Daniel G. Fernández-Ávila

Tocilizumab en paciente con gota tofácea severa refractaria al tratamiento

Gout is a disease characterized by acute episodes of pain, which occurs as the result of monosodic urate crystal deposit in the joint and periarticular tissue. In some cases, gout behaves as a severe inflammatory arthopathy that is difficult to manage, generating structural joint damage and functional impairment. We report the case of a 44 years old man with gouty arthritis for 12 years, not responding to NSAIDs, alopurinol, colchicine or corticosteroids. Tocilizumab was started with favorable clinical and laboratory results after treatment.

Perfil epidemiológico de pacientes colombianos con artritis reumatoide evaluados en una clínica especializada de atención integral

INTRODUCTION Few studies report the epidemiological profile of RA patients attending clinics for comprehensive care. We describe the clinical, socio-demographic characteristics and comorbidities of a cohort of patients with RA. METHODS Cross-sectional study in a cohort of patients according to ACR criteria/EULAR 2010 classification who have entered to the AR clinic since October 2012 until May 2014, referred from primary care. Frequencies for socio-demographic, comorbidity, state of disease activity, functional status, biomarkers and therapeutic modalities variables are described. RESULTS In total, 1652 patients were included with a mean age of 58 years and a duration of 9 years. Rheumatoid factor was positive in 80% and anti-citrullinated peptide antibody in 63% of patients. In total, 43.6% of patients had comorbidities: Hypertension (20.4%), osteoporosis (17.3%) and Sjögrens syndrome (10.4%). Fifty percent of the patients had moderate and high disease activity level measured by DAS-28 score, and the mean HAQ score was 0.64 (DS 1.12). Seventy three percent of patients were treated with oral disease modified anti rheumatic treatment and 63.6% of them were with methotrexate. 42.4% of the patients were treated with glucocorticoids (mean dose 6.3mg). CONCLUSIONS The epidemiological behavior of a group of RA patients is reported. The presence of comorbidities is significant affecting the risk of morbidity and mortality in these patients. The definition of the epidemiological profile of this population will allow the design of research questions to resolve outstanding problems in the clinical context of this pathology.

Meningoencefalitis criptococócica en una paciente con artritis reumatoide tratada con metotrexato y prednisona

10. Nam JL, Ramiro S, Gaujoux-Viala C, Takase K, Leon-Garcia M, Emery P, et al. Efficacy of biological disease-modifying antirheumatic drugs: a systematic literature review informing the 2013 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis. 2014, doi: 10.1136/annrheumdis-2013-204577. [Epub ahead of print]. 11. Dhillon S. Intravenous Tocilizumab: A Review of Its Use in Adults with Rheumatoid Arthritis. BioDrugs. 2013 [Epub ahead of print]. 12. Lambert CM, Sandhu S, Lochhead A, Hurst NP, McRorie E, Dhillon V. Dose escalation of parenteral methotrexate in active rheumatoid arthritis that has been unresponsive to conventional doses of methotrexate: a randomized, controlled trial. Arthritis Rheum. 2004;50:364–71. 13. Visser K, van der Heijde D. Optimal dosage and route of administration of methotrexate in rheumatoid arthritis: a systematic review of the literatura. Ann Rheum Dis. 2009;68:1094–9. 14. Bakker MF, Jacobs JWG, Welsing PMJ, Verstappen SMM, Tekstra J, Ton E, et al., on behalf of the Utrecht Rheumatoid Arthritis Cohort Study Group. Low-dose prednisone inclusion in a methotrexate-based, tight control strategy for early rheumatoid arthritis. A randomized trial. Ann Intern Med. 2012;156:329–39. 15. de Jong PH, Hazes JM, Barendregt PJ, Huisman M, van Zeben D, van der Lubbe PA, et al. Induction therapy with a combination of DMARDs is better than methotrexate monotherapy: first results of the tREACH trial. Ann Rheum Dis. 2012;72:72–8.

