Thorough assessment of the effectiveness of belimumab in a large Spanish multicenter cohort of systemic lupus erythematosus patients.

OBJECTIVES: To provide an overview on the current use of belimumab (BLM) in SLE patients in clinical practice and to examine its efficacy in terms of standardized outcomes, drug survival, as well as patient and safety profiles. METHODS: A longitudinal retrospective multicentre cohort including SLE patients treated with BLM at 18 Spanish centers. Data was collected upon initiation of BLM, at 6 and 12 months after initiation, and at the last recorded visit. Changes in SLEDAI-2K, the proportion of patients who achieved LLDAS and DORIS 2021, and number of flares were compared between visits. Changes in damage, glucocorticoids use and employment status pre-BLM and post-BLM were also assessed. RESULTS: A total of 324 patients were included with a mean follow-up of 3.8 (±2.7) years. LLDAS was attained by 45.8%, 62% and 71% of patients, and DORIS by 24%, 36.2% and 52.5% on successive visits, respectively. Twenty-seven-point two percent of patients were in DORIS ≥ 50% of the visits and a 46% in LLDAS-50. Flares and number of flares were significantly lower one year after treatment with BLM and no changes in damage accrual were observed. Mean (±SD) prednisone dose was significantly reduced over time, with 70 (24%) patients discontinuing GC. CONCLUSION: Our study not only demonstrates belimumab´s efficacy in attaining treat-to-target goals in SLE patients, but also confirms its GC-sparing effect, and its prevention of flares and organ damage accrual.

Clinical spectrum time course in non-Asian patients positive for anti-MDA5 antibodies.

OBJECTIVES: To define the clinical spectrum time-course and prognosis of non-Asian patients positive for anti-MDA5 antibodies. METHODS: We conducted a multicentre, international, retrospective cohort study. RESULTS: 149 anti-MDA5 positive patients (median onset age 53 years, median disease duration 18 months), mainly females (100, 67%), were included. Dermatomyositis (64, 43%) and amyopathic dermatomyositis (47, 31%), were the main diagnosis; 15 patients (10%) were classified as interstitial pneumonia with autoimmune features (IPAF) and 7 (5%) as rheumatoid arthritis. The main clinical findings observed were myositis (84, 56%), interstitial lung disease (ILD) (108, 78%), skin lesions (111, 74%), and arthritis (76, 51%). The onset of these manifestations was not concomitant in 74 cases (50%). Of note, 32 (21.5%) patients were admitted to the intensive care unit for rapidly progressive-ILD, which occurred in median 2 months from lung involvement detection, in the majority of cases (28, 19%) despite previous immunosuppressive treatment. One-third of patients (47, 32% each) was ANA and anti-ENA antibodies negative and a similar percentage was anti-Ro52 kDa antibodies positive. Non-specific interstitial pneumonia (65, 60%), organising pneumonia (23, 21%), and usual interstitial pneumonia-like pattern (14, 13%) were the main ILD patterns observed. Twenty-six patients died (17%), 19 (13%) had a rapidly progressive-ILD. CONCLUSIONS: The clinical spectrum of the anti-MDA5 antibodies-related disease is heterogeneous. Rapidly-progressive ILD deeply impacts the prognosis also in non-Asian patients, occurring early during the disease course. Anti-MDA5 antibody positivity should be considered even when baseline autoimmune screening is negative, anti-Ro52 kDa antibodies are positive, and radiology findings show a NSIP pattern.

Risk of Severe COVID-19 Infection in Patients With Inflammatory Rheumatic Diseases.

