The burden of the most common rheumatic disease in Colombia.

BACKGROUND: Estimating the burden of rheumatic diseases (RDs) requires proper evaluation of its lethal and nonlethal consequences. In Colombia, it is possible to find local data and Global Burden of Disease (GBD) reports that collect information from varied contexts and apply complex statistical models, but no on-site estimations are available. METHODS: This was a descriptive study on the burden of RD based on occurrence and mortality data in the general population during 2015, including information and prevalence estimations from the Community Oriented Program for the Control of Rheumatic Diseases (COPCORD) study. Disability-adjusted life years (DALYs) were estimated by combining measures of years of life lost (YLL) and years lived with disability (YLDs). For disability weight estimations among cases, different COPCORD responses were mapped using flowcharts to show the severity distribution according to GBD. All model parameters and results were validated through an expert consensus panel. RESULTS: Low back pain (LBP) was the RD with the greatest burden of disease, costing 606.05 (95% CI 502.76-716.58) DALYs per 100,000 inhabitants, followed by osteoarthritis (292.11; 95% CI 205.76-386.85) and rheumatoid arthritis (192.46, 95% CI 109.7-239.69). CONCLUSIONS: The burden of RD is as high in Colombia as in other countries of the region. The results offer an interesting tool for optimizing healthcare system design as well as for planning the distribution of human and economic resources to achieve early diagnosis and adequate care of these diseases.

Uso de medicina complementaria y alternativa y su asociación con la relación médico-paciente en enfermos con artritis reumatoide / Association between physician-patient relationship and the use of complementary and alternative medicine in patients with rheumatoid arthritis

RESUMEN Introducción: El uso de medicina complementaria y alternativa (MCA) en pacientes con enfermedades reumáticas es prevalente pero la comunicación con el reumatólogo suele ser deficiente, lo cual afecta la relación médico-paciente (RMP). Objetivos: Evaluar la asociación entre el uso de MCA y la RMP en enfermos con artritis reumatoide. Como objetivos adicionales, describir la percepción del paciente sobre la comunicación con su reumatólogo respecto al uso de MCA y el patrón de uso de las diferentes modalidades terapéuticas. Materiales y métodos: Estudio descriptivo de corte transversal. El uso de MCA y la RMP se evaluaron mediante la autoaplicación de cuestionarios validados (I-CAM-Q y PDRQ-9 respectivamente). Resultados: Se incluyó a 246 pacientes ambulatorios de una institución de tercer nivel de atención. Se encontró asociación entre una mayor satisfacción con el tratamiento y el no usar MCA, y entre el hecho de informar al reumatólogo sobre el uso de MCA con un mayor grado de acuerdo con el médico sobre el origen de los síntomas y mayor satisfacción con el tratamiento. Las modalidades más frecuentemente utilizadas fueron: quiropraxia, acupuntura y productos herbales. El 78,5% afirmaron estar de acuerdo con comunicar el uso de este tipo de medicación al reumatólogo, sin embargo, solo el 31,3% lo notificó, por temor a represalias (54,4%). Conclusiones: Pese a la alta prevalencia de uso de MCA en nuestros pacientes, la mayoría no lo comunicó al reumatólogo. Se encontró asociación entre el uso de MCA y una menor satisfacción del paciente con el tratamiento y entre la comunicación médico-paciente sobre la práctica de MCA y una mejor satisfacción con el tratamiento.

ABSTRACT Introduction: Although complementary and alternative medicine (CAM) use among patients with rheumatic diseases is extensive, discussions regarding these treatments occur rarely in the rheumatology setting, directly affecting the physician-patient relationship (PPR). Objectives: The aim of this study was to evaluate the association between patient-physician relationship and complementary and alternative medicine use. As secondary objectives, to describe the patient's perspective towards CAM use and estimate the prevalence of CAM treatments used in patients with rheumatoid arthritis. Methods and materials: A descriptive cross-sectional survey was conducted, in which CAM use and physician-patient relationship were assessed by self-reported validated questionnaires (I-CAM-Q and PDRQ-9, respectively). Results: The study included a total of 246 outpatients of a tertiary care hospital. There were no significant differences between CAM users vs. non-users, or informers vs. non-informers in terms of physician-patient relationship measured by PDQR. The most frequent used CAM treatments were: chiropractice, acupuncture, and herbal products. A large majority (78.5%) of the patients expressed agreement to the discussion of CAM use with the rheumatologist, but only 31.3% of total CAM users did so because of fear of retaliation (54.4%). Conclusion: Despite the extensive practice of CAM among patients with rheumatoid arthritis, most patients did not discuss these treatments with their physicians. Associations were found between MCA use and a lower patient's treatment satisfaction and between physician-patient communication about CAM practice and a higher patient's treatment satisfaction.