Artritis reumatoide en el anciano. Revisión narrativa

Resumen Colombia esta viviendo 2 fenomenos importantes, las transiciones demografica y epidemiologica, los cuales se ven reflejados en un proceso acelerado de enveje cimiento poblacional que, a su vez, aumenta la prevalencia de enfermedades cronicas, entre ellas la artritis reumatoide (AR). De acuerdo con la edad de aparicion, la AR se clasifica en 2 subgrupos: la enfermedad reumatoide de aparicion temprana y la AR de aparicion tardia (en pacientes > 65 anos). Anteriormente, se pensaba que la diferencia mas importante entre los 2 subgrupos era que la AR de aparicion tardia tenia un mejor pronostico que la enfermedad reumatoide de aparicion temprana. En la actualidad, se han descrito las diferencias que existen entre estas 2 formas de presentacion de la AR. A traves de este articulo se describiran las principales diferencias que existen en cuanto a la epidemiologia, patogenia, manifestaciones clinicas, tratamiento, pronostico y funcionalidad de los pacientes con AR de presentacion temprana y tardia.

Impacto terapéutico de las estatinas en el perfil lipídico y el riesgo cardiovascular en pacientes con lupus eritematoso sistémico: revisión sistemática de la literatura y metaanálisis

BACKGROUND There is strong evidence of a rise in cardiovascular risk in patients suffering from autoimmune diseases, especially in those with Sistemic Lupus Erythematosus. Until now, there are a few trials that assess the potencial benefit of statins on the incidence of cardiovascular events and on lipid profile of patients with SLE. This evidence has not been synthesized and assessed altogether. METHODS We performed a search in databases of literature published until August of 2016 (Embase, MEDLINE, Cochrane Library, SciELO, Clinical Evidence, DynaMed, Cochrane Central Register of Controlled Trials, LILACS), identifying controlled clinical trials that could estimate the impact of statins on mortality, cardiovascular events, C-reactive protein and lipid profile in patients with Systemic Lupus Erythematosus. The quality of the information available was assessed with a meta-analysis, using a random effects model, employing the RevMan 5.3 software. RESULTS 6 trials and 412 patients were included in the analysis. The use of statins in patients with SLE was found to significantly reduce the levels of serum total cholesterol (mean difference [MD] -31,4 mg/dL; CI 95% -43,0; -19,9), and serum low density cholesterol (MD -31,4 mg/dL; IC 95% -43,0; -19,9), but had no impact on levels of serum triglycerides (MD 4 mg/dL; IC 95% 2,49; 6,21) and C-reactive protein (MD -0,78; IC 95% -1,43; -0,13). No evidence was found about the impact on the risk of mortality or cardiovascular events. CONCLUSION Statins have a significant effect on the levels of serum total cholesterol, LDL cholesterol and C-reactive protein, however, more randomized controlled trials with long-term follow-up are necessary to assess the impact on mortality and cardiovascular risk.

The effect of an educational intervention, based on clinical simulation, on the diagnosis of rheumatoid arthritis and osteoarthritis

OBJECTIVE The aim of the present study was to evaluate the effectiveness of an educational tool for general physicians, based on rheumatological clinical simulation, for the diagnosis of rheumatoid arthritis and osteoarthritis. METHODS A randomized clinical study was carried out, in which the physician research subjects were assigned to one of two groups: the experimental group (educational intervention for rheumatoid arthritis with clinical simulation) or the control group (educational intervention for the basic aspects of the diagnosis and treatment of osteoporosis). Four weeks after the educational intervention, the members of both groups completed an examination that included four clinical cases with real patients, two clinical cases with two clinical simulation models and six virtual clinical cases. In this examination, the participants noted clinical findings, established a diagnosis and defined the complementary tests they would request, if necessary, to corroborate their diagnosis. RESULTS A total of 160 doctors participated (80 in the active educational intervention for rheumatoid arthritis and 80 in the control group), of whom 89 were women (56%). The mean age was 35 (standard deviation 7.7) years. Success was defined as a physician correctly diagnosing at least 10 of the 12 cases presented. A significant difference of 81.3% (95% confidence interval 72-90%; p < 0.001) in success was found in favour of the active group (88.8% versus 7.5%). A greater number of correct answers was found in the active group compared with the control group in the detection of clinical findings and in the number of complementary tests requested (p < 0.001). CONCLUSIONS The study showed the effectiveness of an educational intervention based on clinical simulation to improve the diagnostic approach to rheumatoid arthritis and osteoarthritis. The results open a new horizon in the teaching of rheumatology.

