Cambio de diagnóstico y de categoría diagnóstica en pacientes con artritis idiopática juvenil en 7 años de seguimiento / Change of diagnosis and diagnostic category in patients with juvenile idiopathic arthritis within 7 years of follow-up

Resumen: Introducción: Al menos 50% de los pacientes pediátricos portadores de artritis idiopática juvenil (AIJ) continuará control en reumatología adulto. La clasificación de la Liga Internacional de Asociaciones de Reumatología (ILAR) vigente, actualmente en revisión, difiere de la clasificación de las artritis inflamatorias del adulto. Se ha reportado cambios de categoría en 10,8% de los pacientes durante el seguimiento. Objetivo: Analizar los pacientes con AIJ seguidos al menos 7 años para objetivar cambios de diagnós tico en la transición, e identificar factores de mal pronóstico funcional. Pacientes y Método: Estudio retrospectivo en base a registros clínicos. Se incluyó a la totalidad de los pacientes con AIJ controla dos en policlínico pediátrico del Hospital de Puerto Montt entre el año 2005 y 2017, que cumplieron siete o más años de seguimiento. Se realizó análisis descriptivo en base a variables clínicas: categoría diagnóstica, tiempo de evolución al diagnóstico, actividad clínica y serológica, y tiempo de evolución al inicio de la terapia farmacológica. Resultados: Se evaluaron 18 pacientes, 3 Oligo-articular (OA) persistente, 1 OA extendida, 4 Poli-articular (PA) factor reumatoide (FR) negativo, 4 PA FR positivo, 5 Sistémicas, 1 Psoriática, todos con seguimiento mayor a 7 años. Once de 18 niños fueron transfe ridos a adultos. Tres de 11 cambiaron de diagnóstico a Artritis Reumatoide (AR) más otra enferme dad autoinmune: Síndrome de Sjögren + Lupus eritematoso sistémico, Púrpura trombocitopénico inmune, Enfermedad autoinmune no clasificada y cinco de 11 niños de categoría ILAR: OA a Artritis reumatoide juvenil, OA extendida a PA FR negativo, 3 Sistémicas a PA FR negativo. Edad de inicio, formas poli-articulares, retrasos en diagnóstico y comienzo de terapia se asociaron a secuelas e infla mación persistente. Conclusiones: Ocho de once pacientes transferidos cambiaron denominación diagnóstica y/o presentaron otras enfermedades autoinmunes. Algunos factores de mal pronóstico deben mejorar.

Abstract: Introduction: At least 50% of pediatric patients with Juvenile Idiopathic Arthritis (JIA) will require continued fo llow-up in adult rheumatology. The present International League of Associations for Rheumatology (ILAR) classification, currently under revision, differs from its classification of inflammatory arthritis in adults. Category changes have been reported in 10.8% of patients during follow-up. Objective: To analyze JIA patients in follow-up for at least 7 years to detect diagnosis changes during transition to adult care, identifying factors of poor functional prognosis. Patients and Method: Retrospective study based on medical records of JIA patients seen at the pediatric polyclinic of the Puerto Montt Hospital between 2005 and 2017, who were monitored for at least 7 years. Descriptive analysis was performed according to clinical variables: diagnostic category, evolution before diagnosis, clinical and serological activity, and evolution before starting drug therapy. Results: We evaluated 18 pa tients, corresponding to 3 patients with persistent oligoarticular arthritis (OA), 1 with extended OA, 4 with polyarticular arthritis (PA) rheumatoid factor (RF) negative, 4 with PA RF positive, 5 with syste mic JIA, and 1 with psoriatic arthritis, all have had follow-up more than 7 years. 11 out of 18 patients transitioned to adult care. Three out of 11 patients changed diagnosis to Rheumatoid Arthritis (RA) plus another autoimmune disease such as Sjögren's Syndrome + Systemic Lupus Erythematosus, Immune thrombocytopenia, or unclassified autoimmune disease, and 5 out of 11 children changed ILAR category from OA to Juvenile Rheumatoid Arthritis, extended OA to PA RF negative, and 3 from Systemic arthritis to PA RF negative. Age of onset, polyarticular forms, delay in diagnosis, and the start of therapy were associated with sequelae and persistent inflammation. Conclusions: Eight of the eleven JIA patients who transitioned to adult care changed their diagnosis or presented other autoimmune diseases. Some factors of poor prognosis must improve.

