Perfil lipídico e inflamación en pacientes con artritis reumatoidea: una contradicción? / Lipid profile and inflammatory state in patients with rheumatoid arthritis

INTRODUCCIÓN: Los pacientes con artritis reumatoidea (AR) presentan una mobimortalidad cardiovascular (CV) 50-60% más alta comparada con la población general. En este grupo poblacional, la carga inflamatoria acumulada, medida por los niveles de VSG y PCR durante un período prolongado, se ha asociado con aterosclerosis subclínica, riesgo cardiovascular y mortalidad. En contrapartida, la presencia de un estado pro-inflamatorio conduciría a una disminución del colesterol total (CT), colesterol HDL y colesterol LDL, por lo que la contribución de los lípidos como factor de riesgo CV es, ciertamente, contradictorio. OBJETIVO Correlacionar los reactantes de fase aguda (VSG-PCR) y los valores de lípidos (CT, HDL, LDL) en una muestra de pacientes con AR. PACIENTES Y METODO: Estudio observacional, retrospectivo, analítico, en el que se incluyeron pacientes con diagnóstico de AR según criterios ACR/EULAR 2010. La relación entre los valores de CT, HDL, LDL con la PCR y VSG se analizó con correlación de Pearson. Dada la distribución no simétrica de los valores de PCR, se obtuvo una transformación logarítmica (logaritmo normal) de la misma. En un segundo modelo, los valores de CT, HDL y LDL se correlacionaron con el logaritmo normal de la PCR realizando distintos cortes de la misma (concentración de PCR ≤5 mg/l, > 5 a 10 mg/l). Finalmente, las correlaciones significativas, se incluyeron en un modelo de regresión lineal multivariado ajustado por edad, género, tiempo de evolución de la enfermedad, uso de hipolipemiantes, medicamentos biológicos y dosis de glucocorticoides. RESULTADOS El análisis de este estudio incluyó 449 mediciones del perfil de lípidos y reactantes de fase aguda (PCR y VSG) correspondientes a 318 pacientes. Los pacientes fueron predominantemente mujeres (79.5%), con una edad media (desviación estándar) de 57.7 (12.3) años. La mediana (rango intercuartilo) del tiempo de evolución de la enfermedad fue de 74.0 (108.0) meses. La mayoría de los pacientes eran seropositivos (67%). La correlación entre PCR y CT (r= 0.16; p= 0.60), así como sus fracciones HDL (0.09; p= 0.30) y LDL (r= 0.09; p= 0.36), fueron débiles. En el sub-análisis de la PCR dividida en tres valores de corte, tanto el CT (r= -0.18 a 0.09) y la fracción LDL (r= -0.34 a 0.11) mostraron correlaciones débiles, independientemente del valor de corte analizado de PCR. Por el contrario, se observó una correlación positiva moderada entre los valores positivos intermedios de PCR y HDL (r= 0.53; p= 0.01). Las correlación entre VSG y CT (r=- 0.03; p= 0.58), así como su fracción LDL (r= 0.10; p= 0.88), fueron débiles. Se observó una correlación negativa débil, pero estadísticamente significativa entre VSG y la fracción HDL (r=-0.14; p= 0.02). En el análisis multivariado de regresión lineal la VSG mantuvo una asociación negativa y significativa con los valores de colesterol HDL (coeficiente ß= -0.179, IC95% -0.28 -0.07; p= 0.001). CONCLUSION: En este estudio pudimos corroborar una relación inversa, aunque débil, entre la VSG y la fracción HDLcolesterol, por el contrario, no pudimos reproducir los hallazgos previamente publicados sobre la relación inversa entre la PCR y los niveles séricos de colesterol y sus fracciones. (AU)

