Negative association between 25-hydroxyvitamin D and inflammatory markers in rheumatologic diseases / Asociación negativa entre 25-hidroxi vitamina D y los marcadores inflamatorios en enfermedades reumatológicas

Objective: The main purpose of this study was to evaluate serum 25-hydroxyvitamin D (25OHD) levels and its association with in"ammatory markers in patients with rheumatologic diseases (RD). Methods: A cross-sectional study in 154 women with RD (rheumatoid arthritis, spondyloarthritis and other connective tissue diseases) and 112 healthy individuals as a control group (CG) was carried out. Results: No differences in serum and urine calcium, serum phosphate, and urinary deoxypyridinoline were found. RD group had lower 25OHD and higher PTH compared to CG. RD group had higher C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) compared to CG. The overall mean level of 25OHD (ng/ml) was 26.3±12.0 in the CG and 19.4±6.8 in the RD group (p<0.0001). Moreover, CG had lower percentage of individuals with 25OHD de!ciency compared to RD (29.9% vs 53.2%). The femoral neck BMD was signi!cantly lower in postmenopausal RD women compared to CG. 25OHD levels signi!cantly correlated with ESR and CRP as in"ammatory markers. Age, BMI, presence of RD, and CRP were signi!cantly and negatively associated with 25OHD levels through linear regression analysis. According to univariate logistic regression analysis for 25OHD deficiency (<20 ng/ml), a significant and negative association with BMI, presence of RD, ESR and CRP were found. Conclusion: Patients with RD had lower 25OHD levels than controls and the presence of a RD increases by 2.66 the risk of vitamin D de!ciency. In addition, 25OHD has a negative correlation with ESR and CRP as in"ammatory markers. (AU)

Objetivo El objetivo principal de este estudio fue evaluar los niveles séricos de 25-hidroxivitamina D (25OHD) y su asociación con marcadores inflamatorios en enfermedades reumatológicas. Materiales y métodos: Se realizó un estudio transversal en 154 mujeres con enfermedades reumatológicas (artritis reumatoide, espondiloartritis y otras enfermedades del tejido conectivo) y 112 individuos sanos como grupo control (GC). Resultados: No se encontraron diferencias en el calcio sérico y urinario, el fosfato sérico y la desoxipiridinolina urinaria entre el GC y los sujetos con enfermedades reumatológicas. El grupo de pacientes con enfermedades reumatológicas tenía 25OHD más bajo y PTH más alto en comparación con el GC. Asimismo, el grupo de individuos con enfermedades reumatológicas tenía proteína C reactiva (PCR) y velocidad de eritrosedimentación (VES) más altas en comparación con el GC. El nivel de 25OHD (ng/ml) fue 26,3±12,0 en el GC y 19,4±6,8 en el grupo con enfermedades reumatológicas (p<0,0001). Además, el GC presentó un porcentaje menor de deficiencia de 25OHD en comparación con el grupo con enfermedades reumatológicas (29,9% vs 53,2%). La DMO del cuello femoral fue significativamente menor en las mujeres posmenopáusicas con enfermedades reumatológicas en comparación con el GC. La 25OHD correlacionó significativamente con la VES y la PCR como marcadores inflamatorios. El análisis de regresión lineal mostró que la edad, el IMC, la presencia de una enfermedad reumatológica y la PCR se asociaron significativa y negativamente con los niveles de 25OHD. Mientras que el análisis de regresión logística univariada mostró que la deficiencia de 25OHD (<20 ng/ml), se asoció significativa y negativamente con el IMC, la presencia de una enfermedad reumatológica, la VES y los niveles de PCR. Conclusiones: Los pacientes con enfermedades reumatológicas tenían niveles de 25OHD más bajos que los controles y la presencia de una enfermedad reumatológica aumenta en 2.66 el riesgo de deficiencia de vitamina D. Además, la 25OHD mostró correlación negativa con la VES y la PCR como marcadores inflamatorios. (AU)

Five year retrospective study of mortality in systemic inflammatory rheumatologic disorders

Background: Inflammatory systemic rheumatologic disorders are responsible for significant morbidity and premature deaths. The present study was done to assess causes of mortality in these patients.Methods: In the retrospective study, the death records of patients with inflammatory rheumatologic illnesses from January 2012 to January 2017 were studied. The demographic details, disease activity, organ involvement, treatment received and evidence of infection were noted.Results: 50 records were analyzed (25 systemic lupus erythematosus (SLE), 13 rheumatoid arthritis (RA), four immune myositis, three systemic sclerosis (SS), two takayasu’s arteritis (TA), two ankylosing spondylitis (AS) and one granulomatosis with polyangiitis (GPA)). The me an age of death was 39.94 years. Sixteen patients had disease related organ damage, 17 had active disease. Infection was present in 31 patients (gram negative organisms most commonly isolated), being the major contributor of mortality. Only two patients succumbed to acute coronary syndrome.Conclusions: Infection, disease activity and organ damage due to the disease are the major contributors to of death in hospitalized patients with inflammatory rheumatological disorders.