Therapeutic plasma exchange in rheumatic diseases: a university hospital experience

INTRODUCTION Each day, evidence accumulates related to the use of therapeutic plasma exchange (TPE) in patients with rheumatic diseases. San Ignacio University Hospital has recorded all of the TPE sessions performed by the institutions apheresis group. OBJECTIVE To describe the TPE experience of patients with rheumatologic diseases in a hospital setting. METHODS Descriptive, observational, retrospective analysis. This study included analyses of the TPE sessions that were performed in patients with rheumatic diseases from November 2009 to November 2013. RESULTS The apheresis group performed 136 sessions in 27 patients. The mean patient age was 43 years (SD 18.5), and 59.3% of the patients were female. Regarding the diagnosis, the most frequents ones where: ANCA-associated vasculitis followed by systemic lupus erythematosus and catastrophic antiphospholipid syndrome. The average number of sessions per patient was 5 (SD 1.8), and the average plasma exchange per patient was 1.3 plasma volume replacement units. The most used replacement solution was frozen fresh plasma (FFP; 63.2% of the sessions). Of all the sessions, 4.4% presented complications, and the majority of the complications were related to vascular access. Fifteen patients required renal replacement therapy (RRT) secondary to the same cause that created the need for TPE, 3 patients required RRT due to causes other than the TPE diagnostic intervention and 1 patient had undergone chronic dialysis. CONCLUSIONS TPE is a therapeutic alternative that is needed for the management of patients with rheumatic diseases with renal involvement and those who are refractory to conventional management. Our clinical results were in agreement with the global literature.

AB1114 Prevalence of HLA-B27 in a Cohort of Transplant of a University Hospital in Colombia:

Background The Human Leukocyte Antigen HLA B 27; is a class I antigen from MHC that is strongly associated with ankylosing spondylitis (AS) and other spondyloarthritis (SPA), with positivities for HLA-B27 in the population from 80 to 95% worldwide. The prevalence of HLA-B27 in the general population varies by geographic area, with ratios ranging between 2-4% in African/African American compared to 8% in Caucasian populations 1 Objectives To determine the proportion of positive HLA B 27 in the population of transplanted and donors treated at the San Ignacio University Hospital; their clinical characteristics and relationship to the presence of spondyloarthritis. Methods It was performed a descriptive cross-sectional study of 465 individuals typed for HLA of a cohort of transplants in a university hospital in Colombia including donors and receivers. Designing a database in Excel to include data relevant to the study. The search was performed in hospital records and telephone contact for family not treated at the hospital to extract information. Results 465 individuals with an age range between 10 and 80 years with a mean of 44.9 years (SD: 14.04); finding 21 positive cases for HLA B 27 indicating a prevalence of 4.5% positivity for HLA-B27 in this population. At evaluating the behavior by gender, a proportion of HLA B 27 of 6,5% was found in the group of men (n=261; 56.1%) compared with 2.0% in women. Of the 21 patients positive for HLA B 27 it was found that 4 of them (19%) had joint pain of small and large joints so they were referred to evaluation by the Rheumatology service at Hospital where the presence of spondyloarthritis or other autoinmune disease was discarted. Proportion of HLA B 27 (+) in the population of renal and bone marrow transplanted and donors at San Ignacio Universitary Hospital Type transplantation No. patients HLA B 27 (+) % HLA B 27 (+) Marrow 96 3 3,1% Renal 369 18 4,9% Total 465 21 4,5% Conclusions It has been described in the literature the prevalence of HLA B 27 in ranges from 2% to 8%, according to the region evaluated; it was found in our study a ratio of 4.5% of the total population and comparing by gender a higher proportion in males (6.5% compared with 2% in women). Spondylitis or other autoimmune disease were not detected in any patient of the series evaluated in our study; although 19% of the populatinon with positive HLA B 27 was referred to rheumatology for articular symptoms discarding the presence of it. San Ignacio Universitary Hospital is a reference center of the city to perform transplants, so it is important to emphasize the prevalence found in our study that fits within international parameters reported. Disclosure of Interest None declared