OBJECTIVE: To describe the cohort of patients with inflammatory rheumatic diseases (IRD) hospitalized due to SARS-CoV-2 infection in the Ramón y Cajal Hospital, and to determine the increased risk of severe coronavirus disease 2019 (COVID-19) in patients with no IRD. METHODS: This is a retrospective single-center observational study of patients with IRD actively monitored in the Department of Rheumatology who were hospitalized due to COVID-19. RESULTS: Forty-one (1.8%) out of 2315 patients admitted due to severe SARS-CoV-2 pneumonia suffered from an IRD. The admission OR for patients with IRD was 1.91 against the general population, and it was considerably higher in patients with Sjögren syndrome, vasculitis, and systemic lupus erythematosus. Twenty-seven patients were receiving treatment for IRD with corticosteroids, 23 with conventional DMARDs, 12 with biologics (7 rituximab [RTX], 4 anti-tumor necrosis factor [anti-TNF], and 1 abatacept), and 1 with Janus kinase inhibitors. Ten deaths were registered among patients with IRD. A higher hospitalization rate and a higher number of deaths were observed in patients treated with RTX (OR 12.9) but not in patients treated with anti-TNF (OR 0.9). CONCLUSION: Patients with IRD, especially autoimmune diseases and patients treated with RTX, may be at higher risk of severe pneumonia due to SARS-CoV-2 compared to the general population. More studies are needed to analyze this association further in order to help manage these patients during the pandemic.

Rheumatoid meningitis as a complication of long-standing rheumatoid arthritis: a case treated with rituximab.

Rheumatoid meningitis is a rare complication of long-standing rheumatoid arthritis. We present the case of a 39-year-old Bolivian woman with a history of seropositive rheumatoid arthritis of 12 years of evolution without extra-articular manifestations that develops a severe headache with vomiting. The diagnosis of rheumatoid meningitis was performed based on clinical history, blood count and biochemistry results, cerebrospinal fluid analysis and cranial magnetic resonance imaging findings. High-dose intravenous glucocorticoids were started, followed by rituximab. After treatment, a significant clinical improvement was observed and repeat magnetic resonance imaging scan confirmed an improvement of the meningeal lesions.

Determination of serum free light chains as a marker of systemic lupus flare.

INTRODUCTION: The aim of this study was to explore the usefulness of the determination of free light chains (FLC) in serum as a biomarker of flare in patients with systemic lupus erythematosus (SLE) and to analyze the differences in their discriminatory capacity with complement C3 and C4. METHODS: This was a prospective cohort study. The definition of flare was based on the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) Flare Index. The discriminatory capacity of FLC and C3 and C4 levels was compared using receiver operating characteristic (ROC) curves and the area under the curve (AUC). RESULTS: Forty-six patients were enrolled. Patients with SLE flare showed significantly lower C3 (p = 0.025) and C4 levels (p = 0.028), as well as a higher concentration of lambda light chains (λ-LC) (p = 0.028) compared with the non-flare group. λ-LC, as opposed to kappa light chains and total light chains, demonstrated a discriminatory capacity for detecting the presence of SLE flare (AUC 0.781), with 100% sensitivity, 65% specificity, and 69.6% of patients correctly classified for a cutoff point of ≥ 19.5 mg/L. Complement C3 and C4 also showed a high discriminatory capacity for SLE flare (AUC 0.804 and 0.837, respectively). Comparing λ-LC, C3, and C4, the last one demonstrates better discriminatory capacity for SLE flare with the highest AUC (0.837; 95% CI 0.663-1.000). CONCLUSIONS: λ-LC have good discriminatory capacity for SLE flare and could be useful as a biomarker of SLE exacerbation.Key Points• The usefulness of free light chains as a biomarker could be compared with complement.• Lambda free light chains have good discriminatory capacity for SLE flare.• Free light chains are a promising marker of SLE activity.

Influence of Antisynthetase Antibodies Specificities on Antisynthetase Syndrome Clinical Spectrum Time Course.

Antisynthetase syndrome (ASSD) is a rare clinical condition that is characterized by the occurrence of a classic clinical triad, encompassing myositis, arthritis, and interstitial lung disease (ILD), along with specific autoantibodies that are addressed to different aminoacyl tRNA synthetases (ARS). Until now, it has been unknown whether the presence of a different ARS might affect the clinical presentation, evolution, and outcome of ASSD. In this study, we retrospectively recorded the time of onset, characteristics, clustering of triad findings, and survival of 828 ASSD patients (593 anti-Jo1, 95 anti-PL7, 84 anti-PL12, 38 anti-EJ, and 18 anti-OJ), referring to AENEAS (American and European NEtwork of Antisynthetase Syndrome) collaborative group's cohort. Comparisons were performed first between all ARS cases and then, in the case of significance, while using anti-Jo1 positive patients as the reference group. The characteristics of triad findings were similar and the onset mainly began with a single triad finding in all groups despite some differences in overall prevalence. The "ex-novo" occurrence of triad findings was only reduced in the anti-PL12-positive cohort, however, it occurred in a clinically relevant percentage of patients (30%). Moreover, survival was not influenced by the underlying anti-aminoacyl tRNA synthetase antibodies' positivity, which confirmed that antisynthetase syndrome is a heterogeneous condition and that antibody specificity only partially influences the clinical presentation and evolution of this condition.