Anestesia, analgesia, reumatología y alivio del dolor agudo y crónico / Anesthesia, analgesia, rheumatology and relief of acute and chronic pain

Introducción: el tratamiento eficaz del dolor postquirúrgico es hoy un reto para los anestesistas, reumatólogos, traumatólogos, cirujanos e investigadores de diversas especialidades, quienes proponen constantemente protocolos que toman como base a la evidencia científica. Objetivo: reflexionar y abrir el debate respecto al rol de la anestesia en el alivio del dolor de origen reumatológico. Desarrollo: en Reumatología, se recomienda, en todo paciente con dolor reumático crónico, calcular la intensidad del dolor, tanto para la elección primera del tratamiento analgésico como para la medición de la respuesta. Y, para ello, se han propuesto varios métodos de cuantificación. Conclusiones: el manejo diagnóstico y el tratamiento multidisciplinario presiden cuando se examina a este tipo de casos, ya que es la única manera de identificar el origen del dolor y suministrar un alivio prudente. En su generalidad, los pacientes responden al tratamiento conservador y solo un exiguo grupo va a necesitar de técnicas anestésicas invasivas(AU)

Introduction: The effective treatment of postoperative pain is today a challenge for anesthetists, rheumatologists, orthopedic surgeons, surgeons and researchers of various specialties, who constantly propose protocols based on scientific evidence. Objective: Reflect and open the debate regarding the role of anesthesia in the relief of pain of rheumatological origin. Development: In Rheumatology, it is recommended, in all patients with chronic rheumatic pain, to calculate the intensity of the pain, both for the first choice of the analgesic treatment and for the measurement of the response. And, for this, several methods of quantification have been proposed. Conclusions: Diagnostic management and multidisciplinary treatment preside when this type of case is examined, since it is the only way to identify the origin of pain and provide prudent relief. In general, patients respond to conservative treatment and only a small group will need invasive anesthetic techniques(AU)

Estrés, psiconeuroendocrinoinmunología y enfermedades reumatológicas. Actualización del tema / Stress, Psychoneuroendocrinoimmunology and rheumatological diseases. Actualization of this topic

El estrés se define como el estado de alarma de los organismos ante diversos desafíos. La Psiconeuroendocrinoinmunología es una ciencia que integra la psiquis, el sistema nervioso, endocrino e inmune; y estudia las múltiples y complejas interrelaciones entre ellos lo cual permite tratar de manera integral el proceso salud-enfermedad. La alteración del equilibrio entre la psiquis y los sistemas mencionados puede ocasionar daños al organismo como es el caso de algunas enfermedades reumatológicas(AU)

Stress is defined as the state of alarm of living beings in case of various challenges. Psycho-neuro-endocrine-immunology is a science that integrates the psyche with the nervous, endocrine and immune systems. It studies the multiple and complex interrelations among them, which allows us to deal comprehensively with the health-disease process. The alteration if the balance between the psyche and the aforementioned systems can cause damage to the organism, as in the case of some rheumatologic diseases(AU)

Hidroxicloroquina y retinopatía en pacientes reumatológicos / Hydroxychloroquine use and retinopathy in rheumatologic patients

: relacionar el uso de hidroxicloroquina con la presencia de retinopatía en pacientes reumatológicos. Métodos: se realizó un estudio retrospectivo y descriptivo, de revisión de historias clínicas de pacientes reumatológicos en tratamiento con hidroxicloroquina. Se seleccionaron aquellos con evaluación oftalmológica previa al inicio del tratamiento y estudios como la OCT-SD. Se recolectaron variables clínico epidemiológicas, cálculo de dosis diaria y acumulada del fármaco, y duración del tratamiento. Resultados: se revisaron 150 historias, de las cuales 47 cumplieron con los criterios de inclusión; 44 (93,6%) eran del género femenino y 3 (6,4%) del género masculino. La edad promedio fue de 47 ± 14 años. La hipertensión arterial fue la comorbilidad más frecuente. La patología reumatológica más frecuente fue el Lupus (53,2%). La dosis diaria de hidroxicloroquina fue ≤ 6,5 mg/kg/día en los 47 pacientes; el tiempo promedio de consumo fue de 5 años; y la dosis acumulada promedio fue de 498,5 ± 503,68 gramos. Se detectó toxicidad retiniana en 18 pacientes (38,3%), de los cuales: 17(36,2%) tuvo daño precoz y 1 (2,1%) daño moderado. Se observó relación estadística significativa entre toxicidad retiniana y dosis acumulada menores a 1.000 gramos (p= 0,032) y un tiempo de consumo mayor o igual a 5 años (p = 0,045) Conclusiones: las alteraciones iniciales en las capas externas de la retina ayudan a la detección precoz de toxicidad retiniana por hidroxicloroquina, siendo la OCT-SD un método sensible y fácil de realizar en la práctica clínica(AU)

To establish the relationship between the use of hydroxychloroquine and retinopathies in rheumatologic patients. Methods: This is a retrospective, descriptive study of the medical charts of rheumatologic patients' who were receiving hydroxychloroquine. We selected patients previously seen in ophthalmologic services, and ophthalmologic coherence tomography (SD OCT) had been realized. We collected clinical and epidemiologic variables such as daily doses, accumulated doses and prescription duration. Results: we selected 47 medical charts; the female gender is 44 and three gender male. Mean age was 47 +14 years.Hypertension was the most frequent comorbidity.Lupus was the most frequent rheumatologic illness.Hydroxychloroquine daily dose was < 6.5 mg/Kg/day and treatment`s mean duration was 5 years; average accumulated dosage was 498.5 + 503.68 grs. We established retinal toxicity in 18 patients (38.3%), in which 17 (36.2%) had early damage, and 1(2.1%) had moderated damage. There was a statistical correlation between retinal toxicity and accumulated doses of less than 1.000 grs. (p: 0.032) as well as with time of use > 5 years (p:0.045) Conclusions: Early alterations of retinal superficial layers help in the detection of early retinal toxicity due to hydroxychloroquine use. OCTSD is a feasible and sensible study in daily medical practice(AU)

