Marta Larrosa

Antimalarial myopathy: an underdiagnosed complication? Prospective longitudinal study of 119 patients

Objectives: To evaluate the prevalence and incidence of antimalarial myopathy in patients with rheumatic diseases treated with antimalarial drugs. Methods: Over a three year period, all patients with rheumatic diseases who were taking antimalarial drugs were studied. Serum muscle enzymes were assessed at the time of inclusion and every six months thereafter. Muscle strength, electromyography (EMG), and muscle biopsy were assessed in patients with a persistent muscle enzyme disturbances. Results: 119 patients were included (111 chloroquine, eight hydroxychloroquine). Of these, 22 (18.5%) had a persistent muscle enzyme disturbance: lactate dehydrogenase 19/22 (86%); creatine kinase 7/22 (32%), and aldolase 3/22 (14%). Findings of antimalarial myopathy were detected in 3/15 biopsied patients (20%) by light microscopy and in all 15 by electron microscopy. Eleven patients had myopathy at the time of inclusion (prevalence 9.2%) and four patients developed muscle injury during follow up (annual incidence 1.2%). Muscle weakness was observed in 8 of 15 patients with biopsy proven myopathy, giving a prevalence of clinical antimalarial myopathy of 6.7%. All these patients also had a myopathic pattern on electromyography. Conclusions: The prevalence of antimalarial myopathy is higher than previously recognised when muscle enzyme determination is used as a screening method. When a persistent muscle enzyme disturbance is observed, clinical and electromyographic studies should be undertaken periodically to detect the development of clinical myopathy. In cases of clinical myopathy, an anatomical-pathological tissue study, including an ultrastructural study, is mandatory to confirm the diagnosis.

Prevalencia de hipovitaminosis D en una población anciana institucionalizada. Valoración del tratamiento sustitutivo

Fundamento La osteoporosis senil es una enfermedad grave y prevalente, uno de cuyos mecanismos causantes mas importantes parece ser el deficit de vitamina D. La hipovitaminosis D es probablemente frecuente entre la poblacion anciana, en especial en la institucionalizada. El objetivo de este trabajo fue determinar la prevalencia de hipovitaminosis D en una poblacion anciana institucionalizada. Sujetos y metodo Estudio transversal en el que se incluyo de forma aleatoria 100 ancianos institucionalizados. Se valoro la prevalencia de hipovitaminosis D, asi como las posibles repercusiones sobre el metabolismo fosfocalcico y la presencia de hiperparatiroidismo secundario. Se recogieron ademas el grado de exposicion solar y la presencia de comorbilidad. Estudio longitudinal (6 meses) en el que se incluyeron los individuos con hipovitaminosis D y se valoro la eficacia de dos pautas terapeuticas distintas con calcidiol (16.000 UI a la semana o 16.000 UI cada tres semanas). Resultados El 87% de los individuos presentaron hipovitaminosis D. El 21,8% de ellos presentaron ademas un hiperparatiroidismo secundario. La poblacion estudiada tuvo tambien un bajo grado de exposicion solar y una alta prevalencia de comorbilidad. Las dos dosis de calcidiol consiguen normalizar las concentraciones de 25-OHD 3 y compensar el hiperparatiroidismo secundario, si bien con la administracion semanal se consiguieron concentraciones sanguineas mas elevadas. Conclusiones En la poblacion anciana institucionalizada y con elevada comorbilidad, la prevalencia de hipovitaminosis D es muy alta. El aporte de calcio y calcidiol consigue normalizar la 25-OHD 3 , mejorar la absorcion de calcio y compensar el hiperparatiroidismo secundario. En la poblacion geriatrica institucionalizada deberia considerarse la necesidad de la suplementacion con calcio y vitamina D.

Diagnostic and prognostic value of antibodies against chimeric fibrin/filaggrin citrullinated synthetic peptides in rheumatoid arthritis