Emerging intervention of antidepressant with DMARD in non-cancerous nociceptive persistent pain associated depression in FCA induced rheumatoid arthritic rats

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that causes pain, systemic complications and premature mortality. Depression has also been identified as a problem for persons with RA. This association remaining significant even after the degree of disease activity is controlled. In the present study, the efficacy of combination therapeutic effect of antidepressant (amitriptyline) with Disease Modifying Anti rheumatoid drug (leflunomide) was determined in rheumatoid arthritis pain associated depression in Freund's complete adjuvant (FCA) induced arthritic rats. Drug treatment was started 9 days after induction of FCA induced arthritis in rats. The antiarthritic activity was assessed by measuring paw volume, weight-bearing, hematological, biochemical, serological parameters, Radiographic analysis and Histopathology of tibiotarsal joints. The antidepressant activity was assessed by Forced swimming test, Rota-rod test and confirmed by estimation of brain neuro transmitters (serotonin and norepinephrine) level. Results of this study revealed that leflunomide and amitriptyline combination showed more significant (p<0.001) antiarthritic and antidepressant action and leflunomide alone treatment showed significant (p<0.001) antiarthritic activity only as compared to arthritic control. The leflunomide and low dose amitriptyline combination found to be more effective in pain associated depression in rheumatoid arthritic rats

Effect of iguratimod on diclofenac metabolism by CYP2C9 in rats and human recombinant CYP2C9 yeast cells

Iguratimod (IGU, also known as T-614), a novel disease modifying antirheumatic drug intended to cure patients with rheumatoid arthritis (RA). The purpose of this study is to evaluate the effect of IGU on the pharmacokinetics of CYP2C9 probe drug diclofenac and its metabolite 4′-hydroxy diclofenac in vivo and in vitro. In in vivo experiments, 24 rats were randomly assigned to three groups consisting of the control group (Normal saline), low dose IGU group (10 mg/kg) and high dose IGU group (30 mg/kg). Blood samples were collected from orbital sinuses vein before 1 hour and serial times of giving diclofenac (15 mg/kg) to all the rats. Plasma concentration of diclofenac and its metabolite 4´-hydroxy diclofenac were assayed by high performance liquid chromatography. Pharmacokinetic parameters were assessed by Winnonlin 6.4 pharmacokinetic software. Moreover, in vitro studies were performed in recombinant human CYP2C9 yeast cell system. IGU at low dose showed no significant differences in the pharmacokinetic parameters of diclofenac and 4-hydroxy diclofenac in vivo when compared with control group (p>0.005). However, at the high dose of IGU, the pharmacokinetic parameters of 4´-hydroxy metabolite of diclofenac increase in half-life (T1/2) and mean area under the curve (AUC0→24), while a decrease in mean clearance (CL, mL/h/kg) and volume of distribution Vz (mL/kg). In addition, in in vitro study, high doses of IGU reduces the metabolism rate of diclofenac. IGU at high dose significantly increase the pharmacokinetics parameters of 4´-hydroxy diclofenac in rats. Additionally, it also showed the potent inhibitory effect on diclofenac metabolism in recombinant human CYP2C9 yeast cells.

Comparison of Plasma Cytokine Levels before and after Treatment with Rituximab in Patients with Rheumatoid Arthritis and Systemic Lupus Erythematosus-Associated Polyautoimmunity / Comparación de citocinas plasmáticas antes y después del tratamiento con rituximab en pacientes con artritis reumatoide y lupus eritematoso sistémico asociado a poliautoinmunidad

