resultant sensitivity of Amor's and ESSG criteria ranged from 40% to 46%. An unexpectedly high freuqency (9.5%) of psoriasis was observed in the whole group. There is a high prevalence of isolated subclinical sacroiliitis in IBD. This may represent a forme fruste of enteropathic ankylosing spondylitis, a stunted form of axial involvement because of therapy, or a third category of rheumatic disease associated with IBD. It may also represent a common characteristic of spondyloarthropathies, rather than a specific finding of IBD. The recently developed spondyloarthropathy criteria are not particularly helpful for the diagnosis of this milder form of spondyloarthropathy.

Osteoarticular and muscle infectious lesions in patients with the human immunodeficiency virus.

Between 1988 and 1995, 1832 HIV positive patients were evaluated in our institution. We studied the epidemiologic, immunologic and bacteriologic data, laboratory tests, and X-Ray films in those with musculoskeletal infection. We reviewed twenty-one cases of musculoskeletal infection in twenty patients aged 23-35 years (mean 28,6 years, M:F= 15:5). In all of them risk factor for HIV was intravenous drug abuse. The number of CD4 positive lymphocytes ranged from 0,003 to 0,5 10(9)/l. Staphylococcus aureus was the organism responsible of the infection in twelve cases, all active intravenous drug abusers at the time the diagnosis was done. The remaining causative agents were: Mycobacterium tuberculosis (3 cases), Candida albicans (2 cases), Salmonella subgroup 1 (1 case), Neisseria gonorrhoeae (1 case), Pseudomona aeruginosa (1 case) and Streptococcus agalactiae (1 case). Fifteen infections were diagnosed between 1988 and 1991 and 6 between 1992 and 1995. Musculoskeletal infectious lesions in HIV positive patients in our country are related in the majority of cases to intravenous drug abuse. In the last four years due to a National medical health care plan conducted to educate this group of people the number of musculoskeletal infections is decreasing.

Haematogenous vertebral osteomyelitis in the elderly.

The aim of our study was to analyse the characteristics of haematogenous vertebral osteomyelitis (HVO) in the elderly. A retrospective comparative analysis of the medical records of 72 patients (38 younger than 63 years, group 1, and 34 aged 63 years and over, group 2) with haematogenous vertebral osteomyelitis of confirmed aetiology was carried out. Intravenous drug addiction and infection with the human immunodeficiency virus were seen in 4/38 (10%) and 5/38 (13%) patients from group 1 and 0/34 patients (0%) from group 2 (P = 0.05 and 0.035, respectively). Seven of 34 elderly (20%) and 0/38 (0%) young individuals had recently had surgery (P = 0.0036). Escherichia coli was isolated in 7/34 elderly (20%) and 0/38 (0%) young patients (P = 0.0036). The remaining studied data did not reach statistical significance. Recent surgery is a risk factor for developing HVO in the elderly, the urinary tract being the source of the pathogen in a large number of elderly patients with spinal infection.

Clinically asymptomatic axial disease in psoriatic spondyloarthropathy. A retrospective study.

The aim of this study was to analyse retrospectively the prevalence and the clinical features of clinically asymptomatic axial involvement in patients with psoriasis and axial radiological features of spondyloarthropathy (PsSpA). We performed a cross-sectional study based on the clinical records of 70 patients, 44 men and 26 women, with a mean age of 48.7+/-14.2 years. PsSpA was defined by the presence of radiographic sacroiliitis (SI) greater than or equal to grade 2, and/or any other typical radiological sign of spondylitis in patients with psoriasis. When the radiological signs were present in the absence of inflammatory back pain and/or buttock pain, patients were grouped as having asymptomatic axial disease. HLA-B27 was determined by serological methods in the 70 patients and in 82 healthy controls from our general population. Fourteen patients (20%), 11 with radiological SI, two with facet joint erosion-fusion and one with aseptic discitis, showed no evidence of symptomatic spinal disease. Twenty-nine patients (41%) showed cervical spine disease (CSD), but only 17 of them (58.6%) had pain and rigidity at this level, whereas 12 (41.4%) did not show clinical symptoms. CSD was associated with duration of arthritis (P = 0.043) and peripheral erosions (P = 0.037). HLA-B27 correlated well with bilateral SI (P = 0.002) and PsSpA (P<0.0004, RR 6.4), but showed no association with unilateral SI nor with syndesmophytes or asymptomatic disease. Univariate analysis demonstrated associations between symptomatic disease and longer duration of arthritis (P = 0.041) and higher IgM values (P = 0.05). There is a high prevalence of asymptomatic involvement in patients with PsSpA The significance of these asymptomatic changes is not known, but they probably represent a common characteristic of spondyloarthropathies rather than a specific feature associated with psoriasis.

Primary tuberculous muscle abscess in a patient with systemic lupus erythematosus.

Infectious complications are a very common and prominent cause of both morbidity and mortality in patients with systemic lupus erythematosus. We present a patient who developed a paravertebral primary tuberculous muscle abscess after aggressive treatment with corticosteroids and immunosuppressive agents.

HLA-A*9, a probable secondary susceptibility marker to ankylosing spondylitis in Basque patients.

HLA-B27 is strongly associated to ankylosing spondylitis (AS). The objective of our study was to analyze HLA-B27 association, B27 subtype distribution and frequency of other HLA class I and DR antigens in a group of Basque AS patients. HLA class I antigens were typed serologically and HLA-B27 and A9 subtypes were determined by DNA typing in samples from 46 patients with AS, 54 B27-positive spondyloarthropathies, 82 healthy subjects and 20 B27-positive controls. A class I HLA 9.2 kb PvuII restriction fragment length polymorphism (RFLP), previously associated with AS, was analyzed in a representative group of patients and controls. We found that HLA-B*2705 conferred a relative risk of 126 for AS in this group. HLA-A9 (A*2402) allele was significantly increased in AS patients compared with healthy controls and B27-positive control group (Pcorr<0.0001) and also increased in patients affected with peripheral arthritis. No association between class I HLA 9.2 Kb RFLP and AS was found. These results suggest that HLA-A*9 allele itself or another linked gene could act as a secondary and independent susceptibility allele to AS.