Telomeres Length Variations in a Rheumatoid Arthritis Patients Cohort at Early Disease Onset and after Follow-Up

ABSTRACT Background: Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic synovial joint inflammation, progressive disability, premature immune aging, and telomere length (TL) shortening. Objective: The objective of the study was to study TL changes in patients at early disease onset and after follow-up. Methods: Relative leukocyte TL (rLTL) was measured by quantitative polymerase chain reaction (qPCR) in 88 at-admission patients (AAP) with < 1 year of symptoms onset, self-compared after follow-up, and a reference group of sex- and age-matched healthy individuals. Correlations between rLTL percentage change after variable disease exposure time (DET) and clinical laboratory disease activity markers and treatments were assessed. Non-parametrical statistics were applied, considering < 0.05 p-value significant. Results: The median (p25, p75) rLTL was lower in patients after DET (0.61, 0.49-0.70) than in AAP (0.64, 0.50-0.77), p = 0.017. Furthermore, telomeres at early stages of RA were shorter than in the reference group (0.77, 0.59-0.92; p = 0.003). HLA-DRB1*04 allele carrier status did not significantly affect rLTL at an early stage and after follow-up. The patients' rLTL shortening was mainly associated with longer at-admission telomeres (OR 16.2, 95%CI: 3.5-74.4; p < 0.0001). Conclusion: At follow-up, RA patients showed significantly shorter rLTL than AAP, particularly in those AAP with longer telomeres, disregarding disease activity and treatments, denoting an rLTL shortening effect influenced by age, DET, and native rLTL.

Uso de medicina complementaria y alternativa y su asociación con la relación médico-paciente en enfermos con artritis reumatoide / Association between physician-patient relationship and the use of complementary and alternative medicine in patients with rheumatoid arthritis

RESUMEN Introducción: El uso de medicina complementaria y alternativa (MCA) en pacientes con enfermedades reumáticas es prevalente pero la comunicación con el reumatólogo suele ser deficiente, lo cual afecta la relación médico-paciente (RMP). Objetivos: Evaluar la asociación entre el uso de MCA y la RMP en enfermos con artritis reumatoide. Como objetivos adicionales, describir la percepción del paciente sobre la comunicación con su reumatólogo respecto al uso de MCA y el patrón de uso de las diferentes modalidades terapéuticas. Materiales y métodos: Estudio descriptivo de corte transversal. El uso de MCA y la RMP se evaluaron mediante la autoaplicación de cuestionarios validados (I-CAM-Q y PDRQ-9 respectivamente). Resultados: Se incluyó a 246 pacientes ambulatorios de una institución de tercer nivel de atención. Se encontró asociación entre una mayor satisfacción con el tratamiento y el no usar MCA, y entre el hecho de informar al reumatólogo sobre el uso de MCA con un mayor grado de acuerdo con el médico sobre el origen de los síntomas y mayor satisfacción con el tratamiento. Las modalidades más frecuentemente utilizadas fueron: quiropraxia, acupuntura y productos herbales. El 78,5% afirmaron estar de acuerdo con comunicar el uso de este tipo de medicación al reumatólogo, sin embargo, solo el 31,3% lo notificó, por temor a represalias (54,4%). Conclusiones: Pese a la alta prevalencia de uso de MCA en nuestros pacientes, la mayoría no lo comunicó al reumatólogo. Se encontró asociación entre el uso de MCA y una menor satisfacción del paciente con el tratamiento y entre la comunicación médico-paciente sobre la práctica de MCA y una mejor satisfacción con el tratamiento.

ABSTRACT Introduction: Although complementary and alternative medicine (CAM) use among patients with rheumatic diseases is extensive, discussions regarding these treatments occur rarely in the rheumatology setting, directly affecting the physician-patient relationship (PPR). Objectives: The aim of this study was to evaluate the association between patient-physician relationship and complementary and alternative medicine use. As secondary objectives, to describe the patient's perspective towards CAM use and estimate the prevalence of CAM treatments used in patients with rheumatoid arthritis. Methods and materials: A descriptive cross-sectional survey was conducted, in which CAM use and physician-patient relationship were assessed by self-reported validated questionnaires (I-CAM-Q and PDRQ-9, respectively). Results: The study included a total of 246 outpatients of a tertiary care hospital. There were no significant differences between CAM users vs. non-users, or informers vs. non-informers in terms of physician-patient relationship measured by PDQR. The most frequent used CAM treatments were: chiropractice, acupuncture, and herbal products. A large majority (78.5%) of the patients expressed agreement to the discussion of CAM use with the rheumatologist, but only 31.3% of total CAM users did so because of fear of retaliation (54.4%). Conclusion: Despite the extensive practice of CAM among patients with rheumatoid arthritis, most patients did not discuss these treatments with their physicians. Associations were found between MCA use and a lower patient's treatment satisfaction and between physician-patient communication about CAM practice and a higher patient's treatment satisfaction.