INTRODUCTION: Cardiovascular disease (CVD) is the main cause of premature mortality in patients with rheumatoid arthritis (RA). The risk of CVD mortality is increased by approximately 50% compared to the general population. In patients with RA, the cumulative inflammatory burden, as measured by the levels of the globular sedimentation rate (GSR) and the Creactive protein (CRP), has been associated with sub-clinical atherosclerosis, CV risk and mortality. On the contrary, the presence of a proinflammatory state, as observed in patients with RA, may lead to a decline of the total cholesterol (TC) and HDL fraction. This observation suggests that inflammation may play a confounding role in the association of lipids with CVD. OBJETIVO: To correlate acute phase reactants (GSR and CRP) with the lipid measurements (TC, HDL and LDL) in a sample of patients with RA. PATIENTS Y METHOD: In this observational, retrospective and analytic study, we included 318 patients fulfilling the CR/EULAR 2010 criteria for RA. The relationship between the TC, HDL, LDL and the CRP (normal logarithm) and GSR was analyzed with the Pearson´s correlation. In a second model, the relationship of the TC, HDL and LDL with the normal logarithm of CRP was analyzed using different cutoff values (CRP ≤5 mg/l, > 5 a <10 mg/l y >10 mg/l). Finally, all the significant correlations were included in a multivariate linear regression model adjusting for age, gender, disease duration, use of lipid lowering drugs, biologic disease modifying antirheumatic drugs and glucocorticoid doses. RESULTS: The study included 449 measurements of the lipid profile and acute phase reactants. Patients were predominantly women (79.5%) with mean (SD) age of 57.7 (12.3) years. Median (IQR) disease duration was 74.0 (108.0) months. Most of the patients (67%) were either positive for the rheumatoid factor and/or anti-citrullinated antibodies. The correlation of the CRP and TC (r= 0.16; p= 0.6) and their fractions HDL (0.09; p= 0.30) and LDL (r= 0.09; p= 0.36) were positive and weak. In the sub-analyses using the three cut-off values of the CRP, the correlations of both, TC (r= -0.18 to 0.09) and LDL (r= -0.34 to 0.11) were also weak. On the contrary, the correlation between the intermediate values of CRP and HDL was positive and moderate (r= 0.53; p= 0.01). The correlation of the GSR and TC (r=-0.03; p= 0.58) and LDL (r= 0.10; p= 0.88) were weak. There was, however, a negative and significant, although weak correlation between the GSR and HDL (r=-0.14; p= 0.02). In the multivariate analyses, the GSR had a negative and significant association with the levels of HDL (ß coefficient = -0.179, 95%CI - 0.28 -0.07; p= 0.001). CONCLUSION: In this study we confirmed an inverse, although weak, relationship between the GSR and HDL-cholesterol. On the contrary, we were not able to reproduce previous published data regarding the inverse relationship between the CRP values and the levels of the TC or their fractions. (AU)

Is entheses ultrasound reliable? A reading Latin American exercise.

The objective of this study is to evaluate inter-reader entheses ultrasound (US) reliability and the influence of the type of image or degree of sonographer experience on US reliability in patients with spondyloarthritis (SpA). Eighteen Latin American ultrasonographers with different experience took part in an US reading exercise evaluating 60 entheseal images (50 % static images and 50 % videos) from healthy controls and SpA patients. The following sonographic lesions were assessed: structure, thickness, bone proliferation/tendon calcification, erosions, bursitis, and Doppler signal. Another group of three experts with significant experience in entheses US read all images too. Inter-reader reliability among participants and experts was calculated by the Cohen's kappa coefficient. Thresholds for kappa values were <0.2 poor, 0.21-0.4 fair, 0.41-0.6 moderate, 0.61-0.8 good, and 0.81-1 excellent. Furthermore, the results for the expert group were stratified based on the type of image. Kappa correlation coefficients among participants, showed variability depending on the type of lesion, being fair for structure and thickness, moderate for calcifications, erosions, and bursitis, and excellent for Doppler signal. Inter-reader reliability among experts was higher, being moderate for structure and thickness, good for calcifications and bursitis, and excellent for erosions and Doppler. Inter-reader reliability for assessing calcification and structure using static images was significantly higher than for videos. Overall inter-reader reliability for assessing entheses by US in SpA is moderate to excellent for most of the lesions. However, special training seems fundamental to achieve better inter-reader reliability. Moreover, the type of image influenced these results, where evaluation of entheses by videos was more difficult than by static images.

Factors associated with arterial vascular events in PROFILE: a Multiethnic Lupus Cohort.

