Joint ultrasound baseline abnormalities predict a specific long-term clinical outcome in systemic lupus erythematosus patients.

Objective To describe long-term clinical and serological outcome in all systemic lupus erythematosus (SLE) domains in SLE patients with hand arthralgia (HA) and joint ultrasound (JUS) inflammatory abnormalities, and to compare them with asymptomatic SLE patients with normal JUS. Methods SLE patients with HA who presented JUS inflammatory abnormalities ('cases') and SLE patients without HA who did not exhibit JUS abnormalities at baseline ('controls') were included. All SLE clinical and serological domain involvement data were collected. End follow-up clinical activity and damage scores (systemic lupus erythematosus disease activity index (SLEDAI), Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR)) were recorded. JUS inflammatory abnormalities were defined based on the Proceedings of the Seventh International Consensus Conference on Outcome Measures in Rheumatology Clinical Trials (OMERACT-7) definitions. Statistical analyses were carried out to compare 'cases' and 'controls'. Results A total of 35 patients were recruited. The 'cases', n = 18/35, had a higher incidence of musculoskeletal involvement (arthralgia and/or arthritis) through the follow-up period (38.9% vs 0%, p = 0.008) and received more hydroxychloroquine (61.1% vs 25.0%, p = 0.034) and methotrexate (27.8% vs 0%, p = 0.046) compared to 'controls', n = 17/35. Other comparisons did not reveal any statistical differences. Conclusions We found SLE patients with arthralgia who presented JUS inflammatory abnormalities received more hydroxychloroquine and methotrexate, mainly due to persistent musculoskeletal involvement over time. JUS appears to be a useful technique for predicting worse musculoskeletal outcome in SLE patients.

Prevalence and predictors of vitamin D deficiency in non-supplemented women with systemic lupus erythematosus in the Mediterranean region: a cohort study.

OBJECTIVES: Over the past few years researchers have suggested that vitamin D plays a diverse role in autoimmune diseases such as systemic lupus erythematosus (SLE). We sought to determine the prevalence and predictors of vitamin D deficiency in a cohort of non-supplemented female SLE patients from the Mediterranean region. METHODS: We carried out a prospective cohort study on all SLE patients who had visited the Department of Rheumatology at the Parc de Salut MAR (Barcelona, Spain) between June 2007 and December 2008, excluding those who had been taking vitamin D supplements (total: 73 patients, all female). For each patient, demographic information was collected; scores were measured for disease severity [SLE Disease Activity Index (SLEDAI)] and structural damage [Systemic Lupus International Collaborating Clinic/American College of Rheumatology, (SLICC/ACR) Damage Index]; pharmacological treatment was recorded; analytical variables were analysed; and plasma levels of 25-hydroxy vitamin D [25(OH)D] were quantified. RESULTS: Among the patients in our cohort, 68.5% [95% confidence interval (CI) 60.3-79.2] exhibited vitamin D deficiency [plasma level of 25(OH)D < 30 ng/mL]. The predictors for vitamin D deficiency were daily sunscreen use [odds ratio (OR) 1.67, p = 0.02] and high body mass index (BMI) (OR 1.32 when adjusted for seasons and patient age, p = 0.04). We did not find any correlation between vitamin D deficiency and SLEDAI score (p = 0.31), SLICC/ACR score (p = 0.82), or any other of the variables. CONCLUSIONS: Vitamin D insufficiency is highly prevalent among SLE patients, even in southern regions. Sunscreen use and obesity increase the risk. Clinicians should be aware of these factors and supplement SLE patients at risk of vitamin D deficiency accordingly.

Association between fibromyalgia and psychiatric disorders in systemic lupus erythematosus.

OBJECTIVES: Systemic lupus erythematosus (SLE) is an autoimmune disease that may affect many organs, with musculoskeletal symptoms being the most common. Fibromyalgia (FM) is frequent in SLE patients. Psychiatric disorders such as anxiety and depression are also present in many SLE patients. The aim of our study is to determine the relationship between FM and psychiatric symptoms (PS), both anxious (AS) and depressive (DS), and its impact on health status in SLE patients. METHODS: In a total of 84 SLE patients we studied the presence of both FM and PS using specific questionnaires (Hamilton). We also evaluated health status and SLE disease activity by both the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and serological markers. Patients performed the Short Form 12 (SF-12) questionnaire as a quality of life measure. Qualitative variables were compared using Pearson's chi-square test and Fisher's exact test, and Student's t-test was used for quantitative variables. The Mann-Whitney U-test was applied if a normal distribution was not observed. RESULTS: Thirty patients were diagnosed with FM (35.7%), 16 had clinical signs DS (19%) and 30 had clinical signs AS (35.7%). We found a statistically significant association between FM and AS (p<0.001), and between FM and DS (p<0.001). Higher SF-12 physical component and mental component scores were observed in FM group compared to non-FM group (p<0.001). We have not found any associations between SLE activity and FM and PS. CONCLUSIONS: There is a high prevalence of FM in SLE patients, and a strong association with DS and AS. FM contributes to worsening health status in SLE patients. SLE activity has little or no impact either on psychiatric symptoms or FM.