Introducción: La coexistencia de más de una enfermedad autoinmune (EAI) en un paciente se conoce como poliautoinmunidad (PAI) y se observa en el 35% de los pacientes con EAI. La eliminación de linfocitos B usando rituximab (RTX) controla la actividad de diferentes EAI. En el lupus eritematoso sistémico (LES) y en PAI no es clara la producción de citocinas por los linfocitos B. Métodos: Estudio exploratorio. Se obtuvo plasma de 11 pacientes con artritis reumatoide (AR) y poliautoinmunidad asociada a LES (PAILES) antes y después de rituximab (i. e., 6 meses). Como controles se utilizaron ocho individuos sanos. Las citocinas se midieron por ELISA (IFN-a, TGF-pl) o Cytometnc Bead Array (TNF-a, IL-ip, IL-ó, IL-8, IL-10, IL-12p7O). Resultados: Previo a RTX, IL-ó se encontró elevada únicamente en AR, mientras que IL-8 lo estuvo en AR y en PAILES, comparados con controles. Después de RTX se encontró una disminución significativa de IL-ó en AR y de IL-8 en PAILES. Las concentraciones de otras citocinas medidas fueron similares (IFN-a, TGF-B1) o se encontraron por debajo de límite de detección (TNF-a, IL-1[3, IL-10, IL-12p7O), tanto en pacientes como en controles. Conclusión: Los datos resaltan la importancia de la secreción de citocinas por los linfocitos B y sugieren un rol diferencial en cada patología. El incremento de IL-8 previo a RTX en ambos grupos y la reducción después de la terapia en PAILES respaldan el potencial de la IL-8 como objetivo terapéutico. La heterogeneidad de la población de pacientes con PAI reafirma la importancia de la selección de subgrupos específicos en estudios futuros.

Introduction: Coexistence of more than one autoimmune disease (AD) in a single patient is known as polyautoimmunity, and may be seen in up to 35% of patients with ADs. The elimination of B-cells using Rituximab (RTX) improves clinical status in different ADs. The role of cytokine production by B-cells is unclear in systemic lupus erythematosus (SLE) and polyautoimmunity. Methods: As an exploratory study, plasma from 11 patients with either rheumatoid arthritis (RA) or SLE-associated polyautoimmunity was assessed prior and 6 months after therapy with RTX. Eight healthy individuáis were used as Controls. Cytokine levels were measured using ELISA (IFN-a and TGF-61) or Cytometric Bead Array (TNF-a, IL-1

Analysis of four serum biomarkers in rheumatoid arthritis: association with extra articular manifestations in patients and arthralgia in relatives / Análise de quatro marcadores sorológicos na artrite reumatoide: associação com manifestações extra-articulares no paciente e artralgia em familiares

ABSTRACT Objectives: To evaluate the frequency of four serum biomarkers in RA patients and their relatives and identify possible associations with clinical findings of the disease. Methods: This was a transversal analytical study. Anti-cyclic citrullinated peptide (anti-CCP), anti-mutated citrullinated vimentin (anti-MCV) and IgA-rheumatoid factor (RF) were determined by ELISA and IgM-RF by latex agglutination in 210 RA patients, 198 relatives and 92 healthy controls from Southern Brazil. Clinical and demographic data were obtained through charts review and questionnaires. Results: A higher positivity for all antibodies was observed in RA patients when compared to relatives and controls (p < 0.0001). IgA-RF was more frequent in relatives compared to controls (14.6% vs. 5.4%, p = 0.03, OR = 2.98; 95% CI = 1.11-7.98) whereas anti-CCP was the most common biomarker among RA patients (75.6%). Concomitant positivity for the four biomarkers was more common in patients (46.2%, p < 0.0001). Relatives and controls were mostly positive for just one biomarker (20.2%, p < 0.0001 and 15.2%, p = 0.016, respectively). No association was observed between the number of positive biomarkers and age of disease onset, functional class or tobacco exposure. In seronegative patients predominate absence of extra articular manifestations (EAMs) (p = 0.01; OR = 3.25; 95% CI = 1.16-10.66). Arthralgia was present in positive relatives, regardless the type of biomarker. Conclusions: A higher number of biomarkers was present in RA patients with EAMs. Positivity of biomarkers was related to arthralgia in relatives. These findings reinforce the link between distinct biomarkers and the pathophysiologic mechanisms of AR.