Mesenchymal stromal cells represent a therapeutic option for systemic sclerosis patients / Células estromales mesenquimales representan una opción terapéutica en pacientes con esclerosis sistémica

ABSTRACT The mesenchymal stromal cells (MSCs) are hematopoietic stem cells with high capacity of differentiation to other cellular lineages, depending on the microenvironment in which they live as well as on the interaction and signaling pathways they establish with the extracellular matrix. Several properties have been described in these cells: proangiogenic, antifibrotic and immunomodulatory. These properties are being studied as a therapeutic approach for autoimmune diseases such as cutaneous systemic sclerosis (SSc). SSc is a systemic chronic disease, with an approximate prevalence of 35.6 cases per 100,000 inhabitants in North America and of 0.02% in Colombia in 2018. There are two different clinical variants, diffuse and localized. In both variants an important skin involvement and a rapidly deterioration of organs is present, which can overshadow the clinical prognosis and increase the mortality. Options for the treatment of advanced diffuse SSc are scarce mainly targeting symptomatic control with little impact on the progression and mortality. Therefore, there is an increasing interest in new therapies like advanced cellular therapy with hematopoietic stem cells and stromal mesenchymal cells. This article reviews the information related to the use of stromal mesenchymal cells in patients with this disease.

RESUMEN Las células mesenquimales estromales son células madre no hematopoyéticas pluripotenciales con alta capacidad de derivación a diferentes linajes celulares, dependiendo tanto del microambiente en el que se encuentren, como de la interacción y señalización que establezcan con la matriz extracelular del entorno, esto ha permitido describir un potencial proangiogénico, antifibrótico e inmunomodulador, que ha sido blanco de investigación en enfermedades autoinmunes como la esclerosis sistêmica cutánea. Considerando que la esclerosis sistêmica cutánea es una enfermedad inflamatoria crónica, con una prevalencia estimada de 35,6 casos por cada 100.000 habitantes en Norte América y de 0,02% en nuestro país para el 2018, se caracteriza por presentar dos variables clínicas principalmente; una variante limitada y una variante difusa, presentando en ambas un compromiso extenso de piel y órganos que puede ser rápidamente progresivo y deteriorar el pronóstico de los pacientes que la padecen aumentando su mortalidad. Debido a que las opciones terapéuticas en esta entidad son limitadas y buscan únicamente el control de síntomas, pero con poco impacto en progresión y mortalidad, terapias celulares avanzadas han surgido como nuevas opciones terapéuticas incluyendo el trasplante de células madre hematopoyéticas y las células mesenquimales estromales. A continuación, se revisará acerca de la utilidad y evidencia de células mesenquimales estromales en pacientes con esta enfermedad.

Comparison of quality of life in patients with musculoskeletal symptoms, those with other comorbidities, and healthy people, in a Colombian open population study / Comparación de la calidad de vida de pacientes con síntomas musculoesqueléticos, comorbilidades asociadas y personas sanas en un estudio abierto de población colombiano