IntroductionEvidence suggests that citrullinated fibrin(ogen) may be a potential in vivo target of anticitrullinated protein/peptide antibodies (ACPA) in rheumatoid arthritis (RA). We compared the diagnostic yield of three enzyme-linked immunosorbent assay (ELISA) tests by using chimeric fibrin/filaggrin citrullinated synthetic peptides (CFFCP1, CFFCP2, CFFCP3) with a commercial CCP2-based test in RA and analyzed their prognostic values in early RA.MethodsSamples from 307 blood donors and patients with RA (322), psoriatic arthritis (133), systemic lupus erythematosus (119), and hepatitis C infection (84) were assayed by using CFFCP- and CCP2-based tests. Autoantibodies also were analyzed at baseline and during a 2-year follow-up in 98 early RA patients to determine their prognostic value.ResultsWith cutoffs giving 98% specificity for RA versus blood donors, the sensitivity was 72.1% for CFFCP1, 78.0% for CFFCP2, 71.4% for CFFCP3, and 73.9% for CCP2, with positive predictive values greater than 97% in all cases. CFFCP sensitivity in RA increased to 80.4% without losing specificity when positivity was considered as any positive anti-CFFCP status. Specificity of the three CFFCP tests versus other rheumatic populations was high (> 90%) and similar to those for the CCP2. In early RA, CFFCP1 best identified patients with a poor radiographic outcome. Radiographic progression was faster in the small subgroup of CCP2-negative and CFFCP1-positive patients than in those negative for both autoantibodies. CFFCP antibodies decreased after 1 year, but without any correlation with changes in disease activity.ConclusionsCFFCP-based assays are highly sensitive and specific for RA. Early RA patients with anti-CFFCP1 antibodies, including CCP2-negative patients, show greater radiographic progression.

Déficit de vitamina D en la fractura osteoporótica de cadera y factores asociados

Fundamento Y Objetivo La hipovitaminosis D es frecuente entre los ancianos y especialmente prevalente en los pacientes con fractura de cadera. La prevalencia y los factores asociados a este deficit vitaminico son poco conocidos en nuestro medio. El objetivo del presente trabajo ha sido determinar la prevalencia de hipovitaminosis D en los pacientes con fractura osteoporotica de cadera y analizar los posibles factores que favorecen dicho deficit. Pacientes Y Metodo Se ha realizado un estudio transversal, en el que se incluyo de forma consecutiva a todos los pacientes mayores de 65 anos ingresados con fractura osteoporotica de cadera durante el periodo comprendido entre marzo de 2002 y febrero de 2003. Se investigo la prevalencia de hipovitaminosis D y de hiperparatiroidismo secundario. Se recogieron el grado de exposicion solar, la capacidad funcional, el estado nutricional y la presencia de comorbilidad. Resultados Se incluyo a 324 pacientes con una edad media (desviacion estandar) de 83 (7) anos; un 80% eran mujeres. Se observo hipovitaminosis D en 217 casos (67%; intervalo de confianza [IC] del 95%, 62-72%), de los que el 57% presentaba hiperparatiroidismo secundario. El mal estado nutricional –valores de albumina Conclusiones La prevalencia de hipovitaminosis D es alta en los pacientes con una fractura osteoporotica de cadera y en mas de la mitad de ellos condiciona la presencia de hiperparatiroidismo secundario. Este deficit es especialmente prevalente entre los individuos con poca exposicion solar, mal estado nutricional y baja capacidad funcional.

Utilidad del pamidronato en el tratamiento de la artropatía de Charcot

OBJECTIVE To investigate the usefulness of pamidronate in the management of active Charcots arthropathy. MATERIAL AND METHODS Open prospective study with a follow-up of 12 months, including patients with active neuroarthropathy seen over a period of 3 years in our rheumatology unit. Patients received three pamidronate infusions at 0, 2, and 4 months. Clinical assessment, serum and urine bone turnover markers, radiological exam, and scintigraphy were performed before and after treatment. RESULTS Seven patients were ncluded (4F/3M), mean age, 51.3 years (30-64). The underlying disease was diabetes mellitus in 4 cases, syringomyelia in 2, and sensory and autonomic neuropathy in 1. The joints affected were shoulder, ankle, tarsians, metacarpophalaneal, and metatarsophalangeal. All patients showed a rapid resolution of clinical symptoms, with a clear reduction of all bone remodeling markers that achieved statistical significance for urine NTX and urinary pyridoline (P=.04 and P=.03, respectively). Six of 7 patients disclosed at the end of follow-up a radiological healing. Quantitative scyntigraphy showed a clear reduction of the bone (99)Tm uptake. No important side affects were reported. CONCLUSIONS Pamidronate appears as a useful treatment for neuroarthropathy independently of the underlying disease. A rapid diagnosis and early pamidronate treatment could avoid severe articular consequences.Objetivo: Investigar la utilidad del pamidronato en el tratamiento de la neuroartropatia en fase activa. Material y metodos: Estudio prospectivo, abierto, con un seguimiento de 12 meses. En un periodo de 3 anos todos los pacientes con neuroartropatia activa visitados en la unidad de reumatologia recibieron tres infusiones de pamidronato a los 0, 2 y 4 meses. Se realizo valoracion clinica, de marcadores de remodelado oseo en sangre y orina, radiografia simple y gammagrafia osea cuantitativa antes y despues del tratamiento. Resultados: Se incluyo a 7 pacientes (4 varones y 3 mujeres), con una media de edad de 51,3 (30-64) anos. La enfermedad de base fue diabetes mellitus en 4 casos, siringomielia en 2 y neuropatia sensitiva autonomica en 1. Las articulaciones afectadas fueron hombro, tobillo, tarsianas, metatarsofalangicas y metacarpofalangicas. Todos los pacientes mostraron una rapida resolucion de los sintomas, con una clara reduccion de todos los marcadores de remodelado oseo siendo estadisticamente significativa en el caso del NTX y piridolina en orina (p = 0,04 y p = 0,03, respectivamente). Seis de los 7 pacientes mostraron una mejoria radiologica. La gammagrafia cuantitativa mostro una reduccion evidente de la captacion. No se observaron efectos adversos importantes. Conclusiones: El pamidronato parece un tratamiento util para la artropatia de Charcot independientemente de la enfermedad de base. El diagnostico precoz y la administracion rapida del tratamiento puede evitar complicaciones articulares graves