RESUMO Objetivos: Avaliar a frequência de quatro marcadores sorológicos em pacientes com AR e seus familiares e identificar possíveis associações com achados clínicos da doença. Métodos: Estudo analítico transversal. Determinaram-se os níveis de anticorpos antipeptídeo citrulinado cíclico (anti-CCP), anticorpos antivimentina citrulinada-mutada (anti-MCV) e fator reumatoide (FR) IgA por Elisa e de FR-IgM por aglutinação em látex em 210 pacientes com AR, 198 familiares e 92 controles saudáveis do sul do Brasil. Coletaram-se dados clínicos e demográficos por meio da revisão de prontuários e questionários. Resultados: Observou-se maior positividade para todos os anticorpos em pacientes com AR em comparação com os familiares e controles (p < 0,0001). O FR-IgA era mais frequente em familiares quando comparados com os controles (14,6% versus 5,4%, p = 0,03, OR = 2,98; IC95% = 1,11 a 7,98). O anti-CCP foi o biomarcador mais comum entre pacientes com AR (75,6%). A positividade concomitante para os quatro biomarcadores foi mais comum nos pacientes (46,2%, p < 0,0001). Familiares e controles eram positivos em sua maioria para apenas um biomarcador (20,2%, p < 0,0001 e 15,2%, p = 0,016, respectivamente). Não foi observada associação entre o número de biomarcadores positivos e a idade de início da doença, classe funcional ou exposição ao fumo. Em pacientes soronegativos, predominou a ausência de manifestações extra-articulares (MEA) (p = 0,01; OR = 3,25; IC95% = 1,16 a 10,66). A artralgia estava presente em familiares positivos, independentemente do tipo de biomarcador. Conclusões: Um maior número de biomarcadores estava presente em pacientes com AR com MEA. A positividade dos biomarcadores estava relacionada com a artralgia em familiares. Esses achados reforçam a ligação entre os diferentes biomarcadores e os mecanismos fisiopatológicos da AR.

Profile of patients with rheumatic diseases undergoing treatment with anti-TNF agents in the Brazilian Public Health System (SUS), Belo Horizonte - MG

The aim of this study was to describe the baseline demographic and clinical characteristics as well as the functional status of a prospective cohort of patients with rheumatic diseases assisted by the Brazilian Public Health System (SUS). Data for 302 patients receiving tumor necrosis factor α inhibitors (anti-TNF agents) was collected through a standard form. Among patients, 229 (75.8%) were female and 155 (51.3%) were Caucasian; the mean age was 50.3 ± 12.8 years, and the mean disease duration was 9.9 ± 8.7 years. Among them 214 patients (70.9%) received adalimumab, 72 (23.8%) etanercept, and 16 (5.3%) infliximab. Mean Health Assessment Questionnaire-Disability Index (HAQ-DI) was 1.37 ± 0.67 for all participants. Poor functional response was associated with female gender, married patients and with a score of < 0.6 on the EuroQoL-5 dimensions (EQ-5D). Significant correlation was found between the HAQ-DI values, disease activity and quality of life (QOL). The results obtained in this study contribute to a better understanding of the clinical and demographic characteristics of patients with rheumatic diseases at the beginning of anti-TNF-agent treatment by SUS. Furthermore, our findings are consistent with another Brazilian and foreign cross-sectional investigations. This knowledge can be of great importance for further studies evaluating the effectiveness of biological agents, as well as, to contribute to improve the well-being of the patients with rheumatic diseases.