A b s t r a c t Purpose: To describe health-related QOL (HRQOL) in patients with musculoskeletal symptoms, compared to a population with other comorbidities, and a healthy population. Methods: A cross-sectional study was carried out on an open population involved in a community-oriented program for control of rheumatic diseases (COPCORD) study in Colombia, using EQ-5D-3L for estimating QOL, and the health assessment questionnaire disability index (HAQ-DI) for functional capacity. Results: Out of the total 4020 individuals evaluated, 2274 had rheumatic diseases, 642 had non-rheumatic diseases, and 1104 were healthy subjects. Spondyloarthritis (SpA) and rheumatoid arthritis (RA) patients had more complaints regarding pain/discomfort and mobility. As for daily activities, the diseases that mostly affected them were systemic lupus erythematosus (SLE) and RA. RA and fibromyalgia (FM) patients had the worst scores as regards anxiety/depression and self-care dimensions. FM patients had the lowest QOL measured by EQ-VAS (57.7 ± 26.2). The most frequent non-rheumatic diseases were cardiovascular and mental disorders, with 20% of these patients having a moderate level of pain/discomfort and anxiety/depression. The rheumatic patients reported a decrease in functional capacity (HAQ: 0.49), in contrast to the healthy population (0.01), and the population having other diseases (0.06). Conclusion: Rheumatic disease patients in Colombia had the worst QOL compared to the healthy population and patients with other comorbidities. Rheumatic patients had greater functional limitations, even more so when having comorbidities. This study revealed potential factors of interest requiring the attention of public health authorities, and for improving patients' QOL.

RESUMEN Objetivo: Describir la calidad de vida relacionada con la salud en pacientes con síntomas musculoesqueléticos, en comparación con pacientes con enfermedades no reumáticas y una población sana. Métodos: Se realizó un estudio transversal en comunidad abierta, en personas involucradas en un programa orientado a la comunidad para el control de enfermedades reumáticas (COP-CORD) en Colombia, utilizando el EQ-5D-3L para estimar la calidad de vida y el cuestionario de evaluación de la salud (HAQ- DI) para la capacidad funcional. Resultados: Se evaluaron 4.020 individuos; 2.274 tenían enfermedades reumáticas, 642 tenían enfermedades no reumáticas y 1.104 eran sujetos sanos. Los pacientes con espondiloartritis (SpA) y artritis reumatoide (AR) tuvieron mayores quejas con respecto al dolor/malestar y la movilidad. En cuanto a las actividades diarias, los enfermos con lupus eritematoso sistémico (LES) y AR fueron los más afectados. Los pacientes con AR y fibromialgia (FM) tuvieron las peores puntuaciones en ansiedad/depresión en las dimensiones de cuidado personal. Los pacientes con FM tuvieron la calidad de vida más baja medida por EQ-VAS (57,7 ± 26,2). Las enfermedades no reumáticas más frecuentes fueron los trastornos cardiovasculares y mentales; el 20% de estos pacientes tenía un nivel moderado de dolor/malestar y ansiedad/depresión. Los pacientes reumáticos reportaron una disminución de la capacidad funcional (HAQ: 0,49); en contraste con la población sana (0,01) y la población con otras enfermedades (0,06). Conclusión: Los pacientes con enfermedades reumáticas en Colombia tuvieron la peor calidad de vida en comparación con la población sana y los pacientes con otras enfermedades. Los pacientes reumáticos tuvieron una mayor limitación funcional, incluso más que los que tenían otras enfermedades. Este estudio reveló posibles factores relacionados con las enfermedades reumáticas que requieren la atención de las autoridades de salud pública con el objetivo de mejorar la calidad de vida de los pacientes.

Carcinoma de pulmón como disparador de una respuesta autoinmune: un desafío médico / Lung cancer acting as a trigger of autoimmunity: a medical challenge

RESUMEN Existe una relación compleja, dinámica y bidireccional entre la autoinmunidad y el cáncer. Si bien los mecanismos carcinogénicos y fisiopatológicos de las enfermedades autoinmunes no están claramente dilucidados, existe una base inmunológica común relacionada con la expresión de autoantígenos por parte de las células tumorales que desencadenan una respuesta antitumoral, facilitando el desarrollo de síndromes paraneoplásicos reumáticos y enfermedades autoinmunes reumáticas en población genéticamente susceptible. Se presenta un caso de un hombre que debutó con un síndrome pulmón riñón y se diagnosticó cáncer de pulmón y lupus eritematoso sistémico de forma simultánea.

A B S T R A C T There is a complex, dynamic, and bidirectional connection between autoimmunity and cancer. The underlying mechanisms of carcinogenesis and physiopathological aspects of autoimmune diseases are not fully understood. However, there is a common immunological base related to expression of autoantigens by tumour cells that cause an anti-cancer immune response, thereby, triggering the development of paraneoplastic rheumatic syndromes and autoimmune rheumatic diseases in a genetically predisposed population. The case is reported of a 57 year-old man presenting with pulmonary renal syndrome, and who was diagnosed lung cancer and systemic lupus erythematosus at the same time.