La consulta especializada de reumatología en un servicio de urgencias: un año de experiencia con la unidad de urgencias reumatológicas y musculoesqueléticas (URMES) / Specialized rheumatology clinic in an emergency department: A year of the rheumatology and musculoskeletal emergencies clinic (RMSEC) experience

Introducción. En octubre de 2013, el servicio de urgencias de nuestro hospital implementó una consulta de urgencias reumatológicas y musculoesqueléticas (URMES) atendida por 3 especialistas en Reumatología. El propósito del presente estudio es describir la experiencia acumulada en el primer año desde el inicio de la actividad de esta consulta. Método. Se realizó un estudio descriptivo de la actividad asistencial de la URMES a lo largo de su primer año de funcionamiento. Resultados. Se realizaron 1.788 atenciones a un total de 1.663 pacientes. La media de la edad de los pacientes atendidos fue de 67años (DE 7); 1.530 (85,57%) valoraciones se realizaron en pacientes correspondientes al área de influencia de nuestro hospital. De todas las valoraciones realizadas, 633 (35,4%) correspondieron a juicios clínicos relacionados con procesos inflamatorios y el resto, 1.155 (64.6%), a procesos mecánicos o degenerativos, articulares, paraarticulares o de partes blandas. De acuerdo con la topografía del motivo de consulta, 435 (24,3%) pacientes consultaron por un proceso relacionado con la rodilla, 362 (20,3%) con la región axial lumbar y 336 (18,8%) con el hombro. Conclusión. Nuestros resultados denotan una intensa actividad asistencial que parece repercutir positivamente en el manejo de las urgencias reumatológicas y musculoesqueléticas en general (AU)

Background. In October 2013, the emergency department of our hospital started up a rheumatology and musculoskeletal emergencies clinic (RMSEC) with the participation of three specialists in Rheumatology. The purpose of this study was to describe the experience gained in the first year since the beginning of our activity. Method. A descriptive study of healthcare activity of the RMSEC throughout its first year of operation was performed. Results. 1788 assessments on 1663 patients were performed. The range of age was 7 to 67 years. 1530 (85.57%) assessments were performed in patients of the healthcare area of our hospital. Of all the assessments made, 633 (35.4%) were related to inflammatory processes and the remaining 1155 (64.6%) to mechanical or degenerative joint or soft tissue processes. According to the topography of the complaint, 435 (24.3%) patients consulted for a process related to the knee, 362 (20.3%) with axial lumbar region and 336 (18.8%) with the shoulder. Conclusion. Our results denote an intense clinical activity that could have a positive impact on the management of rheumatic and musculoskeletal general emergency (AU)

Specialized rheumatology clinic in an emergency department: A year of the rheumatology and musculoskeletal emergencies clinic (RMSEC) experience. / La consulta especializada de reumatología en un servicio de urgencias: un año de experiencia con la unidad de urgencias reumatológicas y musculoesqueléticas (URMES).

BACKGROUND: In October 2013, the emergency department of our hospital started up a rheumatology and musculoskeletal emergencies clinic (RMSEC) with the participation of three specialists in Rheumatology. The purpose of this study was to describe the experience gained in the first year since the beginning of our activity. METHOD: A descriptive study of healthcare activity of the RMSEC throughout its first year of operation was performed. RESULTS: 1788 assessments on 1663 patients were performed. The range of age was 7 to 67 years. 1530 (85.57%) assessments were performed in patients of the healthcare area of our hospital. Of all the assessments made, 633 (35.4%) were related to inflammatory processes and the remaining 1155 (64.6%) to mechanical or degenerative joint or soft tissue processes. According to the topography of the complaint, 435 (24.3%) patients consulted for a process related to the knee, 362 (20.3%) with axial lumbar region and 336 (18.8%) with the shoulder. CONCLUSION: Our results denote an intense clinical activity that could have a positive impact on the management of rheumatic and musculoskeletal general emergency.