Síndromes paraneoplásicas reumatológicas / Rheumatologic paraneoplastic syndromes

Introdução: As síndromes paraneoplásicas são entidades polimórficas cujos sintomas não são atribuíveis a um tumor primário ou metastático. Seu aparecimento pode preceder, ser sincrônico ou suceder o diagnóstico de uma neoplasia. São geralmente deflagradas por mecanismos imunológicos em resposta a antígenos tumorais, ou por fatores hormonais. As paraneoplasias se caracterizam por relação de temporalidade com o surgimento de neoplasia, resposta parcial ou nula aos tratamentos convencionais, morbidade elevada e remissão com o tratamento adequado do tumor. Objetivamos aqui atualizar as principais síndromes paraneoplásicas musculoesqueléticas, utilizando-se os critérios de Bradford Hill. Serão discutidas as características clínicas, a frequência em determinados tumores e, quando possível, sua terapêutica. Métodos: revisão de literatura efetuada entre abril e maio de 2018 nos bancos de dados PubMed, Google Scholar e OMNIS PUCRS, utilizando as palavras-chaves: "paraneoplasm", "rheumatological", "osteomuscular". As síndromes paraneoplásicas osteomusculares descritas neste manuscrito foram identificadas através dos critérios de Brandford Hill, que priorizam a temporalidade entre seu surgimento e o diagnóstico de tumor. Resultados: Foram identificadas as seguintes paraneoplasias osteomusculares: osteoartropatia hipertrófica, poliartrite paraneoplásica, sinovite simétrica com "pitting" edema (RS3PE), fasciite palmar e poliartrite, miosites e a osteomalácia induzida por tumor. Conclusão: O reconhecimento precoce das paraneoplasias osteomusculares é de suma importância na cronologia diagnóstica de certos tumores. As síndromes paraneoplásicas osteomusculares estão relacionadas tanto a tumores sólidos quanto a hematológicos. A literatura acerca das síndromes paraneoplásicas reumatológicas se mostra limitada em número e rigor científico.

Introduction: Paraneoplastic syndromes are polymorphic entities whose symptoms are not attributable to a primary or metastatic tumor. Their appearance can precede, be contemporary or succeed the diagnosis of a neoplasm. They are usually deflagrated by immunological responses to tumor antigens or by hormonal factors. Paraneoplasias are characterized by relation of temporality with the onset of neoplasia, partial or no response to conventional treatments, high morbidity and remission with appropriate treatment of tumor. This study aims to update the main musculoskeletal paraneoplastic syndromes based on the Bradford-Hill criteria. Clinical characteristics, frequency in certain tumor and, when possible, their therapy will be discussed as well. Methods: Literary review performed between April and May 2018 in PubMed, Google Scholar and OMNIS PUCRS databases with keywords: "paraneoplasm", "rheumatological" and "osteomuscular". The musculoskeletal paraneoplastic syndromes described in this article were identified based on Bradford-Hill criteria, which prioritizes the temporality between its onset and the diagnosis of tumor. Results: Were identified the following musculoskeletal paraneoplasias: hypertrophic osteoarthropathy, paraneoplastic polyarthritis, Remitting seronegative symmetrical synovitis with pitting edema (RS3PE), palmar fasciitis and polyarthritis and cancer-associated myositis, tumor-induced osteomalacia. Conclusion: The early recognition of musculoskeletal paraneoplasias is of substantial importance in the diagnostic chronology of certain tumors. The musculoskeletal paraneoplastic syndromes are related to both solid and hematological tumors. The literature on rheumatological paraneoplastic syndromes is limited in number and scientific rigor.

Disfunción de la película lagrimal en pacientes reumatológicos / Disfunction tear film in patients rheumatologic

El síndrome de disfunción de la película lagrimal mejor conocido como ojo seco, por su variación clínico patológica conlleva a un subregistro en los pacientes, por lo que es necesario la valoración en nuestra consulta, para determinar varios aspectos en torno a la patología y su prevalencia en los pacientes del servicio de reumatología del Hospital Universitario de Caracas. Métodos: fue de tipo observacional descriptivo de corte transversal, evaluando pacientes con patologías reumatológicas que acudieron a la consulta en el servicio de oftalmología, la muestra fue de 59 pacientes con antecedentes reumatológicos, que no presentaron síntomas específicos de ojo seco del servicio de reumatología del Hospital Universitario de Caracas, durante el período junio 2013 ­ diciembre 2013.Se empleó la técnica de encuesta mediante un instrumento de recolección de datos tipo cuestionario que permitió identificar signos, síntomas y se logró medir cuantitativa y cualitativamente la secreción lagrimal y el grado de daño epitelial. Resultados: Se observó una prevalencia de 41,9 % del Síndrome Sjögren siendo más común en el sexo femenino y 44,8 % cursaban con SDPL, siendo más frecuente en el Síndrome de Sjögren. Asimismo 64,3 % de los pacientes con SDPL leve se encontraban sin tratamiento. Por su parte, 71,4 % de los pacientes con SDPL pertenecen al Síndrome de Sjögren. Conclusiones: El síndrome de disfunción de la película lagrimal es una entidad muy frecuente que debe tenerse presente siempre en patologías reumatológicas, y su control es esencial para la calidad visual del paciente(AU)