The objective of this study was to determine the factors associated with the occurrence of arterial vascular events in a multiethnic systemic lupus erythematosus (SLE) cohort. The PROFILE cohort, comprised SLE patients (n = 1333) of defined ethnicity from five different US institutions, was studied to determine demographic, clinical and biological variables associated with vascular events. An arterial vascular event (first episode) was either a myocardial infarction, angina pectoris and/or a vascular procedure for myocardial infarction, stroke, claudication and/or evidence of gangrene. Patient characteristics were analyzed by univariable and multivariable Cox proportional hazards regression analyses. One-hundred twenty-three (9.8%) patients had at least one incident arterial event. Age at cohort enrollment (HR = 1.04, 95% CI 1.03-1.06), smoking (HR = 2.20, 95% CI 1.40-3.46) and the CRP2* C alleles (HR = 1.91, 95% CI 1.04-3.49) were associated with a shorter time-to-the occurrence of arterial vascular events. Some clinical manifestations of disease activity were associated with a shorter time-to-occurrence [psychosis (HR = 2.21, 95% CI 1.10-4.44), seizures (HR = 1.85, 95% CI 1.00-3.24) and anaemia (HR = 1.83, 95% CI 1.02-3.31)], but others were not [arthritis (HR = 0.32, 95% CI 0.18-0.58)]. In conclusion, older patients, especially in the context of a predisposing environmental factor (smoking) and severe clinical manifestations, are at higher risk of having arterial vascular events. The genetic contribution of the variation at the CRP locus was not obscured by demographic or clinical variables. Awareness of these factors should lead to more effective management strategies of patients at risk for arterial vascular events.

Adverse pregnancy outcomes in women with systemic lupus erythematosus from a multiethnic US cohort: LUMINA (LVI) [corrected].

OBJECTIVE: To study the factors associated with an adverse pregnancy outcome in women with systemic lupus erythematosus (SLE). METHODS: SLE women from LUMINA of Hispanic, African American and Caucasian ethnicity were studied. Adverse pregnancy outcome was a miscarriage or abortion (<20 weeks), a stillbirth (> or = 20) and/or a moderate to severe preterm-baby (<34 weeks); good outcome was either a mild preterm-baby (> or = 34 weeks) or a full-term baby [C-section or vaginal delivery (38-42 weeks)]. Pregnancies occurring after SLE diagnosis (TD) were included; pregnancy outcome was the unit of analyses. The relationship between selected variables and pregnancy outcomes was examined by univariable and multivariable analyses. RESULTS: Adverse outcomes occurred in 63.7% of 102 pregnancies. In the univariable analyses, Texan Hispanic and African American ethnicities, fewer years of education, higher number of ACR criteria, renal involvement, glucocorticoid exposure and the maximum dose of glucocorticoids used prior to the pregnancy outcome were associated with an adverse pregnancy outcome. Renal involvement was independently associated with an adverse pregnancy outcome [Odds ratio (OR)=5.219 (95% Confidence Interval (CI) 1.416-19.239, p=0.0131] as were the maximum dose of glucocorticoids used prior to the pregnancy outcome (OR=1.028; CI:1.002-1.054; p=0.0315) and fewer years of education (OR=1.204; CI:1.006-1.472; p=0.0437). Ethnicity was not retained in the multivariable model. CONCLUSION: Renal involvement, the maximum dose of glucocorticoids used prior to pregnancy and fewer years of education were associated with adverse pregnancy outcomes. These data have implications for the management of women with lupus planning to become pregnant.

Systemic lupus erythaematosus in a multiethnic US cohort (LUMINA) LIII: disease expression and outcome in acute onset lupus.

OBJECTIVE: To determine the features associated with acute onset systemic lupus erythaematosus (SLE). METHODS: A total of 631 SLE patients from LUMINA (for "lupus in minority populations: nature vs nurture"), a multiethnic (Hispanics, African-Americans and Caucasians) cohort, were studied. Acute disease onset was defined as the accrual of > or = 4 American College of Rheumatology (ACR) criteria for the classification of SLE in < or = 4 weeks. Socioeconomic demographic features, clinical manifestations, disease activity, damage accrual, mortality, autoantibodies, HLA class II and FCGR alleles, behavioural/psychological variables were compared between patients with acute and insidious disease onset by univariable (chi(2) and Student t test) and multivariable (stepwise logistic regression) analyses. RESULTS: A total of 94 (15%) patients had acute disease onset. In the multivariable analysis, patients with acute onset lupus had more renal involvement (odds ratio (OR) = 1.845, 95% CI 1.076-3.162; p = 0.026) and higher disease activity (OR = 1.057, 95% CI 1.005-1.112; p = 0.030). By contrast, age (OR = 0.976, 95% CI 0.956-0.997; p = 0.025), education (OR = 0.901, 95% CI 0.827-0.983, p = 0.019), health insurance (OR = 0.423, 95% CI 0.249-0.718; p = 0.001) and skin involvement (OR = 0.346, 95% CI 0.142-0.843; p = 0.019) were negatively associated with acute onset lupus. No differences were found regarding the serological, genetic and behavioural/psychological features; this was also the case for damage accrual and mortality. CONCLUSIONS: Patients with acute onset lupus seem to be younger, have a lower socio-economic status and display more severe disease in terms of clinical manifestations and disease activity. However, intermediate (damage) and long-term (mortality) outcomes appear not to be influenced by the type of disease onset in SLE.