Association of significant risk perception with the use of complementary and alternative medicine: A cross-sectional study in Hispanic patients with rheumatoid arthritis.

BACKGROUND: Risk perception (RP) describes patient´s judgment of the likelihood of experiencing something unpleasant, and has been associated to the adoption of health behaviors. Current rheumatoid arthritis (RA) guidelines recommend early and intensive treatment, although patients also commonly use Complementary and Alternative Medicine (CAM). We aimed to investigate if significant RP was associated to CAM use in Hispanic RA outpatients and to describe additional associated factors. METHODS: Between March and August 2019, 266 consecutive outpatients were invited to a face-to-face interview to collect socio-demographic and RA-related information, to assess comorbidity and the following patient-reported-outcomes: pain, overall-disease and treatment adherence with visual analogue scales, disease activity with RAPID-3, RP with a validated questionnaire, and CAM use with a translated and cross-culturally adapted for Argentina version of the International CAM questionnaire. Medical records were reviewed to corroborate the data provided by the patients. CAM use definition was restricted to "in the last 3 months". Significant RP was defined based on published cut-off. Multiple logistic regression analysis was used to investigate factors associated to CAM use. The study received IRB approval. RESULTS: There were 246 patients included, primarily middle-aged women, with substantial disease duration, moderate disease activity and 70 patients (28.5%) had significant RP. Two hundreds patients (81.3%) were CAM users. Significant RP (OR: 2.388, 95%CI: 1.044-5.464, p = 0.039) and access to Federal health care system (OR: 2.916, 95%CI: 1.081-7.866, p = 0.035) were associated to CAM use. CONCLUSIONS: Patient´s perception of RA-related negative consequences was associated to recent CAM use in Hispanic RA outpatients.

TLR expression in peripheral monocyte subsets of patients with idiopathic inflammatory myopathies: association with clinical and immunological features.

BACKGROUND: Monocytes and toll-like receptors (TLR) have been found in the inflammatory infiltrate of muscle biopsies in patients with idiopathic inflammatory myopathies (IIM), suggesting an important role of these cells in the pathogenesis of myositis. The monocyte subsets, their TLR expression in peripheral blood and their relationship with the clinical characteristics of patients with IIM has not been addressed. METHODS: We recruited 45 patients with IIM diagnosis and 15 age and sex-adjusted healthy controls. We assessed the disease activity and damage, performed a nailfold capillaroscopy and registered the cardio-pulmonary parameters from the medical charts. Monocyte subsets, their expression of TLR2 and TLR4 and the serum Th1/Th2/Th17 cytokines levels were evaluated by flow cytometry. We expressed quantitative variables as medians and interquartile ranges (IQR) or minimum and maximum (min-max). Differences between groups were assessed with Mann-Whitney U and the Kruskal-Wallis tests. Correlation between quantitative variables was assessed with Spearman Rho. RESULTS: Twenty-nine patients were women (64.4%) and 32 (71.1%) had dermatomyositis. In comparison to healthy controls, patients with active IIM had a higher percentage of intermediate monocytes and lower amounts of classical monocytes. Patients with IIM had a higher expression of TLR4 in all their monocyte subsets, regardless of disease activity and prednisone treatment. Serum IL-6 correlated with the TLR2 expression in every monocyte subset and the expression of TLR2 in intermediate monocytes was higher among patients with dysphagia. Subjects with nailfold capillaroscopy abnormalities had a higher amount of TLR2+ classical and non-classical monocytes and those with interstitial lung disease (ILD) had a higher percentage of TLR4+ non-classical monocytes. The classical and intermediate monocytes from patients with anti Mi2 antibodies had a higher expression of TLR4. The percentage of intermediate monocytes and the expression of TLR4 in all monocyte subsets showed a good diagnostic capacity in patients with IIM. CONCLUSION: Patients with IIM have a differential pool of monocyte subsets with an enhanced expression of TLR2 and TLR4, which correlates with disease activity and distinctive clinical features including dysphagia, ILD, vasculopathy, and pro-inflammatory cytokines. These immunological features might be useful as a potential diagnostic tool as well as novel disease activity biomarkers in IIM.