Syndrome of dysfunction of tear film as all too dry eye, for is relation pathologic clinic that begin to sub register in the patients, for that reason in necessary have a register in consult, for determine some aspects in relation with the illness and prevalence of tear film dysfunction in the patients of the rheumatology service University hospital of Caracas. Methods: The investigation was observation type, descriptive court traversal, evaluating patients on rheumatology pathologic that go to our ophthalmologist service. The total patients was 59 with antecedent rheumatologic, without specific symptoms of dry eye of the rheumatology service University Hospital of Caracas between June to December 2013. Using an assessment through an instrument of recollection information for tis way identify tool signs, symptoms were identified and managed quantitatively and qualitatively measure tear secretion and the degree of epithelial damage Results: The prevalence of 41.9 % of Sjögren 's syndrome is more common in females and 44.8 % were enrolled with SDPL, being more common in Sjögren's syndrome was observed. Also 64.3 % of patients with mild SDPL were untreated. Meanwhile, 71.4 % of patients with SDPL belong to Sjögren's syndrome. Conclusions: The syndrome of the tear film dysfunction is a very common condition that must be always present in rheumatologic diseases, and their control is essential for the patient's visual quality(AU)

Importancia diagnóstica de los anticuerpos antinucleares

Los anticuerpos antinucleares se presentan en el suero de pacientes con enfermedades de origen reumáticas, como el lupus eritematoso sistémico, síndrome de Sjögren, esclerosis sistémica progresiva y polimiositis. En 1948, descubrieron la célula lupus eritematoso y su relación con el lupus eritematoso sistémico, señalando el carácter autoinmune de la enfermedad, al demostrar la existencia de unas sustancias que la llamarían autoanticuerpos. Las pruebas de los anticuerpos antinucleares son muy útiles en el estudio de las enfermedades autoinmunes del tejido conjuntivo. Cada una de ellas dispone de una colección particular de anticuerpos que ayuda, en unos casos, a poder establecer el diagnóstico y, en otros, además, a señalar el pronóstico de la enfermedad

Antinuclear antibodies present in the serum of patients with rheumatic diseases origin, such as Systemic Lupus Erythematosus, Sjögren's syndrome, Progressive Systemic Sclerosis and Polymyositis. In 1948, they discovered the lupus Erythematosus cell and its relationship with Systemic Lupus Erythematosus, pointing to the autoimmune nature of the disease, by demonstrating the existence of substances that autoantibodies call. Testing antinuclear antibodies are very useful in the study of autoimmune connective tissue diseases. Each has a private collection of antibodies that help, in some cases, be able to establish the diagnosis, in others point the prognosis of the disease. There proteins is very important, and it constitutes a valuable tool like marker inflammatory in rheumatologic illnesses of immunological origin

Influência dos polimorfismos genéticos (IL10/CXCL8/CXCR2/ NF?B) na susceptibilidade das doenças reumatológicas autoimunes / Influence of genetic polymorphisms (IL-10/CXCL8/CXCR2/ NF?B) on the susceptibility of autoimmune rheumatic diseases

As doenças reumatológicas autoimunes, na maioria das vezes, possuem uma via genética comum para a autoimunidade. Vários genes foram associados com as doenças reumatológicas, para tanto iremos analisar somente alguns genes nos quais há várias evidências da existência de associação com risco ou proteção de doença autoimune. O fator de transcrição nuclear kappa B (NF-kappa B), o qual regula as respostas imunes e inflamatórias, está associado com esclerose sistêmica (ES), artrite reumatoide (AR) e lúpus eritematoso sistêmico (LES), assim como os genes CXCR2 e CXCL8. Já a interleucina 10 (IL-10), que é uma citocina anti-inflamatória, está associada com quase todas as doenças reumatológicas. Neste artigo, revisamos os potenciais papéis desses genes no sistema imunológico e em diversas doenças reumatológicas. Com relação à IL-10, diversos estudos foram realizados, porém em sua maioria contraditórios - alguns encontraram ausência de associação e outros encontraram associação em diferentes polimorfismos do genes. Já em relação ao NF-kappa B, somente foi estudado em AR e LES, e não foram observadas análises significativas relevantes. Os polimorfismos genéticos do gene CXCR2 foram associados com ES, mas não estão associados com AR e LES. Já os polimorfismos genéticos do gene CXCL8 não estão associados com ES, mas estão associados com AR.