Clinical, biological and ultrasonographic remission in a patient with musculoskeletal systemic lupus erythematosus with rituximab.

Systemic lupus erythematosus (SLE) is a multiorganic autoimmune disease that affects skin, osteoarticular and kidney frequently. Rituximab showed efficacy in treatment of osteoarticular and haematological SLE, but its use has been generalised for renal disease. In our case, we showed efficacy of rituximab in SLE articular disease, showing an ultrasonographic improvement.

Aceclofenac vs paracetamol in the management of symptomatic osteoarthritis of the knee: a double-blind 6-week randomized controlled trial.

OBJECTIVE: To evaluate the efficacy and tolerability of aceclofenac, 200 mg/day, and paracetamol, 3000 mg/day, in the treatment of osteoarthritis (OA) of the knee. METHODS: This was a double-blind, parallel-group, multicentre clinical trial involving patients with symptomatic OA of the knee, conducted in Spain. Patients were randomly allocated to aceclofenac 100 mg twice daily (n=82) or paracetamol 1000 mg three times daily (n=86). Patients were assessed at baseline and 6 weeks. Primary efficacy measures were severity of pain (visual analogue scale, VAS), Lequesne OA knee index, and patient's and physician's global assessment of disease activity. Severity of knee pain at rest or walking, stiffness, knee swelling and tenderness, and assessment of health-related quality of life (Health Assessment Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index, and Short Form 36) were included as secondary endpoints. RESULTS: Both treatment groups showed significant improvement compared with their baseline values in the four primary endpoints. Mean between-treatment differences favoured aceclofenac over paracetamol on pain (VAS, 7.64 mm [95% confidence interval (CI), 0.44-14.85 mm]), Lequesne OA index (1.41 [95% CI, 0.45-2.36]), and patient's (0.33 [95% CI, 0.06-0.61]) and physician's (0.23 [95% CI, 0.01-0.47]) global assessments. Adverse events were similar for both drugs (paracetamol, 29% patients vs aceclofenac, 32%; P=0.71). Four patients withdrew in each group due to adverse events. Patients tended to prefer aceclofenac to paracetamol (P=0.001), and more treated with paracetamol withdrew from the study due to lack of efficacy (n=8 vs n=1, P=0.035, for paracetamol and aceclofenac, respectively). CONCLUSION: At 6 weeks, patients with symptomatic OA of the knee showed a greater improvement in pain and functional capacity with aceclofenac than paracetamol with no difference in tolerability.

III Actualización del Consenso de la Sociedad Española de Reumatología sobre terapia biológica en la artritis reumatoide / No disponible

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[Pain in Spanish rheumatology outpatient offices: EPIDOR epidemiological study]. / El dolor en las consultas de Reumatología españolas: estudio epidemiológico EPIDOR.

OBJECTIVE: To establish the prevalence and characteristics of rheumatologic pain in Spanish adult population cared in specialized rheumatology offices. DESIGN: Cross selection study in a population of patients cared in rheumatology offices of public Spanish hospitals. SUBJECTS: 1,134 patients selected through random sampling based on waiting lists of patients, during a period of 1 week, in rheumatology offices of each participating hospital. MAIN OUTCOMES OF THE STUDY: Reason behind the consultation (a new patient [NP] or a patient for revision [RP]), characteristics of the patient (sex, age, habits [alcohol/tobacco], marital status), location, type, intensity, duration, tolerance and management of pain; treatment (pharmacological or non-pharmacological) carried out; satisfaction with the treatment; and association with fibromyalgia. RESULTS: The prevalence of pain in NP was 98.6% and in RP 95.1%, with a global prevalence of 96%, predominating mainly in adult sedentary women with fibromyalgia. The frequency of acute pain was 20.9% and this of chronic pain 79.1% [corrected] The prevalence of fibromyalgia was 12% (2.2% in men, and 15.5% in women). The most prevalent pattern of current dominant pain was this of the mechanical type. More frequent associated pathologies were: hypertension (21.7%), depression (14.4%), gastrointestinal diseases (13.8%) and anxiety (13.4%). All variables analyzed in the study showed changes according to age, sex, and type of patient (NP or RP). Most used treatment was pharmacological; more than 57.6% of patients were receiving NSAIDs. In NP, medical prescriber of the treatment was first the general practitioner (56.1%) followed by the rheumatologist (14.1%); in PR the first one was the rheumatologist (69.9%) followed by the general practitioner (16.5%). CONCLUSIONS: Our results show that the prevalence of the rheumatologic pain is very high, predominating mainly in adult women with fibromyalgia. Pain location, intensity, and type, associated pathology, and treatment vary according to age, sex, and type of patient. The most commonly used drugs for pain management were NSAIDs (58%); opiodes were only used in 6.4% of patients even though pain was intense in more than two-thirds.