AB0249 Initial Validation of Compliance-Questionnaire-Rheumatology (CQR) In Patients with Rheumatoid Arthritis in BogotΆ, Colombia

Background Rheumatoid Arthritis (RA) is a systemic inflammatory disease where its physiopathology is based on immunological activity. It has been determined that an early therapy with Disease-Modifying Antirheumatic Drugs (DMARDs) stops the progression of this disease. One of the main limitations to achieve this objective is guarantee compliance to DMARDs. Several methods have been designed to measure compliance such as CQR that provides quick and concise information about medication compliance. Objectives To develop an initial linguistic and psychometric validation of the CQR questionnaire in patients with RA. Methods A validation study was conducted at San Ignacio University Hospital. Steps suggested by ISPOR Task Force for Translation and Cultural Adaptation were followed, and a final Spanish version for Colombia was created with semantic and content equivalence to the original version. Data collection was performed in four outpatient rheumatology wards. The data collection form completed by the patients included demographic data, CQR19, analog scale of compliance, adverse effects associated with the medication; while doctors registered DAS-28, rheumatoid factor, anti-citrulline antibodies and current treatment. Psychometric validation was evaluated from a hypothesis of correlation between compliance (CQR score) and the level of activity of the disease (DAS-28). The association between compliance, the presence of adverse events, and the amount of medication was also evaluated. Results CQR19 was completed by 233 patients with RA diagnosis (Female 75.1%) taking some type of pharmaceutical treatment (single or combined), with a mean of 11.3 years (SD 9.6) into the disease. Correlation between CQR19 score and DAS-28 activity categories was -0.64 (95% CI: -0.71to-0.56). Despite this result, correlation between CQR19 categories [satisfactory compliance (>80%) and unsatisfactory compliance (≤80%)] and DAS-28 was -0.16 (95% CI: -0.28 to -0.03). 97.8% of the patients were classified as satisfactory compliance. All analyses were conducted with Spearmans rank correlation coefficient based on Fisher transformation. Exploratory analysis showed that association between CQR19 score and adverse events was -0.05 (95% CI: -0.18to0.08), while the association between CQR19 score and the amount of medication was -0.34 (95% CI: -0.45to-0.22). Conclusions CQR19 score relates to DAS-28 categories activity indicating that patients with less activity have higher compliance scores. However, this relationship was not evident when applying the compliance categories established by the CQR19 authors (compliance limit of 80%). Validations of CQR19 scores as a measure of compliance do not allow using this instrument in our local clinical practice in a regular basis. Further studies are necessary to evaluate the ability of CQR19 scores to indicate compliance to the treatment beyond just taking the medication in patients with RA. We suggest exploring other sources of evidence to validate this questionnaire. References De.Klerk E, et al. The compliance-questionnaire-rheumatology compared with electronic medication event monitoring: a validation study. J. Rheumatol. 30, 2469–2475 (2003). Disclosure of Interest None declared

Artritis reumatoide en paciente con infección por VIH

Resumen Se presenta el caso clinico de una mujer de 35 anos con infeccion por VIH, desde hace 6 anos, en manejo antirretroviral, sin antecedentes de enfermedad reumatica previa, quien presenta cuadro de poliartralgias de predominio en manos, asociado a sinovitis, con elevacion de reactantes de fase aguda, factor reumatoide y anti CCP positivos, configurandose diagnostico de artritis reumatoide. Esta enfermedad tiene una baja incidencia en el contexto de infeccion por retrovirus y se considera asociada al sindrome de reconstitucion inmune posterior a terapia antirretroviral. Se inicia manejo con farmacos modificadores con lo cual se obtiene control de la enfermedad autoinmune.