The autoimmune rheumatologic disorders mostly have a common genetic path to the autoimmunity. Several genes have been associated with rheumatologic disorders; therefore, we are analyzing just the ones in those containing several evidences of the existence of association with the risk or protection from autoimmune disorder. The nuclear factor kappa beta (NF-kappa B), which regulates the autoimmune and anti-inflammatory responses, is associated with systemic sclerosis (SS), rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), just as the CXCR2 e CXCL8 genes. On the other hand, the interleukin-10 (IL-10), which is an anti-inflammatory cytokine, is associated with almost all rheumatologic disorders. In this article, we are reviewing the potential roles of these genes in the immune system and in several rheumatologic disorders. In relation to IL-10, several studies have been carried out, but most of them are controversial - some detected the absence of association, and others found association in different genetic polymorphisms. Conversely, in relation to NF-kappa B, it was studied just in RA and SLE, and no relevant significant analyses were observed. The genetic polymorphisms of the CXCR2 gene were associated with SS, but not with RA e SLE. On the other side, the genetic polymorphisms of the CXCL8 gene are not associated with SS, but with RA.

The Systemic Rheumatologic Disease and Neuromyelitis Optica

Neuromyelitis optica (NMO), an autoimmune inflammatory disease of the central nervous system (CNS), is related with autoantibodies for aquaporin-4, which is the most abundant water channel in CNS. The clinical syndromes of NMO, such as longitudinally extensive transverse myelitis and optic neuritis, can occur in the context of systemic rheumatologic diseases, such as systemic lupus erythematosus and Sjogren syndrome. It is debatable as to whether NMO is a feature of genetic tendency toward humoral autoimmunity or a CNS complication of systemic rheumatologic diseases. Current evidence suggests that NMO coexists with systemic rheumatologic diseases rather than a complication from them. Early immunosuppressive therapies should be considered in these patients since just one or two attacks can cause severe neurological disability.

Anticoncepción hormonal en mujeres jóvenes con enfermedades reumatológicas / Hormonal contraception in young women with rheumatic diseases

Antecedentes: Las enfermedades reumatológicas (ER) se presentan con mayor frecuencia en mujeres en edad fértil. Es durante este período que muchas mujeres consultan por trastornos de los flujos rojos, dismenorrea y prevención del embarazo. Objetivo: Realizar una puesta al día del uso de anticoncepción hormonal (AH) en mujeres jóvenes con ER, especialmente en las portadoras de lupus eritematoso sistémico (LES) y artritis reumatoide (AR). Método: Se revisó la literatura en Pubmed para los términos AH en ER, con especial énfasis en guías clínicas y ensayos clínicos aleatorizados. Resultados: El uso de AH en pacientes con LES inactivo o con actividad leve no ha mostrado un empeoramiento de la enfermedad. Tampoco existe evidencia categórica que demuestre un mayor riesgo trombótico en aquellas con anticuerpos antifosfolípidos negativos, para las cuales se recomienda el uso de cualquier tipo de AH. En pacientes con AR no se ha demostrado asociación del uso de AH y aumento de la actividad de la enfermedad. Además la interacción farmacológica entre AH y medicamentos reumatológicos es mínima. Existe escasa evidencia del uso de AH en mujeres menores de 18 años con ER. Conclusión: Basado en la evidencia disponible las pacientes con ER con anticuerpos antifosfolípidos negativos podrán utilizar AH según los criterios de la OMS, lo que abre las puertas a mayores alternativas terapéuticas y prevención de embarazo para estas adolescentes y mujeres jóvenes con ER.

Background: Rheumatologic diseases (RD) are most common in women of childbearing age. It is during this period that many women consult for menstrual disorders, dysmenorrhea and pregnancy prevention. Objective: To update the use of hormonal contraception (HC) in young women with RD. Method: Literature was reviewed in PubMed for HC and RD terms, with special emphasis on clinical guidelines and randomized clinical trials. Results: The use of HC in patients with inactive or mild activity systemic lupus erythematosus has not shown a worsening of the disease. Also, there is no evidence demonstrating greater thrombotic risk in those with negative antiphospholipid antibodies, for which the use of any type of HC is recommended. In patients with rheumatoid arthritis an association between use of HC and increases disease activity has not been demonstrated. In addition, there is minimal drug interaction between HC and rheumatologic drugs. There is little evidence of the use of HC in women less than 18 years with RD. Conclusion: Based on the available evidence the patients with RD and negative antiphospholipid antibodies could use HC according to WHO criteria, which leads to greater therapeutic alternatives and pregnancy prevention for these adolescents and young women with RD.

Reactive arthritis in tuberculosis: A case of Poncet’s disease

Reactive arthritis and erythema are uncommon presentations of tuberculosis (TB). Reactive arthritis in tuberculosis (TB) is known as Poncet’s disease, a rare aseptic form of arthritis observed in patients with active TB. We report a case of Poncet’s disease in a 20-year old man whose reactive arthritis overshadowed other clinical symptoms of TB resulting in delayed diagnosis and treatment. Although a conclusive diagnosis of Poncet’s disease is not possible, reactive immunologic reactions such as reactive arthritis and erythema nodosum even without respiratory symptoms should raise suspicion on possible TB. Thus, taking a thorough medical history as well as performing relevant examinations and investigations for possible TB will help expedite the diagnostic process.