Aplicación del método de aprendizaje cooperativo comparado con la técnica tradicional de enseñanza en la formación de residentes en urgencias / Application of a cooperative learning approach for training residents in the emergency department and comparison with a traditional approach

Objetivo: Determinar el beneficio del uso de la técnica de aprendizaje cooperativo (AC) en la docencia de médicos internos residentes (MIR) que realizan actividades de atención continuada en urgencias, comparado con la enseñanza tradicional (ET). Método: Estudio prospectivo secuencial de casos de controles. Se programaron dos sesiones formativas separadas realizadas por expertos en el mismo tema y dirigidas a residentes de primer año. Una sesión se basó en la ET y la otra en el modelo AC. Los MIR realizaron un test con respuesta múltiple diseñado por un tercer experto al término de cada sesión y tres meses después, que incluyó un grupo control de MIR que no habían asistido a ninguna sesión. Resultados: El AC se aplicó sobre 21 alumnos y la ET sobre 17. Las puntuaciones medias y desviaciones estándar de los exámenes escritos realizados inmediatamente después de las sesiones formativas fueron 8,81 (1,40) y 7,88 (1,26) respectivamente (p = 0,0414). Tres meses después de las sesiones formativas, los mismos alumnos y 32 residentes controles fueron sometidos a un nuevo examen escrito con respuesta múltiple. La puntuaciones medias ± desviaciones estándar de este examen fueron 8,19 (1,12), 7,00 (1,22) y 6,37 (1,37) para el grupo AC, ET y control, respectivamente (p < 0,05 entre ACy ET, p > 0,05 entre ET y control). Conclusión: El método AC demuestra superioridad frente a la ET en términos de retención de información a corto y medio plazo. Si bien esta es la primera experiencia documentada en formación médica especializada, su utilidad en la formación transversal en MIR en urgencias podría justificar la extensión de su uso (AU)

Objectives: To analyze the benefits of using a cooperative learning (CL) model to teach hospital residents doing rotations in the emergency department and to compare the CL approach to traditional training. Methods: Two training sessions on the same content were given by 2 expert instructors. A traditional method of instruction was used in one of the sessions and the CL model was used in the other. Immediately after the sessions and 3 months later, the residents took a multiple-choice test that was developed by a third expert. A control group of residents who had not attended either session also took the test. Results: Twenty-one residents were in the CL group and 17 were in the traditional-training group. The mean (SD) scores on the examinations immediately after training were 8.81 (1.40) and 7.88 (1.26), in the CL and traditional groups, respectively (P=.0414). Three months later, the mean scores of these same residents retaking the examination and 32 control residents were as follows: CL group, 8.19 (1.12); traditional group, 7.00 (1.22); and control group, 6.37 (1.37) (P<.05, CL vs traditional; P>.05, traditional vs control). Conclusions: The CL approach proved superior to traditional training in terms of short- and medium-term retention of information. Although this is the first analysis of CL in this type of specialized medical training, extending its use in preparing medical residents working in emergency departments would seem to be justified (AU)

[Application of a cooperative learning approach for training residents in the emergency department and comparison with a traditional approach]. / Aplicación del método de aprendizaje cooperativo comparado con la técnica tradicional de enseñanza en la formación de residentes en urgencias.

OBJECTIVES: To analyze the benefits of using a cooperative learning (CL) model to teach hospital residents doing rotations in the emergency department and to compare the CL approach to traditional training. MATERIAL AND METHODS: Two training sessions on the same content were given by 2 expert instructors. A traditional method of instruction was used in one of the sessions and the CL model was used in the other. Immediately after the sessions and 3 months later, the residents took a multiple-choice test that was developed by a third expert. A control group of residents who had not attended either session also took the test. RESULTS: Twenty-one residents were in the CL group and 17 were in the traditional-training group. The mean (SD) scores on the examinations immediately after training were 8.81 (1.40) and 7.88 (1.26), in the CL and traditional groups, respectively (P=.0414). Three months later, the mean scores of these same residents retaking the examination and 32 control residents were as follows: CL group, 8.19 (1.12); traditional group, 7.00 (1.22); and control group, 6.37 (1.37) (P<.05, CL vs traditional; P>.05, traditional vs control). CONCLUSION: The CL approach proved superior to traditional training in terms of short- and medium-term retention of information. Although this is the first analysis of CL in this type of specialized medical training, extending its use in preparing medical residents working in emergency departments would seem to be justified.