Systemic lupus erythematosus in a multiethnic US Cohort LUMINA XLVIII: factors predictive of pulmonary damage.

The objective of this study was to determine the factors predictive of time to the occurrence of pulmonary damage in systemic lupus erythematosus (SLE). Six-hundred and twenty-six SLE patients from a multiethnic (Hispanics, African Americans and Caucasians) longitudinal study of outcome were studied. Pulmonary damage was defined as per the Systemic Lupus International Collaborating Clinics Damage Index. Socioeconomic-demographic, clinical, genetic, serological features, pharmacologic treatments, behavioural, psychological and disease activity [as per the Systemic Lupus Activity Measure-Revised (SLAM-R)] were examined. Factors associated with time to the occurrence of pulmonary damage were examined by Cox proportional hazards regressions. A Kaplan-Meier survival curve was also examined. Forty-six (7.3%) patients had pulmonary damage after a mean (SD) total disease duration of 5.3 (3.6) years. Among those patients, 25 had pulmonary fibrosis, 12 pulmonary hypertension, eight pleural fibrosis, four pulmonary infarction and four shrinking lung syndrome. Seven patients had more than one type of lung damage. Cumulative rates of pulmonary damage at five and 10 years were 7.6% and 11.6%, respectively. In the multivariable analyses, age (HR = 1.033, 95% CI 1.006-1.060; P = 0.0170), pneumonitis (HR = 2.307, 95% CI 1.123-4.739; P = 0.0229) and anti-RNP antibodies (HR = 2.344, 95% CI 1.190-4.618; P = 0.0138) were associated with a shorter time to the occurrence of pulmonary damage while photosensitivity (HR = 0.388, 95% CI 0.184-0.818; P = 0.0128) and oral ulcers (HR = 0.466, 95% CI 0.230-0.942; P = 0.0335) with a longer time. Pulmonary damage is relatively common in SLE. Age, pneumonitis and anti-RNP antibodies were associated with a shorter time to the development of permanent lung disease.

Systemic lupus erythematosus in a multiethnic US cohort LUMINA LI: anaemia as a predictor of disease activity and damage accrual.

OBJECTIVE: To examine if anaemia (and its severity) is associated with disease activity and damage accrual in systemic lupus erythematosus (SLE). METHODS: Four thousand four-hundred study visits in 613 SLE patients enrolled in LUMINA were studied. Anaemia was expressed in four categories of haematocrit (Hct) as defined by the Systemic Lupus Activity Measure-Revised (SLAM-R): no anaemia (Hct >35%), mild (Hct = 30-35%), moderate (Hct = 25-29%) and severe (Hct <25%). Anti-dsDNA antibodies were measured at baseline. Disease activity was assessed with the SLAM-R and damage with the Systemic Lupus International Collaborating Clinics Damage Index (SDI). The relationship between anaemia and anti-dsDNA antibodies with the SLAM and SDI scores was examined by univariate (one-way ANOVA) and multivariate (generalized linear models and generalized estimating equation regression) analyses. RESULTS: All categories of anaemia and anti-ds DNA were significantly associated with the SLAM-R at baseline and over time. However, only moderate and severe anaemia were associated with the SDI at baseline and over time, while the presence of anti-ds DNA was only associated with the SDI over time but not at baseline. Several clinical domains of the SLAM-R and SDI were associated with anaemia at baseline and over time. CONCLUSIONS: Mild, moderate and marked anaemia are strongly associated with disease activity in SLE. Moderate and marked anaemia are associated with damage accrual. These associations are observed both early and during the course of SLE. Different levels of anaemia could be used to monitor disease activity and predict organ/system damage in SLE.