Indicadores del estrés oxidativo en pacientes afectados por VIH/sida con manifestaciones reumatológicas / Oxidative stress indicators for HIV/AIDS patients with rheumatologic manifestations

Introducción: el estrés oxidativo se ha reconocido como cofactor en la progresión de la infección por el virus de la inmunodeficiencia humana (VIH) y en las manifestaciones reumatológicas. Objetivo: valorar los indicadores del estrés oxidativo en los pacientes afectados por VIH con manifestaciones reumatológicas. Métodos: se estudiaron 31 pacientes VIH con manifestaciones reumatológicas y se compararon los índices evaluados con un grupo control, 31 individuos aparentemente sanos. Los pacientes fueron clasificados según los siguientes criterios de actividad: escala de actividad de la enfermedad para manifestaciones reumatológicas, e índice de actividad de enfermedad y la escala visual analógica de dolor nocturno para manifestaciones reumatológicas. Las concentraciones plasmáticas de los indicadores de estrés oxidativo fueron cuantificadas mediante técnicas espectrofotométricas y el análisis estadístico realizado, mediante el programa estadístico SPSS 13. Resultados: los pacientes VIH evaluados presentaron un estrés oxidativo de moderado a severo, caracterizado por aumento significativo de los parámetros indicadores de daño oxidativo y disminución de los sistemas antioxidantes (p< 0,05), con respecto a lo evaluado en un grupo de pacientes supuestamente sanos relacionado en edad y género. No se encontró significación estadística en los estudios de asociación de las manifestaciones reumatológicas, el tiempo transcurrido desde el diagnóstico confirmado de la infección por el VIH y género, conteo de linfocitos T CD4+ ni la carga viral. Conclusiones: los datos muestran que los indicadores del proceso de estrés oxidativo empleados en los pacientes afectados por VIH con manifestaciones reumatológicas, podrían ser útiles en su seguimiento y tratamiento

Introduction: the oxidative stress has been recognized as a cofactor in the progression of the human immunodeficiency virus (HIV) infection and in the rheumatologic manifestations. Objective: to assess the oxidative stress indicators in those HIV patients with rheumatologic manifestations. Methods: thirty one HIV patients with rheumatologic manifestations were studied and the evaluated indexes were compared to those of a control group made up of 31 apparently healthy individuals. The patients were classified according to the following activity criteria: scale of the disease activity for the rheumatologic manifestations, and index of disease activity and the analogical visual scale of pain at night in terms of the rheumatologic manifestations. The plasma concentrations of the oxidative stress indexes were measured by spectrophotometric techniques. Statistical analysis was made using SPSS 13 program. Results: the evaluated HIV patients presented with moderate to severe oxidative stress, characterized by significant increase in the oxidative damage parameters and decrease in the antioxidizing systems (p< 0.05) after a comparison with those parameters of an apparently healthy control group in terms of age and gender. No statistically significance was found in the studies carried out to relate rheumatologic manifestations, time elapsed from the HIV confirmation, gender, CD4 lymphocyte T count and the viral load. Conclusions: the collected data showed that the oxidative stress indicators could be useful in treating and following-up the HIV patients with rheumatologic manifestations

O papel do gene e da molécula HLA-G na expressão clínica das doenças reumatológicas / The role of the HLA-G gene and molecule on the clinical expression of rheumatologic diseases

O antígeno leucocitário humano G (HLA-G) é uma molécula não clássica de complexo principal de histocompatibilidade (MHC) de classe I, caracterizada por baixo polimorfismo em sua região codificadora, um padrão de distribuição tecidual limitado em condições fisiológicas e expressão por meio de isoformas solúveis e acopladas à superfície de membranas por meio de splicing alternativo. O HLA-G é bastante conhecido por estar envolvido na indução e na manutenção da tolerância entre o sistema imunológico materno e o feto semialogênico ao nível da interface fetoplacentária. Além disso, diversos estudos apontam para um papel imunorregulatório mais amplo dessa molécula. Neste contexto, a expressão de HLA-G em doenças inflamatórias e reumatológicas é uma área relativamente recente de pesquisa. Os primeiros estudos descreveram a expressão de HLA-G em várias miopatias inflamatórias, dermatite atópica e psoríase cutânea. Com base nos achados de que o HLA-G poderia desviar respostas T helper para o tipo Th2, foi levantada a hipótese de que o HLA-G seria uma molécula protetora nas respostas inflamatórias. Neste artigo, revisamos os potenciais papéis da molécula HLA-G no sistema imunológico e em diversas doenças reumatológicas, tais como lúpus eritematoso sistêmico, artrite reumatoide, esclerose sistêmica e outras.

Human leukocyte antigen G (HLA-G) is a non-classic class I major histocompatibility complex (MHC) molecule characterized by low polymorphism in its coding region, a limited tissue distribution pattern in physiologic conditions, and expression through soluble isoforms and isoforms bound to surface membranes through alternative splicing. HLA-G is fairly known since it is involved in induction and maintenance of tolerance between the maternal immunologic system and the semi-allogeneic fetus at the level of the fetal-placental interface. Besides, several studies have indicated a wider immunoregulatory role of this molecule. In this context, the expression of HLA-G in inflammatory and rheumatologic diseases is a relatively recent research area. The first studies described the expression of HLA-G in several inflammatory myopathies, atopic dermatitis, and cutaneous psoriasis. Based on the findings that HLA-G could divert T helper responses to the Th2 type, it was hypothesized that HLA-G would be a protective molecule in inflammatory responses. In this article, we review the potential roles of the HLA-G molecule in the immune system and in several rheumatologic diseases, such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and others.