Filariasis mamaria: a propósito de un caso / Breast filariasis: case report

INTRODUCCIÓN: La filariasis con afectación mamaria es una enfermedad endémica de áreas tropicales y subtropicales de África, Asia, el Pacífico y América, que afecta a unos 120 millones de personas. Aunque es una patología rara en España, dado el aumento de pacientes procedentes de dichos países, debemos conocerla para saber diagnosticarla y tratarla adecuadamente. OBJETIVO DE REPORTAR EL CASO: Dar a conocer la filariasis con afectación mamaria, sus manifestaciones clínicas y radiológicas principales, a través de un caso clínico de nuestras consultas de ginecología. DESCRIPCIÓN DEL CASO: Paciente de 43 años, procedente de Guinea Ecuatorial que acude a la consulta de Ginecología por mastalgia bilateral y aumento del volumen de las mamas de semanas de evolución. La exploración es anodina por lo que se solicita mamografía bilateral en la que describen calcificaciones compatibles con filariasis. A pesar de que el resto de pruebas fueron negativas, dada la alta sospecha clínica y radiológica se diagnosticó de filariasis mamaria. CONCLUSIONES: A pesar de la actual campaña mundial para eliminar la filariasis, el aumento de migración global incrementa la probabilidad de padecer casos importados de filariasis mamaria. Por tanto, el conocimiento de las diferentes parasitosis es imprescindible para realizar un buen diagnóstico diferencial con otras entidades clínicamente similares, e instaurar el tratamiento más adecuado.

INTRODUCTION: Breast filariasis is an endemic disease from tropical and subtropical areas of Africa, Asia, the Pacific and America affecting about 120 million people. Although it is a rare pathology in Spain, given the increase in patients from the referred countries, we must be aware of it in order to know how to diagnose and treat it properly. OBJECTIVE OF REPORTING THE CASE: To raise awareness of filariasis with breast involvement and its main clinical and radiological manifestations, through a clinical case of our gynecology consultations. CASE REPORT: 43-year-old patient from Equatorial Guinea who comes to the Gynecology consultation for bilateral mastalgia and breast enlargement of weeks of evolution. The examination is anodyne, so bilateral mammography is requested in wich calcifications compatible with filariasis are described. Despite the rest of the tests are negative, given the high clinical and radiological suspicion, the diagnosis of breast filariasis is made. CONCLUSIONS: Despite the current worldwide campaign to eliminate filariasis, the increase in global migration enhances the probability of suffering from imported cases of breast filariasis Therefore, the knowledge of the different parasitoses is essential to make a correct differential diagnosis with other clinically similar entities, and to establish the most appropriate treatment.

III. The role of the Research Ethics Committees in the regulation of Pharma-Sponsored studies

Participants of Pharma-sponsored research are exposed to risks, benefits, and uncertainties that do not occur in other forms of clinical studies. Ethics committees represent the subjects’ first line of protection. This responsibility begins with the study review and ends after all study subjects finish the intervention. The objective of this paper is to review the most common controversial issues found in Pharma-sponsored studies. Potential solutions are proposed to prevent or resolve the polemical aspects. However, different challenges will be faced in the near future (e.g., when new therapies reach their late stage of development). All parties involved in research should work together to guarantee the protection of participants, the paramount principle on which clinical investigation is based. Pharma-sponsored research is a crucial driver to develop and implement innovative approaches to improve the informed consent process and the execution of the studies.

Efecto de los antimaláricos sobre los diferentes dominios del índice de daño SLICC en pacientes de la cohorte GLADEL / Effect of antimalarials on the different domains of the SLICC damage index in patients of the GLADEL cohort

Objetivos: Estimar el efecto de los antimaláricos (AM) sobre los diferentes dominios del índice de daño SLICC (SDI). Métodos: Se estudiaron pacientes con diagnóstico clínico reciente (≤2 años) de lupus eritematoso sistémico (LES) de la cohorte GLADEL. Variable de estudio: aumento en los dominios del SDI desde el ingreso a la cohorte. Variables independientes: características sociodemográficas, clínicas, laboratorio y tratamientos. El efecto de los AM, como variable dependiente del tiempo, sobre los dominios más frecuentes del SDI (ajustado por factores de confusión) fue examinado con un modelo de regresión de Cox multivariado. Resultados: De 1466 pacientes estudiados, 1049 (72%) recibieron AM con un tiempo medio de exposición de 30 meses (Q1-Q3: 11-57) y 665 pacientes (45%) presentaron daño durante un seguimiento medio de 24 meses (Q1-Q3: 8-55); 301 eventos fueron cutáneos, 208 renales, 149 neuropsiquiátricos, 98 musculoesqueléticos, 88 cardiovasculares y 230 otros. Después de ajustar por factores de confusión, el uso de AM se asoció a un menor riesgo de daño renal (HR 0,652; IC 95%: 0,472-0,901) y en el límite de la significancia estadística (HR 0,701, IC 95%: 0,481-1,024) para el dominio neuropsiquiátrico. Conclusión: En GLADEL, el uso de AM se asoció independientemente a un menor riesgo de daño acumulado renal.