O objetivo do estudo foi descrever as características demográficas e clínicas iniciais, bem como o estado funcional de uma coorte de pacientes com doenças reumáticas tratados pelo Sistema Único de Saúde (SUS). Dados de 302 pacientes em uso de inibidores do fator de necrose tumoral (agentes anti-TNF) foram coletados por formulário padronizado. Desses, 229 (75.8%) eram mulheres e 155 (51.3%) eram brancos; a idade média foi 50,3 ± 12,8 anos, e a duração média da doença foi de 9,9 ± 8,7 anos. Entre os pacientes 214 (70,9%) usaram adalimumabe, 72 (23,8%) etanercepte e 16 (5,3%) infliximabe. A média do Health Assessment Questionnaire-Disability Index (HAQ-DI) foi 1,37 ± 0,67 para a população total. Pior resposta funcional estava associada com mulheres, pacientes casados e com um valor de EuroQoL-5 dimensions (EQ-5D) < 0.6. Correlação significativa foi obtida entre os valores de HAQ-DI, atividade das doenças e qualidade de vida. Os resultados obtidos no estudo contribuem para o melhor entendimento das características clínicas e demográficas de pacientes com doenças reumáticas iniciando a terapia com agentes anti-TNF pelo SUS. Além disso, nossos achados são consistentes com resultados obtidos em outros estudos transversais nacionais e estrangeiros. Este conhecimento pode ser de grande importância para estudos futuros que avaliem a eficácia de agentes biológicos, assim como, para contribuir para a melhoria do bem-estar das pessoas com doenças reumáticas.

The Role of Bone Scintigraphy in the Diagnosis of Rheumatoid Arthritis According to the 2010 ACR/EULAR Classification Criteria

We aimed to investigate the role of bone scintigraphy (BS) in the diagnosis of rheumatoid arthritis (RA) as a supplement to the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria. A total of 156 patients who underwent BS with screening laboratory to confirm RA were enrolled. We divided them into two groups according to the presence of arthritis upon the first physical examination, and evaluated the diagnostic validity of BS as an independent (BS only) or assistant diagnostic tool using the 2010 criteria (BS-assisted). Seventy-five patients had active arthritis (Group I), while the remaining 81 patients did not (Group II). Among them, 56 patients in group I and 5 patients in group II were finally classified as RA. In the group I patients who were eligible for application of the 2010 criteria, the sensitivity of the BS only and BS-assisted diagnosis was not superior to that of the 2010 criteria. However, BS-assisted diagnosis showed high positive prediction values in group I patients with 2010 criteria score < 6 and group II patients. Therefore, BS is still helpful to detect RA even after the introduction of the 2010 criteria, especially among patients who do not satisfy the 2010 criteria as well as those who are ineligible for the 2010 criteria due to dubitable arthritis at clinical presentation.

Enfermedades del tejido conectivo: importancia del diagnóstico precoz / Connective tissue diseases: importance of early diagnosis

Las Enfermedades del Tejido Conectivo (ETC) son entidades de baja prevalencia en la población general. Son de naturaleza inflamatoria y autoinmune, tienden a la cronicidad y al compromiso de muchos parénquimas, órganos y tejidos, dejando en ellos daño estructural y funcional. Dado lo anterior, amenazan la vida o disminuyen la expectativa y calidad de vida. El diagnóstico y tratamiento precoz de estas entidades, permite cambiar su curso y muchas veces lograr remisión. Es por lo tanto de suma importancia tenerlas en mente y sospecharlas como entidades de enfermedad e iniciar un tratamiento oportuno.

Connective Tissue Diseases have a low prevalence in the general population. They are inflammatory autoimmune diseases, chronic in nature and compromise different tissues and organs, leaving permanent and irreversible damage. They threaten live, and diminish quality and expectancy of life. Early diagnosis and treatment can change their natural course and in many cases induce remission. A high suspicion is necessary for a prompt diagnosis.

Efficacy, safety and tolerability of using abatacept for the treatment of rheumatoid arthritis

The objective is to provide an update on the clinical efficacy, safety and tolerability of the use of abatacept for treating rheumatoid arthritis. A systematic review (up to June 2011) followed by meta-analyses was performed. Randomized controlled clinical trials comparing abatacept at a dose of 10 mg/kg with a placebo, both with concomitant methotrexate, were used. Only high- or moderate-quality studies were included. The efficacy was evaluated based on changes in the ACR, DAS and HAQ; safety was assessed based on serious adverse events, serious infections, malignancies and deaths; tolerability was evaluated based on the withdrawals due to adverse events, serious adverse events and lack of efficacy. All these parameters were evaluated within one year of treatment. Nine studies met the inclusion criteria, comprising 4,219 patients. For all of the efficacy parameters, the abatacept group had better results than the placebo group, except in the case of HAQ improvement >0.3, which presented no statistically significant difference. None of the safety parameters presented a significant difference between the groups. The tolerability parameters were also similar between groups, with the exception of withdrawals due to lack of efficacy. For this criterion, the abatacept group presented favorably compared to the control group. Abatacept showed a higher efficacy compared to placebo without significant differences between the abatacept and control group in terms of safety.