Impact of Rheumatologic Consultations on Detecting Interstitial Lung Disease Associated with Connective Tissue Disease

OBJECTIVE: In patients with interstitial lung disease (ILD) associated with connective tissue disease (CTD), chronic ILD related symptoms may often dominate the clinical picture or precede systemic findings and thus often be seen by a non-rheumatologist. The purpose of this study was to evaluate the importance of rheumatologic consultation during ILD work up. METHODS: We retrospectively reviewed 64 patients with ILD from a single tertiary center for their clinical and laboratory characteristics, rheumatologic consultation status, and result of the consultation. American College of Rheumatology criteria for classification of each connective tissue disease were utilized. Undifferentiated connective tissue disease (UCTD) was classified by pre-specified criteria. RESULTS: A total of 23 (36%) of the ILD patients had associated CTD. Five (8%) patients had underlying CTD before the diagnosis of ILD, whereas 18 (28%) patients were diagnosed with CTD after the rheumatologic consultation. ILD patients with CTD were predominantly female, had significantly more frequent radiographic diagnoses of nonspecific interstitial pneumonia, increased frequencies of high titer antinuclear antibody positivity, and rheumatoid factor positivity. Rheumatologic consultation was referred in 36 (56%) patients. In 18 (50%) of the referred patients, CTD was diagnosed. In 61% of the patients diagnosed with CTD as a result of rheumatologic consultation, changes in therapy occurred. CONCLUSION: A substantial proportion of patients with ILD are found to have an underlying CTD upon evaluation by a rheumatologist. Since ILD associated with CTD mimics idiopathic interstitial pneumonia, rheumatologic consultation may have a significant impact on the clinical care of ILD.

Analysis of Dermatologic Consultations in Rheumatologic Inpatients / 대한피부과학회지

BACKGROUND: Many different dermatologic manifestations can accompany a variety of systemic diseases such as rheumatic disorders. The number of patients who have skin lesions related to systemic diseases is steadily increasing. In such cases, dermatologic consultation can be important to diagnosis and treatment. OBJECTIVE: The purpose of this study was to analyze patterns of skin manifestations in rheumatic diseases. METHODS: We did an analysis of data for 192 inpatients who were referred by the department of rheumatology and consulted by the department of dermatology between May 1, 2005 and April 30, 2009. We retrospectively reviewed their medical records and noted age, sex, reasons for dermatologic consultation, diagnosis of the dermatoses and changed diagnosis after the consultation. RESULTS: The percent of patients who were referred by the department of rheumatology and consulted by the department of dermatology was 15.5% (192 consulted inpatients/1,242 rheumatologic inpatients). The most frequent age group was those in their 5th decade of life (23.0%) and the male to female ratio was 1:2.15. Consultations for dermatologic manifestations unrelated to systemic or rheumatic diseases were the most common reason for consultation (62.0%). Dermatoses related to systemic or rheumatic diseases were the 2nd most common reason of consultation (34.9%). Infectious diseases were the most common dermatoses (46 cases). There were 13 cases where there was a diagnosis of undetermined dermatoses and changed diagnosis after dermatologic consultation. CONCLUSION: Analysis of consultations from inpatients referred by the department of rheumatology to the department of dermatology indicates that there is a substantial number of patients that have skin manifestations of their rheumatic diseases.

El sistema inmunológico como herramienta diagnóstica de enfermedades reumatológicas / The immune system as a diagnosis tool of rheumatologic diseases

Introducción: los sistemas biológicos han sido objeto de muchas observaciones y recientemente se han convertido en modelos para ser emulados en diversos ambientes y ofrecer soluciones a problemas de la vida real. El sistema inmune es uno de los más representativos y en la actualidad constituye motivo de inspiración para la implementa-ción de sistemas computacionales que respondan a diversas tareas, constituyendo los Sistemas Inmunes Artificiales. Objetivo: este estudio busca desarrollar mecanismos computacionales inspirados en la inmunología para el diagnóstico de enfermedades reumatológicas que contribuyan en la educación y la toma de decisiones diagnósticas en reuma-tología. Se pretende obtener una herramienta computacional que, partiendo de un conjunto de historias clínicas como datos de entrenamiento, obtenga una efectividad en el diagnóstico comparable a los sistemas de clasificación de documentos actuales. El sistema está inspirado en la interacción entre los tejidos y los linfocitos B, y se apoya en conceptos de la teoría de la información para extraer relaciones entre términos. Los linfocitos B tendrán la función de discriminar la enfermedad reumatológica de un paciente con base en su historia clínica. Materiales y métodos: se utilizó un conjunto de datos compuesto por 54 historias clínicas de 54 pacientes en reumatología, entre los cuales 21 padecían artritis reumatoide, y el resto padecían otras enfermedades reumatológicas. El conjunto de datos se dividió en dos grupos: pacientes con artritis reumatoide y pacientes sin artritis reumatoide. Se hizo un procesamiento manual de las historias clínicas para eliminar toda la información que no fuera relevante para el sistema en la tarea de diagnóstico. La efectividad del sistema fue comparada frente a otros tres algoritmos de clasificación de texto ampliamente utilizados en tareas de clasificación de documentos (ID3, BayesNet y PsoSVM). Resultados: el sistema obtuvo resultados de efectividad prometedores en comparación con los demás algoritmos, con un promedio de 87,65% de efectividad en el diagnóstico. Sin embargo, debido a la limitación de datos, cabe la posibilidad de sesgo en los resultados. Se observó, como se había previsto, que los anticuerpos que representan la información en varios casos son redundantes. Adicionalmente, la información que representan no corresponde necesariamente a conocimiento médico, sino a reglas de clasificación de texto. Conclusiones: la teoría de la información, ayudada por la teoría del sistema inmunológico adapta-tivo y un mecanismo de señalización, muestra tener un potencial grande para la clasificación de historias clínicas. Debido a la posibilidad de sesgo observada en los resultados, será necesario realizar experimentos adicionales sobre un conjunto de historias clínicas más numeroso y más heterogéneo. Aunque entre los experimentos no se obtuvo anticuerpos que representaran claramente los conceptos, de tal manera que puedan ayudar a un profesional médico en el aprendizaje para la toma de decisiones, el trabajo a seguir consiste en adaptar técnicas de procesamiento de lenguaje natural (i.e., sintaxis y semántica), para así llegar a un sistema de obtención de conocimiento en lugar de un sistema de obtención de reglas de clasificación de texto.