Objective: To assess the effects of antimalarials (AM) over the items of the SLICC Damage Index (SDI). Methods: Patients with recent (≤2 years) diagnosis of systemic lupus erythematosus (SLE) from the GLADEL cohort were studied. End-point: increase in items SDI since cohort entry. Independent variables (socio-demographic, clinical, laboratory and treatment) were included. The effect of AM as a time dependent variable on most frequent SDI items (adjusting for potential confounders) was examined with a multivariable Cox regression model. Results: Of the 1466 patients included in this analysis, 1049 (72%) received AM with a median exposure time of 30 months (Q1-Q3: 11-57). Damage occurred in 665 (45%) patients during a median follow-up time of 24 months (Q1-Q3: 8-55). There were 301 integument, 208 renal, 149 neuropsychiatric, 98 musculoskeletal, 88 cardiovascular and 230 others less frequently represented damages. After adjusting for potential confounders at any time during follow-up, a lower risk of renal damage (HR 0.652; 95% CI: 0.472-0.901) and borderline for neuropsychiatric damage (HR 0.701, 95% CI: 0.481-1.024) was found. Conclusion: In the GLADEL cohort, after adjustment for possible confounding factors, AM were independently associated with a reduced risk of renal damage accrual.

Resultados Funcionales y Complicaciones en pacientes asistidos en UDA-ACV Rehabilitación Instituto de Neurología - Hospital de Clínicas / Functional Results and Complications in Assisted Patients in UDA-ACV Rehabilitation Institute of Neurology - Hospital de Clínicas / Resultados Funcionais e Complicações em Pacientes Assistidos no Instituto de Neurologia de Reabilitação UDA-ACV - Hospital de Clínicas

Resumen: Introducción: el ataque cerebrovascular (ACV) es un importante problema de salud por su alta morbi-mortalidad; en Uruguay representa la primera causa de discapacidad en el adulto. La atención en unidades interdisciplinarias, especializadas en ACV (UACV) se vincula con una disminución en la morbi-mortalidad y mejoría en la independencia al alta. Objetivo: Evaluar el impacto del programa de abordaje precoz, protocolizado y sostenido, en pacientes con ACV asistidos por el Equipo de Rehabilitación integrado a la UACV del HC. Material y método: Se realizó un estudio prospectivo, descriptivo, de cohorte; con un grupo de usuarios de la UACV (n=79) versus grupo histórico (GH) de población asistida fuera del contexto de UACV (n=77). Se tomaron como indicadores: días de internación, complicaciones e impacto funcional del ACV. Resultados: ambas muestras fueron estadísticamente comparables, considerando α<0.05. En la modalidad UACV hubo una franca disminución de las complicaciones extra-neurológicas (21.5% vs 58% del GH), en especial de las infecciosas: urinarias (3.8% vs 21.8% GH) y respiratorias bajas (17.7% vs 27.3% GH); la mortalidad (5.06% vs 10.4% GH) y los días de internación (17.2 días vs 33.5 días del GH). Los pacientes presentaron mejores resultados funcionales al alta, requiriendo menor prescripción de ayudas técnicas: silla de ruedas (18% vs. 45.9% GH), andador o bastón (18% vs 21.6% GH). Conclusiones: el abordaje mediante la modalidad de UACV exhaustiva, influye positivamente en la independencia, calidad asistencial, costos asistenciales y sociales.

Abstract: Introduction: stroke is an important health problem due to its high morbidity and mortality; In Uruguay it represents the first cause of disability in the adult. Attention in interdisciplinary stoke units (SU), is associated with a decrease in morbi-mortality and improvement in independence at hospital discharged. Objective: evaluation of the impact of an early, protocolized and sustained rehabilitation program, at the stroke unit where rehabilitation team take part. Material and method: We carried out a prospective, descriptive, cohort study; with a group of SU patients (n = 79) versus historical group (HG) assisted in general hospital (n = 77). The following indicators were taken: hospitalization days, complications and functional impact of stroke. Results: Both samples were statistically comparable, considering α<0.05. In SU modality there was a frank reduction of extra-neurological complications (21.5% vs 58% of GH), especially of the urinary tract infections (3.8% vs. 21.8% HG) and respiratory infections (17.7% vs 27.3% HG); Mortality (5.06% vs 10.4% HG) and days of hospitalization (17.2 days vs 33.5 days of HG). The patients presented better functional results at hospital discharge requiring less prescription of technical aids: wheelchair (18% vs. 45.9% HG), walker or walking stick (18% vs 21.6% HG). Conclusions: the approach through an exhaustive SU modality has positive effects in patient independence, assistance quality, care and social costs.