O objetivo foi fornecer dados atualizados sobre eficácia clínica, segurança e tolerabilidade do uso de abatacepte para o tratamento da artrite reumatoide. Realizaram-se uma revisão sistemática (com dados até junho/2011) e metanálises. Somente estudos clínicos controlados randomizados comparando o abatacepte (10 mg/kg) com placebo, ambos com uso concomitante de metotrexato, foram incluídos; todos possuíam qualidade alta ou moderada. A eficácia foi avaliada baseando-se em mudanças no ACR, DAS e HAQ; a segurança foi avaliada pelos eventos adversos e infecções graves, malignidades e mortes e a tolerabilidade pelo abandono do tratamento devido a eventos adversos (graves ou não) e falta de eficácia. Todos esses parâmetros foram avaliados ao final de um ano de tratamento. Nove estudos se adequaram aos critérios de inclusão, envolvendo 4219 pacientes. Em todos os parâmetros avaliados, o grupo tratado com abatacepte obteve melhores resultados, exceto para a melhora (>0,3) no HAQ (sem diferença estatisticamente significativa). Nenhum critério de segurança ou tolerabilidade apresentou diferença significativa entre os grupos, com exceção dos abandonos devido à falta de eficácia (grupo abatacepte apresentou resultados favoráveis em relação ao controle). O abatacepte possui maior eficácia quando comparado com o placebo, sem diferença significativa entre os grupos em termos de segurança.

Sinovectomia artroscopica para el tratamiento de la artritis reumatoidea en la rodilla / Arthroscopic sinovectomy for the treatment of rheumatoid arthritis of the knee

El objetivo de este trabajo es presentar nuestra experiencia en 30 rodillas de 27 pacientes sometidos a sinovectomía artroscópica de rodilla por padecer sinovitis de rodilla de más de 6 meses de evolución con el propósito de describir la técnica quirúrgica, evaluar resultados y determinar el lugar de esta técnica dentro del arsenal terapéutico actual de la artritis indiferenciada y reumatoidea. Material y métodos: Se incluyen en el estudio 30 rodillas en 27 pacientes intervenidos entre agosto de 1999 y agosto de 2006, pudiendo ser evaluadas 20 rodillas con un seguimiento mínimo de 12 meses. Resultados: El follow up promedio fue de 44,48 meses. Para la evaluación se utilizó el Score de Lysholm modificado por Klein y Jensen, con un máximo de 100 puntos. El valor promedio preoperatorio de 42,63 puntos se incrementó a 90 puntos en el postoperatorio. El 80 de las rodillas evaluadas fueron catalogadas como resultados buenos y excelentes. Conclusiones: La sinovectomía artroscópica es un procedimiento seguro. Atribuimos los buenos resultados obtenidos a una derivación precoz del paciente y a la completa resección de tejido sinovial.

Pattern of young and elderly onset rheumatoid arthritis among a group of Egyptian patients

Rheumatoid arthritis [RA] differs depending on the age of disease onset. The differences between young onset rheumatoid arthritis [YORA] and elderly onset rheumatoid arthritis [EORA] are important because they have clinical and therapeutic implications. The study was conducted on 1185 patients who were ranked after classification according to age at onset of the disease into YORA I, 16-40 years, YORA II, 41-60 years and EORA >60 years. All were compared, based on disease duration [DD], disease activity, severity parameters and drug history. YORA I comprised 298 patients, 28.85% males, age 29.4 +/- 6 and DD 4 +/- 3.3 y, YORA II included 539 patients, 33.77% males, age 49.7 +/- 6.1 y. and DD 6.5 +/- 5.6 y. EORA included 348 RA patients 40.5% males, age 67.1 +/- 6.6 y, DD 9.95 +/- 7.2 y. Activity was increased in EORA compared to YORA I and YORA II, while severity decreased in EORA. ESR, CRP and degree of anemia were higher in EORA. RF titer was higher in YORA. In YORA peripheral joints of the hands and feet were more involved while, large joints in EORA. Rheumatoid nodules were increased in YORA I than EORA p= 0.04. Polymyalgia rheumatica was exclusively present in EORA group 25 patients 7.2%. YORA used methotrexate and its mean dose was higher than EORA. EORA on multiple DMARD 57.9% or biologics 0.8% was significantly lower compared with YORA 186.3% and 1.7%, p= 0.001. EORA has more active and less disabling and affects more males than YORA. The use of biologic therapy and combination DMARD therapy was less in EORA