Systemic lupus erythematosus in a multiethnic US cohort LUMINA (XLI): factors predictive of self-reported work disability.

OBJECTIVE: To examine the risk factors for self-reported work disability in patients from the LUpus in MInorities: NAture vs. Nurture cohort with systemic lupus erythematosus (SLE). METHODS: Patients with SLE of Hispanic (Texas and Puerto Rico), African American and Caucasian ethnicity were studied. Work disability was defined by patients' self-report. Only patients known to be employed at the baseline visit were included. The probabilities of self-reporting work disability over time were examined by the Kaplan-Meier method; differences between ethnic groups were examined by the log-rank test. The relationship of baseline socioeconomic-demographic, clinical, behavioural and psychological features with work disability was examined by standard statistical tests. Variables with p

Predictors of post-partum damage accrual in systemic lupus erythematosus: data from LUMINA, a multiethnic US cohort (XXXVIII).

OBJECTIVE: To determine the impact of pregnancy on systemic lupus erythematosus (SLE) outcome. METHODS: SLE patients, age >or=16 yrs, disease duration

Systemic lupus erythematosus in a multiethnic U.S. cohort (LUMINA) XXVII: factors predictive of a decline to low levels of disease activity.

The objective of this study was to examine factors predictive of a decline to low levels of disease activity in a cohort of systemic lupus erythematosus (SLE) patients. Patients with SLE of Hispanic (from Texas or Puerto Rico), African-American or Caucasian ethnicity from a multiethnic cohort were included. A decline to low levels of disease activity was defined as a score < or =5 as per the Systemic Lupus Activity Measure-Revised (SLAM-R) at any annual study visit if preceded by a SLAM-R > or =8. Using Generalized Estimating Equation (GEE), socioeconomic-demographic, behavioral, function, psychological, laboratory and clinical data [disease manifestations, number of ACR criteria accrued at diagnosis and damage accrual as per the Systemic Lupus International Collaborating Clinics (SLICC) Damage Index (SDI)] from the visit preceding that meeting the definition were examined as predictors of decline to low levels of disease activity. Two-hundred and eighty-seven patients (67 Hispanics from Texas, 32 Hispanics form Puerto Rico, 120 African-Americans and 68 Caucasians), accounting for 632 visits were analyzed. In the GEE multivariable analysis, higher degrees of social support (OR = 1.208, 95% CI 1.059-1.379; P = 0.005) were predictive of a decline to low levels of disease activity, while the number of ACR criteria accrued at diagnosis (OR = 0.765, 95% CI 0.631-0.927; P = 0.006) and damage (OR = 0.850, 95% CI 0.743-0.972, P = 0.018) were negatively associated. These data suggest that a decline to low levels of disease activity in lupus patients seems to be multifactorial; this study also underscores the importance of social support for lupus patients.

Systemic lupus erythematosus in a multiethnic U.S. cohort (LUMINA) XXXI: factors associated with patients being lost to follow-up.

The objective of this study was to determine the frequency of loss to follow-up and the factors predictive of its occurrence in a systemic lupus erythematosus (SLE) multiethnic cohort. We studied SLE patients from the LUMINA cohort (Hispanics from Texas and from the Island of Puerto Rico, African-Americans and Caucasians). Loss to follow-up was defined as subjects who failed to attend two or more of the latest consecutive yearly study visits. The relationship between baseline features and loss to follow-up was examined by univariable and multivariable Cox regression analyses with loss to follow-up as the dependent variable. The retention rate in the cohort was estimated by the Kaplan-Meier method. Five-hundred and fifty-four patients with a mean (SD) follow-up of 3.4 (2.9) years were studied. One-hundred and fifty-eight (29%) met the definition of lost to follow-up. The cumulative loss to follow-up rate at five years was 36%. The cumulative loss to follow-up rate at five years was higher for the African-Americans. Patients lost to follow-up tended to be younger and more likely to have poor social support and higher levels of helplessness. They also tended to have more renal involvement and more active disease as per the Systemic Lupus Activity Measure-Revised. Disease activity (hazard ratio = 1.04, 95% confidence interval 1.01-1.07, P = 0.02) was the only variable independently contributing to loss to follow-up. Our data suggest that in longitudinal SLE studies, loss to follow-up does not occur at random and it differs between ethnic groups and is also particularly higher among patients with more active disease. Pro-active measures may need to be applied to decrease the probability of patients 'at risk' of becoming lost to follow-up and to preserve the integrity of the cohort.