Epidemiologic Profile of Erectile Dysfunction in Patients with Systemic Lupus Erythematosus: The Latin American Landscape.

OBJECTIVE: The aim of this study was to describe the prevalence of erectile dysfunction (ED), as well as associated demographic and clinical features, in men with systemic lupus erythematosus (SLE), by means of a systematic, standardized evaluation. METHODS: We performed a transversal study in 8 tertiary care centers in Latin America. We included male patients ≥ 16 years who fulfilled ≥ 4 American College of Rheumatology criteria for SLE and had regular sexual activity, and evaluated them with the International Index of Erectile Function-5 questionnaire. Relevant demographic, clinical, and serological characteristics were recorded. We included 2 control groups: the first was made up of healthy men and the second of men with autoimmune diseases other than SLE (non-SLE group). RESULTS: We included 590 subjects (174 SLE, 55 non-SLE, and 361 healthy controls). The prevalence of ED in the SLE group was 69%. Mean age in that group was 36.3 ± 1.03 years. Among SLE patients with and without ED, these factors were significantly different: the presence of persistent lymphopenia (p = 0.006), prednisone dose (9.3 ± 1.2 vs 5.3 ± 1.3 mg, p = 0.026), and the Systemic Lupus International Collaborating Clinics damage score (1.25 ± 0.14 vs 0.8 ± 0.16 points, p = 0.042). Independent risk factors for ED in patients with SLE were persistent lymphopenia (OR 2.79, 95% CI 1.37-5.70, p = 0.001) and corticosteroid use in the previous year (OR 2.15, 95% CI 1.37-3.37, p = 0.001). CONCLUSION: Regardless of comorbidities, treatment (excluding steroids), and type of disease activity, patients with SLE have a high prevalence of ED, especially considering that most patients are young. Recent corticosteroid use and persistent lymphopenia, which could be related to endothelial dysfunction, are risk factors for this complication in men with SLE.

Accuracy and reliability of the sensory test performed using the laryngopharyngeal endoscopic esthesiometer and rangefinder in patients with suspected obstructive sleep apnoea hypopnoea: protocol for a prospective double-blinded, randomised, exploratory study.

INTRODUCTION: Patients with obstructive sleep apnoea hypopnoea syndrome (OSA) might have varying degrees of laryngopharyngeal mechanical hyposensitivity that might impair the brain's capacity to prevent airway collapse during sleep. However, this knowledge about sensory compromises in OSA comes from studies performed using methods with little evidence of their validity. Hence, the purpose of this study is to assess the reliability and accuracy of the measurement of laryngopharyngeal mechanosensitivity in patients with OSA using a recently developed laryngopharyngeal endoscopic esthesiometer and rangefinder (LPEER). METHODS AND ANALYSIS: The study will be prospective and double blinded, with a randomised crossover assignment of raters performing the sensory tests. Subjects will be recruited from patients with suspected OSA referred for baseline polysomnography to a university hospital sleep laboratory. Intra-rater and inter-rater reliability will be evaluated using the Bland-Altman's limits of agreement plot, the intraclass correlation coefficient, and the Pearson or Spearman correlation coefficient, depending on the distribution of the variables. Diagnostic accuracy will be evaluated plotting ROC curves using standard baseline polysomnography as a reference. The sensory threshold values ​​for patients with mild, moderate and severe OSA will be determined and compared using ANOVA or the Kruskal-Wallis test, depending on the distribution of the variables. The LPEER could be a new tool for evaluating and monitoring laryngopharyngeal sensory impairment in patients with OSA. If it is shown to be valid, it could help to increase our understanding of the pathophysiological mechanisms of this condition and potentially help in finding new therapeutic interventions for OSA. ETHICS AND DISSEMINATION: The protocol has been approved by the Institutional Review Board of Fundacion Neumologica Colombiana. The results will be disseminated through conference presentations and peer-reviewed publication. TRIAL REGISTRATION: This trial was registered at Clinical Trials Accuracy of the sensory test using the lLaryngopharyngeal endoscopic esthesiometer in obstructive sleep apnea. Protocol ID: 201611-22405. ClinicalTrials.gov ID: NCT03109171.