El dolor en las consultas de Reumatología españolas: estudio epidemiológico EPIDOR / Pain in spanish Rheumatology outpatient offices: EPIDOR epidemiological study

Objetivo. Estimar la prevalencia y características del dolor reumatológico en la población adulta española atendida en consultas especializadas de Reumatología. Diseño. Estudio transversal de prevalencia en una población de pacientes atendidos en consultas de Reumatología de hospitales públicos españoles. Sujetos. Mil ciento treinta y cuatro elegidos mediante muestreo aleatorio a partir de listados de pacientes citados, durante un período de una semana, en consultas reumatológicas de cada uno de los hospitales participantes. Variables principales del estudio. Motivo de consulta (paciente de nuevo diagnóstico [PND] o de revisión [PR]), características del paciente (sexo, edad, hábitos [alcohol/tabaco], estado civil), localización, tipo, intensidad, duración, tolerancia y manejo del dolor, tratamiento (farmacológico o no farmacológico) realizado y satisfacción con el tratamiento. Resultados. La prevalencia de dolor en PND fue del 98,6% y en PR del 95,1%, con una prevalencia global del 96%, predominando principalmente en mujeres adultas, sedentarias y con fibromialgia. La frecuencia de dolor agudo fue del 80% y crónico del 20%. La prevalencia de fibromialgia fue del 12% (2,2% en hombres y 15,5% en mujeres). El patrón de dolor dominante actual que prevaleció fue de tipo mecánico. Las patologías asociadas más frecuentes fueron: hipertensión arterial (21,7%), depresión (14,4%), enfermedades digestivas (13,8%) y ansiedad (13,4%). Todas las variables del estudio analizadas cambiaron según edad, sexo y tipo de paciente (PND o PR). El tratamiento más usado fue farmacológico con antiinflamatorios no esteroideos (AINE) en más del 57,6%. El médico prescriptor del tratamiento fue primero el médico general (56,1%) seguido del reumatólogo (14,1 %) en PND y el primero fue el reumatólogo (69,9%) seguido del médico general (16,5 %) en PR. Conclusiones. Los resultados muestran que la prevalencia del dolor reumatológico es muy elevada, predominando principalmente en mujeres adultas con fibromialgia La localización, intensidad, tipo, patología asociada y tratamiento varían según edad, sexo y tipo de paciente. Los fármacos más utilizados para el manejo del dolor son los AINE (58%); los opioides tan sólo se utilizaron en el 6,4% de los pacientes a pesar de que el dolor fue intenso en más de dos tercios

Objective. To establish the prevalence and characteristics of rheumatologic pain in Spanish adult population cared in specialized rheumatology offices. Design. Cross selection study in a population of patients cared in rheumatology offices of public Spanish hospitals. Subjects. 1,134 patients selected through random sampling based on waiting lists of patients, during a period of 1 week, in rheumatology offices of each participating hospital. Main outcomes of the study. Reason behind the consultation (a new patient [NP] or a patient for revision [RP]), characteristics of the patient (sex, age, habits [alcohol/tobacco], marital status), location, type, intensity, duration, tolerance and management of pain; treatment (pharmacological or non-pharmacological) carried out; satisfaction with the treatment; and association with fibromyalgia. Results. The prevalence of pain in NP was 98.6% and in RP 95.1%, with a global prevalence of 96%, predominating mainly in adult sedentary women with fibromyalgia. The frequency of acute pain was 80% and this of chronic pain 20%. The prevalence of fibromyalgia was 12% (2.2% in men, and 15.5% in women). The most prevalent pattern of current dominant pain was this of the mechanical type. More frequent associated pathologies were: hypertension (21.7%), depression (14.4%), gastrointestinal diseases (13.8%) and anxiety (13.4%). All variables analyzed in the study showed changes according to age, sex, and type of patient (NP or RP). Most used treatment was pharmacological; more than 57.6% of patients were receiving NSAIDs. In NP, medical precriber of the treatment was first the general practitioner (56.1%) followed by the rheumatologist (14.1%); in PR the first one was the rheumatologist (69.9%) followed by the general practitioner (16.5%). Conclusions. Our results show that the prevalence of the rheumatologic pain is very high, predominating mainly in adult women with fibromyalgia. Pain location, intensity, and type, associated pathology, and treatment vary according to age, sex, and type of patient. The most commonly used drugs for pain management were NSAIDs (58%); opiodes were only used in 6.4% of patients even though pain was intense in more than two-thirds

Guidelines for clinical studies assessing the efficacy of drugs for the management of acute low back pain.