Introduction: the biological systems have been observed and analyzed carefully and they have transformed into models to be emulated in many types of scenery and these offer solutions to problems of the real life, more recently. The immune system is one of the most representatives and at the moment is used for implementation of computational systems to respond to many tasks, constituting the Artificial Immune Systems. Objective: in this work a computational method inspired by immunology for diagnosis of rheuma-tologic diseases is developed. The goal is to obtain a computational tool that, given a group of clinical histories as training data, performs rheumatologic diagnosis comparable to the current systems used in document classification. The proposed tool is expected to contribute in education and decision making in rheumatologic diagnosis. The proposed system is inspired by the interaction between tissues and B lymphocytes, and it relies on concepts of information theory to extract relationships among terms. The B lymphocytes will have the function of discriminating a patient’s rheumatic diseases based on its clinical history. Materials and methods: a dataset consisting of 54 medical records from 54 patients with rheumatologic diseases was used; 21 patients suffered rheumatoid arthritis, and the rest suffered other rheumatologic diseases. The dataset was divided into two groups: patients with and without rheumatoid arthritis. A manual process on the clinical histories was performed to eliminate the irrelevant information in the diagnosis task. The effectiveness of the system was compared to other three text classification algorithms widely used in document classification tasks, namely, ID3, BayesNet and PsoSVM. Results: the proposed system obtained promising results in comparison with other algorithms, with an average of 87,65% effectiveness in the diagnosis. However, due to the limitation of the data, there is a possibility that the results are biased. It was observed, as expected that the antibodies that represent the information in several cases are redundant. Additionally, the information that it represents not necessarily corresponds to medical knowledge, but to rules of text classification. Conclusions: information theory in conjunction with an adaptive immune system and a signaling mechanism showed great potential for the classi-fication of medical records. Due to the possibility of a bias in the results, it will be necessary to carry out additional experiments on a larger and more heterogeneous group of medical records. From the experiments, antibodies that clearly represented concepts explaining rheumatoid arthritis were not obtained, which could help medical trainees in the learning process and medical doctors in decision making. Therefore, in future work, the task to continue consists on adapting natural language processing methods (i.e., syntax and semantics) to obtain a knowledge extraction system instead of a set of rules for text classification.

Use of complementary therapies for rheumatologic conditions among patients of rheumatologists

BACKGROUND: Use of Complementary and Alternative Medicine(CAM) is common among patients with chronic conditions such as rheumatic disorder. This study was conducted to know rate and behavior of using CAM and to improve doctor patient relationship in rheumatic patients. METHODS: Among patients visiting a tertiary hospital rheumatology clinic, 867 persons (15.8% of total) were selected conveniently and interviewed by a trained nurse according to structured questionnaire from July 1st through July 31st 1999. Three hundreds and sixty two CAM users completed the interview. RESULTS: Among 867 persons interviewed, 372 persons had used CAM (use rate 44%). Use rate of Chinese medicine was 26%, CAM except Chinese medicine 21%. Herb medicine(49.4%) was the commonest single category of all CAM. Twenty four percents of users had used two or more types of CAM, 6.8% had experienced adverse effects. The average yearly cost for CAM was 704,000 won/person, 64% of the one for hospital use, 1,100,000 won/person. The subjectively rated degree of effectiveness was 6.3 points which was significantly higher when compared with 5.9 points for hospital services. The degree of satisfaction with CAM was 5.6 points which was higher than that of hospital services, 4.8 points. The most frequently reported reason for using CAM was the hope for synergic treatment effect(32%). The proportion of experiencing adverse effects from CAM was 7% of all users. Only one fourth of the users had discussed on the CAM use with the western doctors. The commonest reason for not discussing CAM was that the respondents had no need to discuss about it (40%). Among doctor's attitudes when discussing CAM with patient, limited approval was most common.(40%) CONCLUSION: Among patients with rheumatic conditions, 44% use CAM. Herb medicine was most commonly used CAM. Comparing with hospital services, cost for CAM is 2/3 but its subjective effectiveness and satisfaction are higher. Western doctors must consider appropriately the need from users of alternative medicine.