Sinovectomia artroscopica para el tratamiento de la artritis reumatoidea en la rodilla / Arthroscopic knee synovectomy in knee rheumatoid arthritis

El objetivo de este trabajo es presentar nuestra experiencia en 30 rodillas de 27 pacientes sometidos a sinovectomÍa artroscópica de rodilla por padecer sinovitis de rodilla de más de 6 meses de evolución con el propósito de describir la técnica quirúrgica, evaluar resultados y determinar el lugar de esta técnica dentro del arsenal terapéutico actual de la artritis indiferenciada y reumatoidea. Material y Métodos: Se incluyen en el estudio 30 rodillas en 27 pacientes intervenidos entre Agosto de 1999 y Agosto de 2006, pudiendo ser evaluadas 20 rodillas con un seguimiento mínimo de 12 meses. Resultados: El follow up promedio fue de 44.48 meses. Para la evaluación se utilizó el Score de Lysholm modificado por Klein y Jensen, con un máximo de 100 puntos. El valor promedio preoperatorio de 42.63 puntos se incrementó a 90 puntos en el postoperatorio. El 80% de las rodillas evaluadas fueron catalogadas como resultados buenos y excelentes. Conclusiones: La sinovectomÍa artroscópica es un procedimiento seguro. Atribuimos los buenos resultados obtenidos a una derivación precoz del paciente y a la completa resección de tejido sinovial.

Diagnóstico y evaluación en pacientes con artritis reumatoidea / Diagnosis and evaluation in rheumatoid arthritis patients

La artritis reumatoidea (AR) es una enfermedad heterogénea y de curso fluctuante, que requiere de la evaluación objetiva por el médico especialista (reumatólogo). Los principales factores de mal pronóstico son: presencia defactor reumatoideo (FR) y anticuerpos anti péptidos cíclicos citrulinados (CCP), actividad inflamatoria elevada, grados elevados de discapacidad funcional, retardo en la iniciación de un tratamiento específico, presencia de manifestaciones extraarticulares, bajo nivel socioeconómico, presencia deerosiones óseas. La evaluación objetiva de pacientes con AR debe incluir: recuento de articulaciones dolorosas y tumefactas, evaluación del dolor y la actividad por escalas visuales, evaluación de la rigidez matinal, evaluación de la capacidad funcional por cuestionarios validados y culturalmente adaptados (HAQDI), evaluación bioquímica de la actividad de la enfermedad con eritrosedimentación y/o proteína C reactiva, evaluación del daño estructural con radiografías de manos, pies y articulaciones afectadas. La utilización de índices compuestos de actividad de la enfermedad ayuda a un mejor control del paciente. Los índices más utilizados son DAS28, SDAI, CDAI y IAS. La evaluación de la calidad de vida por cuestionarios específicos es de utilidad en ensayos clínicos, pero es poco práctico en la consulta diaria. La utilización anual de índices simplificados (SENS) para cuantificar el daño radiológico es aconsejable para un adecuado monitoreo del tratamiento. La utilización de técnicas de imágenes con mayor sensibilidad y especificidad como la ecografía y la resonancia magnética pueden ser de utilidad en casos seleccionados. La pronta derivación al reumatólogo, el diagnóstico temprano y la iniciación de un tratamiento específico antes de los 4 meses son fundamentales para poder revertir el curso natural de la enfermedad.