In this paper we propose guidelines for clinical trials aimed at assessing the efficacy of drugs for acute non-specific low back pain (LBP) with or without radicular pain, preliminary to their approval and registration. To this end, consensus statements were obtained from a group of experts in the fields of rheumatology, clinical medicine, public health and epidemiology. EBM resources were systematically used as references. Four diagnostic categories were defined: type 1--LBP with no radiation; type 2--LBP radiating no further than the knee; type 3--LBP radiating beyond the knee, but with no neurologic signs; and type 4--LBP radiating to a specific and entire leg dermatome, with or without neurologic signs. Studies should be designed on the basis of the claimed indications for the drug, but must be double-blinded whatever the indication. The duration of the study may be shorter for LBP type 1 or 2 (one week) than for LBP types 3 and 4 (up to one month), depending on the aim of the study and the indications for the drug. The comparator may be inactive (placebo) or active (for a superiority trial, e.g., versus paracetamol). Specific inclusion and exclusion criteria have been defined here for each category. An appropriate wash-out period for any drugs that could affect the pain status should be planned. Paracetamol may be allowed as rescue medication. The primary endpoint should be based on a validated pain assessment tool that may be either generic (type 1 or 2) or oriented (back and knee for types 3 and 4). Secondary endpoints could include the assessment of functional performance; the duration of any period of bed-rest; work limitation; a global assessment comprising pain at rest, standing and walking; the time elapsed before epidural injection, the prescription of other therapeutic agents, or surgery; and the use of rescue medication. Adverse events (AE) should be monitored systematically using a methodology that reflects the mode of action of the tested drug. With the application of these guidelines, LBP could serve as an appropriate disease for testing analgesic drugs. Rigorous evaluation may also help to improve the management of acute LBP.

Documento de la sociedad española de reumatología sobre la osteoporosis posmenopáusica . Panel de expertos / Postmenopausal osteoporosis: Expert's opinion on diagnostic, prevention and treatment

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Adaptación del ensayo de reabsorción osteoclástica utilizando el microscopio electrónico de barrido ambiental / Adaptation of osteoclasic resorption assay using the enviromental scanning electronic microscope

Los ensayos de actividad osteoclástica son muy útiles para poder desarrollar trabajos sobre la fisiología de estas células y su comportamiento in vitro frente a fármacos, cambios fisiológicos, comunicación celular, etc. Un inconveniente para este tipo de ensayos es la duración del procedimiento, que requiere una gran inversión de tiempo que a veces no se ve recompensada por los resultados obtenidos. Con el objetivo de mejorar el procedimiento mediante la reducción del tiempo empleado y la obtención de unos mejores resultados se propone la utilización del microscopio electrónico de barrido (ESEM). Mediante la utilización del ESEM se han obtenido imágenes de mayor nitidez de las células y de su actividad. Como conclusión, podemos decir que la aplicación de este procedimiento simplifica la metodología de trabajo y se obtienen mejores resultados en los ensayos de actividad osteoclástica (AU)

[Rheumatoid arthritis and Sjögren's syndrome. Special reference to the course time of rheumatoid arthritis]. / Artritis reumatoide y síndrome de Sjögren. Referencia especial al tiempo de evolución de la artritis reumatoide.

The frequency of Sjögren's syndrome (SS) was evaluated in 45 patients with rheumatoid arthritis (RA). Subsequently, the clinical, biological and evolutive profiles of RA associated or not with SS were compared. The prevalence of definitive SS was 55%, while in 24% isolated data of gland involvement were found. The variables related with the development of SS in patients with RA were: sex, functional respiratory parameters, and, basically, the duration of RA. The latter relationship had a uniform association model, i.e., the prevalence of SS increased in a constant fashion following the duration increments of RA. The change of patients from negative to definite SS was uniform throughout the evolution of RA.

Raised serum alkaline phosphatase activity in one family.

Eleven members of the same family were studied after an incidental detection of raised serum alkaline phosphatase activity in one of them without any apparent underlying cause. Three other members were found to have the same abnormality; none of them had an associated disease. In the four cases with elevated serum alkaline phosphatase levels, its activity showed a preponderance of the bone isoenzyme. Studies of the erythrocyte and histocompatibility antigens in nine members of the family, as well as idiograms of karyotypes of four of them, did not show any relation between histocompatibility antigens and the raised levels of serum alkaline phosphatase. Also, no chromosomal abnormality is shown from karyotypes. The data suggest a probable autosomal dominant pattern of inheritance.