Importancia de los problemas reumáticos en la población de Cataluña: prevalencia y repercusión en la salud percibida, restricción de actividades y utilización de recursos sanitarios

OBJECTIVE To determine the importance of chronic musculoskeletal problems in the adult population of Catalonia (Spain) and their effect on self-perceived health, activity restriction and use of health services. METHODS A population-based survey of 15,926 adults was performed. Multistage stratified sampling was performed. The variables gathered were sociodemographic characteristics, self-reported chronic health problems, self-perceived health, activity restriction and use of health services. Musculoskeletal problems were grouped into four categories: osteoarthritis-arthritis or rheumatism (OA), chronic dorsal or lumbar pain (LBP), chronic cervical pain (UBP), and osteoporosis. RESULTS Chronic health problems were reported by 77.4% of the adult population. The most frequent health problem was LBP, followed by UBP and OA. After adjustment by age was performed, female sex increased the risk of reporting OA, LBP, UBP and osteoporosis (OR=2.6, 1.5, 2.3, and 5.3, respectively). The prevalence increased with greater age and with lower socioeconomic status. After adjustment was performed by age, sex, social class and obesity, self-perceived health was worse in people with these problems (42.7% vs 11%). The four categories were the main causes of activity restriction in the last year (OR 2.70) and the last 15 days (OR=2.32) and were associated with a higher use of health services. CONCLUSIONS Los problemas reumáticos son los principales problemas de salud crónicos declarados por la población adulta. La prevalencia es mayor es las mujeres, aumenta con la edad y en las clases desfavorecidas. Hay una asociación significativa entre declarar problemas musculoesqueléticos y salud autopercibida mala o regular, y mayor restricción de actividades y uso de servicios sanitarios.

Secular trend in the incidence of hip fracture in Catalonia, Spain, 2003–2014

Objectives to describe the secular trend and seasonal variation in the incidence of hip fracture (HF) over 12 years (2003-2014) in Catalonia, the community with the highest incidence of HF in Spain. Methods data about age, gender, type of fracture and month of hospitalisation among patients aged 65 years and older discharged with a diagnosis of HF were collected. Crude and age-standardised annual incidence rate were reckoned. To analyse HF trend, the age/sex-adjusted average annual change in incidence (incidence rate ratio, IRR) was calculated. Results we identified 100,110 HF in the period, with an increase of 16.9% (women 13.4%; men 28.4%). Trochanteric fractures were the most frequent (55.8%). The crude incidence rate (per 100,000 population) decreased from 677.2 (95% confidence interval (95% CI) 662.0-692.7) to 657.6 (95% CI 644.0-671.5). The standardised incidence rate decreased from 754.0 (95% CI 738.6-769.3) to 641.5 (95% CI 627.7-655.3), with a sharp decrease in women (-16.8%) while it was stable in men. The incidence by type of fracture was stable. The trend throughout the period showed a slight decrease with IRR 0.99 (95% CI 0.98-0.99; P = 0.025). The incidence was stable in the oldest group (+85 years), while there was a downward trend in the younger groups. A significant seasonal pattern was observed, with more cases in winter and less in summer (spring as reference). Conclusions the secular trend reveals a decreasing incidence of HF although the absolute number has increased in the last 12 years in Catalonia. Trochanteric fractures were the most prevalent and a seasonal pattern was observed, with more cases in winter.

Synovial fluid adipokines are associated with clinical severity in knee osteoarthritis: a cross-sectional study in female patients with joint effusion.