Uso de infliximab en pacientes de un centro reumatologico / Use of infliximab in patients of a rheumatologic center

The objective of this study was to obtain post-marketing information about the use of infliximab in an ambulatory setting. We studied--retrospectively and prospectively--the case records of patients with rheumatoid arthritis (n=37), psoriatic arthritis (n=5), mixed connective tissue disease (n=1), and ankylosing spondylitis (n=2) who received infliximab (3 mg/kg) from August 2000 to January 2003. Descriptive values were given as percentage, mean or median, and standard deviation or interquartile range. Wilcoxon test was used for paired analysis of pre/post doses of corticosteroids, non-steroidal anti-inflammatory drugs, and methotrexate therapy. A p value < or = 0.05 was considered significant. Forty-five patients were included. A total of 207 infusions were administered. In 4 patients the treatment was permanently discontinued due to severe back pain during the infusion (2 cases) and serious anaphylactic reactions (2 cases). Other adverse reactions occurring during infusions were mild and successfully managed with standard treatment. A case of staphylococcal septic arthritis resolved with standard antibiotic treatment. No patient had evidence of active tuberculosis. One patient with rheumatoid arthritis and chronic renal insufficiency, received treatment with infliximab 1.9 mg/kg, every 30 days, with no changes in renal function. Due to improvement of symptoms, 14/39 (35.9%) patients could decrease the doses of corticosteroids, 15/43 (34.8%) decreased the doses of antiinflammatory drugs and 12/34 (35.3%) decreased methotrexate dosage. Although some questions remain to be elucidated, this case series shows the drug safety profile, the possibility to reduce concomitant drug doses, as well as individual approaches for situations where there are not yet guidelines available, so that rheumatologists have to make decisions based on clinical needs.(AU)

El objetivo de este estudio fue obtener informacion postmarketing sobre el uso de infliximab en un centro reumatologico de atencion ambulatoria. Se realizo un analisis retrospectivo y prospectivo de las historias clinicas de pacientes con diagnostico de artritis reumatoidea (n=37), artritis psoriasica (n=5),enfermedad mixta del tejido conectivo (n=1) y espondilitis anquilosante (n=2) que recibieron infliximab (3 mg/kg) desde agosto de 2000 a junio de 2003. El analisis descriptivo se realizo con porcentajes, media o medianay desviacion estandar o intervalo intercuartilo. La prueba de Wilcoxon se utilizo para el analisis apareado dedosis de antiinflamatorios no esteroideos y metotrexato, anterior y posterior a la administracion de infliximab. Se consideraron significativos valores de p < o = 0.05. Se incluyeron 45 pacientes a los que se les administraron un total de 207 infusiones. En 2 pacientes el infliximab se discontinuó debido a lumbalgia severa durante la infusion y en otros 2 por anafilaxia intrainfusional. Otras reacciones adversas ocurridas durante las infusiones fueron moderadas y respondieron adecuadamente al tratamiento estandar. Se presento un caso de artritis septica de rodilla por estafilococos. Un caso de artritis reumatoidea con insuficiencia renal compensada recibio infliximab en dosis de 1.9 mg/kg cada 30 dias, sin cambios en la funcion renal. Al momento, ningun paciente ha desarrollado tuberculosis activa. Debido a la mejoria clinica, se redujo la dosis de corticoides en 14/39 (35.9%) pacientes, de antiinflamatorios no esteroideos en 15/43 (34.8%) y de metotrexato en 12/34 (35.3%). En estaserie de casos se muestra el perfil de seguridad de infliximab, la posibilidad de reducir la dosis de drogas concomitantes,asi como algunos enfoques individuales sobre situaciones para las cuales no disponemos de guias basadas en la evidencia medica, y en las que los reumatologos debemos tomar decisiones segun las necesidades clinicas.(AU)

Uso de infliximab en pacientes de un centro reumatologico / Use of infliximab in patients of a rheumatologic center