Resumo: Introdução: o ataque cerebrovascular (CVA) é um importante problema de saúde devido à sua alta morbidade e mortalidade; No Uruguai, representa a primeira causa da deficiência no adulto. A atenção em unidades interdisciplinares, especializadas em LCA (UACV), está associada a uma diminuição da morbi-mortalidade e à melhoria da independência na alta. Objetivo: Avaliar o impacto do programa de tratamento precoce, protocolizado e sustentado em pacientes com AVC assistidos pela Equipe de Reabilitação Integrada à UACV do HC. Material e método: Realizamos estudo prospectivo, descritivo e de coorte; com um grupo de usuários UACV (n = 79) versus grupo histórico (GH) de população assistida fora do contexto UACV (n = 77). Foram utilizados os seguintes indicadores: dias de hospitalização, complicações e impacto funcional do AVC. Resultados: Ambas as amostras foram estatisticamente comparáveis, considerando α<0,05. Na modalidade UACV houve uma clara diminuição nas complicações extra neurológicas (21,5% vs 58% da GH), especialmente nas infecciosas: urinária (3,8% vs 21,8% GH) e baixa respiratória (17,7% vs 27,3% GH) ; mortalidade (5.06% vs 10.4% GH) e dias de internação (17.2 dias vs 33.5 dias de GH). Os pacientes apresentaram melhores resultados funcionais na alta, exigindo menos prescrição de auxiliares técnicos: cadeira de rodas (18% vs. 45,9% de GH), andador ou bastão (18% contra 21,6% de GH). Conclusões: a abrangente abordagem UACV influencia positivamente a independência, a qualidade dos cuidados, os custos sociais e de bem-estar.

Desempeño profesional de los egresados de Escuelas de Enfermería en Nuevo León / Professional nursery practice of the graduates from IMSS school and others schools in Nuevo León

Introducción: El departamento de Comportamiento Laboral del IMSS considera el desempeño como la aplicación de habilidades y capacidades que el puesto requiere del ocupante para el manejo eficiente de sus funciones. Objetivo: Describir el desempeño de la práctica profesional de los egresados de escuelas de enfermería en Nuevo León. Metodología: Estudio transversal comparativo a 21 enfermeras generales egresadas de la escuela de enfermería del IMSS y a 23 egresadas de otras escuelas de enfermería. Se visitaron 13 unidades de mediana familiar y hospitales del área metropolitana. El instrumento utilizado fue la cédula de desempeño de evaluación del comportamiento laboral, con 30 reactivos estructurados, contestada por el jefe inmediato. Resultados: EI 100% correspondió al sexo femenino, el estado civil más frecuente fue el de solteras con 52%. El desempeño general de la escuela de enfermería del IMSS obtuvo una mediana de 98 y de otras escuelas de 92, (p=0.0003). De acuerdo al tipo de contratación y estado civil se presentaron diferencias significativas. Conclusiones: El desempeño, habilidades, capacidades y desempeño general de la práctica profesional de egresados de la escuela de enfermería del IMSS es de bueno a excelente y fue mayor en relación a otras escuelas.

Introduction: the laboral behavior department of IMSS defines the professional nursery practice as the application of abilities and capacities the job requires from the worker in order to make him do his best in his workplace, handling his functions in an efficient way. Objective: describe the professional practice development of the graduate students from the IMSS Nursery School, to be compared with the development students from others schools have. Methodology: transversal comparative study to 21 General Nurses from IMSS Nursery School, as well as 23 graduates from others schools. Thirteen Familiar Medical Units and hospitals around downtown were visited. The used instrument was the document of development of laboral evaluation with 30 structured items, which was answered by the immediate cheaf. Results: 100% of interviewed people were female. The marital status with the highest percentage, 52%, was single. The 48% studied in the IMSS Nursery School; 21% were from UANL Nursery College and 31% from different schools. The General Development of the IMSS Nursery School got an average of 98, while others schools got 92 (p=0.0003). According to the types of contracts and marital status, meaningful differences appeared. Conclusions: We can measure the development, abilities, capacities and general development of the professional practice of graduates from IMSS Nursery School, from good to excellent. And results were better than in any other school.