BackgroundAdipokines are related to knee osteoarthritis, but their exact role is not well known. The aim of this study was to evaluate the association between adipokines in synovial fluid and clinical severity in patients with knee osteoarthritis with joint effusion.MethodsCross-sectional study with systematic inclusion of female patients with symptomatic primary knee osteoarthritis with ultrasound-confirmed joint effusion. Age, physical exercise, knee osteoarthritis symptoms duration, classical cardiovascular risk factors and different anthropometric measurements were collected. Metabolic syndrome was defined in accordance to National Cholesterol Education Program-Adult Treatment Panel III. Radiographic severity was evaluated according to Kellgren-Lawrence scale and Lequesne index was used to assess clinical severity. Seven adipokines (leptin, adiponectin, resistin, visfatin, osteopontin, omentin and chemerin) and three inflammatory markers (tumor necrosis factor α, interleukin 6 and high sensitivity C-reactive protein) were measured by enzyme-linked immunosorbent assay in synovial fluid.ResultsKellgren-Lawrence grade, physical exercise, all anthropometric measurements (especially waist circumference), tumor necrosis factor α, and high levels of leptin, resistin, and ostepontin were related to knee osteoarthritis severity. After adjustment for clinical confounders (age, symptom duration, and radiology), anthropometric measurements, inflammatory markers, and all evaluated adipokines, there were independent associations with clinical severity for resistin (directly associated) and visfatin (inversely associated). No other adipokines or inflammatory markers were independently associated with Lequesne index. The association of radiological parameters, physical exercise, and waist circumference with Lequesne index remained after adjustment.ConclusionsResistin was directly associated, and visfatin was inversely associated, with clinical severity in female patients with knee osteoarthritis with joint effusion. These associations were more important after adjustment for confounders, especially when all adipokines were evaluated.

Experiencia de 4 años de funcionamiento de una unidad multidisciplinar de psoriasis y artritis psoriásica

INTRODUCTION AND OBJECTIVES Up to 30% of patients with psoriasis develop joint disease, the course of which can be improved by early diagnosis and treatment. The aim of this study was to describe our experience with a new multidisciplinary psoriasis and psoriatic arthritis unit over a period of 4 years (2009-2012). MATERIAL AND METHODS Implementation of a PSOriasis Rheumatology and Dermatology unit (PSORD) to provide patient care and physician training. In the first phase of the project, referral criteria for the unit were defined and several meetings were organized to train and prepare the specialists involved in the program. In the second phase, a schedule was drawn up for monthly patient visits with the PSORD team. Starting in 2011, training was offered to dermatologists and rheumatologists from other hospitals interested in implementing a similar model. RESULTS A total of 259 visits (71% first visits, 8% no-shows) were scheduled during the period analyzed, with a median of 8 visits (range, 2-14 visits) per session. Sixty-three percent of the patients were referred from the rheumatology department. Diagnosis and treatment were modified in 32% and 47% of cases, respectively. Three training courses were held with 15 physicians from 6 hospitals, 3 of which created similar units. CONCLUSIONS The PSORD model improved the management of difficult-to-diagnose and/or uncontrolled disease, the early diagnosis and treatment of psoriatic arthritis, and collaboration between dermatologists and rheumatologists. Finally, the model lends itself to being exported to other settings.

Osteoporosis en el varón con enfermedad pulmonar obstructiva crónica. Utilidad de la densitometría de falange (AccuDEXA) como método de cribado diagnóstico

OBJECTIVE To analyze the prevalence of osteoporosis in men with chronic obstructive pulmonary disease (COPD) and to evaluate whether phalangeal densitometry (AccuDEXA) could be a useful screening method for identifying osteoporosis in these patients. PATIENTS AND METHODS We performed a cross sectional study in male patients with COPD who were assessed by a pulmonologist in primary care and in our hospital as out-patients. The diagnosis of osteoporosis was established by conventional DEXA (lumbar spine and total hip), according to the WHO criteria. Bone mineral density (BMD) was assessed by AccuDEXA. We used a ROC curve to determine the best cut-off point for screening with this technique. RESULTS One hundred fifty male patients with COPD were included. The mean age was 67 ± 3 years. The prevalence of osteoporosis by DEXA was 34%. BMD in phalanx was significantly correlated with BMD in lumbar spine and hip (r: 0.6). The sensitivity and specificity of AccuDEXA in identifying osteoporosis was 29% and 85%, respectively. The best cut-off point for AccuDEXA was a T-score of -0.8 (sensitivity 85%, specificity 63%, positive predictive value 56%, negative predictive value 89%). Glucocorticoid treatment and COPD severity were significantly associated with the presence of osteoporosis in these patients (p=0.005 and p=0.023 respectively). CONCLUSION The prevalence of osteoporosis in men with COPD is high. This complication seems to be associated with glucocorticoid treatment and COPD severity. AccuDEXA could be a useful screening method for osteoporosis in these patients and could almost halve the number of conventional DEXAs performed.