OBJETIVO: Determinar el beneficio del uso de la técnica de aprendizaje cooperativo (AC) en la docencia de médicos internos residentes (MIR) que realizan actividades de atención continuada en urgencias, comparado con la enseñanza tradicional (ET). METODO: Estudio prospectivo secuencial de casos de controles. Se programaron dos sesiones formativas separadas realizadas por expertos en el mismo tema y dirigidas a residentes de primer año. Una sesión se basó en la ET y la otra en el modelo AC. Los MIR realizaron un test con respuesta múltiple diseñado por un tercer experto al término de cada sesión y tres meses después, que incluyó un grupo control de MIR que no habían asistido a ninguna sesión. RESULTADOS: El AC se aplicó sobre 21 alumnos y la ET sobre 17. Las puntuaciones medias y desviaciones estándar de los exámenes escritos realizados inmediatamente después de las sesiones formativas fueron 8,81 (1,40) y 7,88 (1,26) respectivamente (p = 0,0414). Tres meses después de las sesiones formativas, los mismos alumnos y 32 residentes controles fueron sometidos a un nuevo examen escrito con respuesta múltiple. La puntuaciones medias ± desviaciones estándar de este examen fueron 8,19 (1,12), 7,00 (1,22) y 6,37 (1,37) para el grupo AC, ET y control, respectivamente (p < 0,05 entre ACy ET, p > 0,05 entre ET y control). CONCLUSIONES: El método AC demuestra superioridad frente a la ET en términos de retención de información a corto y medio plazo. Si bien esta es la primera experiencia documentada en formación médica especializada, su utilidad en la formación transversal en MIR en urgencias podría justificar la extensión de su uso.

Periostitis reactiva de la mano / Reactive periostitis of the hand

No disponible

Osteonecrosis multifocal asociada a infección por el virus de la inmunodeficiencia humana / Multifocal osteonecrosis associated with human immunodeficiency virus infection

La osteonecrosis ha emergido en los últimos años como una complicación osteoarticular potencialmente discapacitante en pacientes con infección por el VIH. Existe una alta prevalencia de factores de riesgo tradicionales para el desarrollo de osteonecrosis en estos pacientes, pero también factores asociados a la infección por VIH en sí misma y el tratamiento antirretroviral de gran actividad. La osteonecrosis asociada a VIH suele afectar con mayor frecuencia a las caderas, con tendencia a la bilateralidad, pero la afección simultánea de 3 o más localizaciones (osteonecrosis multifocal) ha sido descrita de forma infrecuente. Presentamos el caso de un paciente varón de 49 años, con infección por el VIH de largo tiempo de evolución y tratamiento antirretroviral, que desarrolló osteonecrosis con afección simultánea de caderas, rodillas, tobillos y tarsos (AU)

The osteonecrosis has emerged in the last years as a potentially disabling osteoarticular complication in HIV-infected patients. There is a high prevalence of traditional risk factors for osteonecrosis development in these patients, but they also have factors associated to HIV infection in itself and the high activity antiretroviral therapy. The HIV-associated osteonecrosis often affects the hips, with a trend to bilaterally, but concomitant affection of 3 or more locations (multifocal osteonecrosis) has been infrequently reported. We present the case of a 49-years-old male patient, with long duration HIV infection and antiretroviral therapy, who developed osteonecrosis with concomitant affection of hips, knees, heels and tarsus (AU)

Multifocal osteonecrosis associated with human immunodeficiency virus infection.

The osteonecrosis has emerged in the last years as a potentially disabling osteoarticular complication in HIV-infected patients. There is a high prevalence of traditional risk factors for osteonecrosis development in these patients, but they also have factors associated to HIV infection in itself and the high activity antiretroviral therapy. The HIV-associated osteonecrosis often affects the hips, with a trend to bilaterally, but concomitant affection of 3 or more locations (multifocal osteonecrosis) has been infrequently reported. We present the case of a 49-years-old male patient, with long duration HIV infection and antiretroviral therapy, who developed osteonecrosis with concomitant affection of hips, knees, heels and tarsus.