The objective of this study was to obtain post-marketing information about the use of infliximab in an ambulatory setting. We studied--retrospectively and prospectively--the case records of patients with rheumatoid arthritis (n=37), psoriatic arthritis (n=5), mixed connective tissue disease (n=1), and ankylosing spondylitis (n=2) who received infliximab (3 mg/kg) from August 2000 to January 2003. Descriptive values were given as percentage, mean or median, and standard deviation or interquartile range. Wilcoxon test was used for paired analysis of pre/post doses of corticosteroids, non-steroidal anti-inflammatory drugs, and methotrexate therapy. A p value < or = 0.05 was considered significant. Forty-five patients were included. A total of 207 infusions were administered. In 4 patients the treatment was permanently discontinued due to severe back pain during the infusion (2 cases) and serious anaphylactic reactions (2 cases). Other adverse reactions occurring during infusions were mild and successfully managed with standard treatment. A case of staphylococcal septic arthritis resolved with standard antibiotic treatment. No patient had evidence of active tuberculosis. One patient with rheumatoid arthritis and chronic renal insufficiency, received treatment with infliximab 1.9 mg/kg, every 30 days, with no changes in renal function. Due to improvement of symptoms, 14/39 (35.9%) patients could decrease the doses of corticosteroids, 15/43 (34.8%) decreased the doses of antiinflammatory drugs and 12/34 (35.3%) decreased methotrexate dosage. Although some questions remain to be elucidated, this case series shows the drug safety profile, the possibility to reduce concomitant drug doses, as well as individual approaches for situations where there are not yet guidelines available, so that rheumatologists have to make decisions based on clinical needs.

El objetivo de este estudio fue obtener informacion postmarketing sobre el uso de infliximab en un centro reumatologico de atencion ambulatoria. Se realizo un analisis retrospectivo y prospectivo de las historias clinicas de pacientes con diagnostico de artritis reumatoidea (n=37), artritis psoriasica (n=5),enfermedad mixta del tejido conectivo (n=1) y espondilitis anquilosante (n=2) que recibieron infliximab (3 mg/kg) desde agosto de 2000 a junio de 2003. El analisis descriptivo se realizo con porcentajes, media o medianay desviacion estandar o intervalo intercuartilo. La prueba de Wilcoxon se utilizo para el analisis apareado dedosis de antiinflamatorios no esteroideos y metotrexato, anterior y posterior a la administracion de infliximab. Se consideraron significativos valores de p < o = 0.05. Se incluyeron 45 pacientes a los que se les administraron un total de 207 infusiones. En 2 pacientes el infliximab se discontinuó debido a lumbalgia severa durante la infusion y en otros 2 por anafilaxia intrainfusional. Otras reacciones adversas ocurridas durante las infusiones fueron moderadas y respondieron adecuadamente al tratamiento estandar. Se presento un caso de artritis septica de rodilla por estafilococos. Un caso de artritis reumatoidea con insuficiencia renal compensada recibio infliximab en dosis de 1.9 mg/kg cada 30 dias, sin cambios en la funcion renal. Al momento, ningun paciente ha desarrollado tuberculosis activa. Debido a la mejoria clinica, se redujo la dosis de corticoides en 14/39 (35.9%) pacientes, de antiinflamatorios no esteroideos en 15/43 (34.8%) y de metotrexato en 12/34 (35.3%). En estaserie de casos se muestra el perfil de seguridad de infliximab, la posibilidad de reducir la dosis de drogas concomitantes,asi como algunos enfoques individuales sobre situaciones para las cuales no disponemos de guias basadas en la evidencia medica, y en las que los reumatologos debemos tomar decisiones segun las necesidades clinicas.

Attitudes and knowledge about presymptomatic genetic testing among individuals at high risk for familial, early-onset Alzheimer's disease.

The study was conducted in a large Cuban family with early-onset familial Alzheimer's disease (AD). Fifty-six first-degree relatives of familial cases with AD were interviewed concerning their clinical and genetic knowledge about AD and their attitudes toward the possible use of presymptomatic genetic testing of AD. The individuals had only limited knowledge about their personal risk of developing AD. All 56 family members would use presymptomatic testing to know their own risk of AD. Confronted with a hypothetical reproductive choice, 50% would choose not to have children if they themselves had the mutation. A positive prenatal test would lead 48.2% of the participants to have an abortion, and 19.7% would continue the pregnancy regardless of the positive test result.

Lung cavitation in primary antiphospholipid syndrome.

Pulmonary complications of primary antiphospholipid syndrome are common and diverse, with thromboembolic events counting as the most frequent manifestation. We present the case of a female patient with a diagnosis of primary antiphospholipid syndrome, pulmonary thromboembolism and infarction followed by lung cavitation.