El laboratorio en las enfermedades reumáticas autoinmunes / The laboratory in the rheumatic diseases autoinmunes

Las enfermedades reumáticas autoinmunes son un grupo de padecimientos crónicos de etiología desconocida, que pueden compartir manifestaciones clínicas y hallazgos de laboratorio similares, lo cual puede dificultar un diagnóstico acertado para el clínico que se enfrenta por primera vez a este tipo de pacientes. El diagnóstico temprano de las enfermedades reumáticas autoinmunes es de gran importancia y los resultados del laboratorio pueden ser de gran utilidad, siempre y cuando sean interpretados en el contexto clínico del paciente. Es bien conocido que un diagnóstico y un tratamiento tempranos conllevan a una disminución de la morbilidad y mortalidad en los pacientes reumáticos. Las enfermedades reumáticas autoinmunes generalmente se caracterizan por la producción de reactantes de fase aguda y de autoanticuerpos que reconocen una gama variada de antígenos nucleares y citoplasmáticos, los cuales ayudan en el diagnóstico diferencial de estos desórdenes, que incluyen la artritis reumatoide, el lupus eritematoso sistémico y el síndrome de Sjõgren, entre otros. Este módulo tiene como finalidad guiar al clínico en el proceso de un diagnóstico temprano de las principales enfermedades reumáticas autoinmunes, incluyendo su diagnóstico diferencial por el laboratorio.

Probable Artritis Reumatoide en un paciente con Enfermedad de Células Falciformes / Probable rheumatoid arthritis in a patient with sickle cell disease

Mujer de 36 años, raza negra con antecedentes de enfermedad de células falciformes (ECF), consulta por compromiso articular generalizado, con varias manifestaciones músculo-esqueléticas de su enfermedad de base, y pruebas serológicas y radiológicas compatibles con el cuadro de Artritis Reumatoide (AR). Dicha asociación es inusual, con pocos casos reportados en la literatura médica. Se discute su posible relación, características clínicas y posibilidades terapéuticas

Durban 1997 ¿una propuesta viable para la clasificación de artritis juvenil? / Durban 1997: a viable proposal for juvenil arthritis classification?

Las Artritis Juveniles son un grupo heterogéneo de padecimientos que a través del tiempo han venido recibiendo diferentes nombres y se han tratado de agrupar de diversas maneras; sin embargo, no se ha logrado un consenso internacional para lograr este fin y es conocida la intención de establecer una clasificación que permita el estudio y seguimiento de estas artritis. En Europa y Estados Unidos de América se han propuesto diferentes clasificaciones en las que han participado algunas organizaciones como el Colegio Americano de Reumatología, la Organización Mundial de la Salud y la Liga Europea contra el Reumatismo. Preocupados por lograr una clasificación que permitiera el estudio de estos padecimientos, la Liga Internacional de Asociaciones de Reumatología formó una fuerza de trabajo para proponer una nueva clasificación; la última reunión de este grupo en Durban, Sudáfrica en 1997 generó una última propuesta de clasificación de la que se aquí se hace una revisión y comparación con clasificaciones previas.

American Rheumatism Association 1958 and 1987 revised criteria for rheumatoid arthritis--how useful to the clinician.

The American Rheumatism Association (ARA) criteria for rheumatoid arthritis (RA) were evaluated in 52 newly referred consecutive, clinically diagnosed cases of RA. The 1958 and 1987 criteria were highly correlated (r = 0.795). By the 1958 criteria, 48 cases (92.3%) had classical/definite RA while 40 cases (76.9%) satisfied the 1987 criteria traditional format. By the 1987 classification tree 50 cases (96.2%) belonged to the first three RA subsets while 2 cases (3.8%) belonged to the non-RA subsets. Comparing the clinicians opinion of the outcome with the statistical modelling of variables based on ARA criteria, we conclude that the clinicians opinion of the outcome is reflected by a combination of morning stiffness duration, number of swollen joints, erosion score on hand radiographs and erythrocyte sedimentation rate. We conclude that evaluation of ARA 1958 and 1987 criteria in individual cases has both diagnostic and prognostic significance. We propose a short questionnaire based on ARA criteria, for use in hospital out patient clinic for diagnosis of RA.