Relación entre fibromialgia y sarcopenia: el papel del abordaje nutricional / Fibromyalgia and sarcopenia relation: the role of nutritional approach

Introducción: la fibromialgia (FM) es un síndrome caracterizado por la presencia de dolor musculoesquelético crónico y generalizado, de origen no articular, que puede llegar a ser invalidante y afectar la esfera biológica, psicológica y social del paciente. Estado del arte: no se han publicado recomendaciones nutricionales específicas para las personas con FM y también existe un vago conocimiento acerca de los parámetros relacionados con la evaluación de la composición corporal (masa musculoesquelética, masa grasa, agua corporal, etc.) y la alteración en la fuerza muscular (p. ej., dinapenia, por dinamometría de mano, flexión de la rodilla, entre otras), así como la evaluación en términos de sarcopenia. Discusión: pocos estudios publicados hasta el momento describen en profundidad la composición corporal de las personas con FM. La mayoría se centran casi exclusivamente en la descripción del peso y el índice de masa corporal (IMC), por lo que existe poco conocimiento acerca de otros parámetros de relevancia, como por ejemplo aquellos relacionados con masa y fuerza muscular o masa grasa. La alimentación se menciona en varias publicaciones, pero no existen guías o pautas específicas de recomendaciones nutricionales para esta población. Algunos pacientes adoptan diversas dietas, estrategias o planes alimentarios sin ningún tipo de orientación de los profesionales de la salud, e incluso a veces, siguiendo fuentes de información no fiables, poniendo en riesgo su salud. Las publicaciones científicas no evalúan la asociación o el impacto del estado nutricional y la inadecuada alimentación en la calidad de vida. Conclusiones: en las personas con FM, conocer el estado nutricional, más allá del peso, determinando la composición corporal y la prevalencia de dinapenia o sarcopenia o ambas permitiría realizar un abordaje nutricional más adecuado. Este conocimiento podría ser coadyuvante en la terapéutica, logrando una mejoría en su desempeño físico y una mejor calidad de vida. (AU)

Introduction: fibromyalgia (FM) is a syndrome charcaterized by the presence of chronic, and generalized musculoskeletal pain, not articular in origin, which can become disabling and affect the biological, psychological, and social sphere of the patient. State of the art: no specific nutritional recommendations have been published for people with FM and there is also a vague knowledge regarding parameters related to body composition assessment (skeletal muscle mass, body fat mass, water, etc.) and loss of muscle strength (for example, dynapenia, by handgrip, knee flexion, among others), as well as assessment in terms of sarcopenia. Discussion: there are few studies published so far that completely describe the body composition in people with FM. Most of them focus almost exclusively on weight and body mass index (BMI), so there is a lack of knowledge about other descriptive parameters, such as those related to muscle mass and strength or fat mass. Diet is mentioned in several publications, but there are no specific guidelines for nutritional recommendations for this population. Some patients follow several diets, strategies or eating plans without health care professionals' guidance, and sometimes even following unreliable sources of information, putting themselves at risk. Scientific publications do not evaluate the association or impact of nutritional status and inadequate nutrition on quality of life in FM. Conclusions: in people with FM, knowledge of the nutritional status, beyond weight, determining body composition and the prevalence of dynapenia and/or sarcopenia would allow a more accurate nutritional approach. This knowledge could be helpful for the treatment, achieving an improvement in their physical performance and a better quality of life. (AU)

Sarcopenia y su relevancia en la práctica clínica / Sarcopenia and its relevance in clinical practice

La sarcopenia se define como una combinación de baja fuerza y masa muscular con alteración funcional del músculo, que afecta a poblaciones de diferentes edades por diversos motivos. La prevalencia global en adultos mayores se ha estimado en 10% (IC 95%: 8-12%) en hombres y 10% (IC 95%: 8-13%) en mujeres. Recientemente ha cobrado importancia su detección en enfermedades reumáticas, particularmente las inflamatorias. En esta revisión narrativa hemos considerado: a) recomendaciones para el diagnóstico de la sarcopenia; b) herramientas útiles para la práctica clínica y la investigación; c) su relación con las enfermedades reumáticas. Según el último Consenso Europeo de Sarcopenia la búsqueda debe comenzar cuando el paciente reporta síntomas y/o signos (debilidad, lentitud al caminar, desgaste muscular, pérdida de masa muscular, etc.). Para los adultos mayores se recomienda el cuestionario SARC-F como herramienta de tamizaje. Varias pruebas establecen los puntos de corte que deben utilizarse para diagnosticar la baja fuerza muscular, la disminución en la masa muscular y la alteración en el rendimiento físico. La relevancia de diagnosticar precozmente la sarcopenia se basa en el impacto clínico, económico y social que tiene, incluyendo la funcionalidad y calidad de vida de las personas, muy importante en aquellas con enfermedades reumatológicas.

Sarcopenia is defined as a combination of low muscle strength and mass with muscle function impairment that affects the population at different age ranges for different reasons. The global prevalence at the elderly was estimated at 10% (95% CI: 8-12%) in men and 10% (95% CI: 8-13%) in women. In recent years, the detection of sarcopenia in rheumatic diseases has become relevant. The aim of this revision was to develop a review regarding: a) recommendations for the diagnosis of sarcopenia; b) most useful tools for detection in clinical practice and research; c) relationship with some rheumatic diseases. According to the latest European Sarcopenia Consensus, in clinical practice, the search must start when the patient reports symptoms and signs (weakness, slow walking, muscle wasting, disease that leads to muscle loss, etc.). For the elderly population the SARC-F test is recommended as a screening tool. Several tests have established cut-off points to be used to diagnose low muscle strength, decrease in muscle mass or physical performance impairment. The relevance of early diagnosis of sarcopenia is based on the clinical, economic, social impact and also on functionality and quality of life in people, particularly in those with rheumatic diseases.

Osteoporotic fractures in rheumatoid arthritis patients in Argentina: a matched retrospective cohort study.

BACKGROUND: To compare the incidence of osteoporotic fractures in patients with rheumatoid arthritis (RA) with matched controls from a university hospital. METHODS: Consecutive RA patients (n = 100) were matched (age and sex) with controls (1:2). The follow-up period began at the index date, defined as the date of diagnosis for RA patients and the date of the first medical claim at the Health Management Organization (HMO) for non-RA patients. Fracture incidence rates per 1000 persons-years (PY) for distinct types of fractures were calculated. Multivariate cox regression analysis was performed to identify factors associated with fractures. RESULTS: One hundred RA patients were followed for a total of 975.1 patients-years and 200 controls for 1485.7 patients-years. No difference was found in the overall fracture incidence rate per 1000 PY between RA and controls (19.5, 95% CI 12.7-28.6 vs 12.1, 95% CI 7.7-18.7, p = 0.07). In the Cox regression analysis, only age (HR 1.06, 95% CI 1.02-1.11, p = 0.006) and history of a prior fracture (HR 9.85, 95% CI 2.97-32.64, p <  0.001) were associated with fractures after the index date. The stratified analysis of the fractures by location showed that only the vertebral fractures were more frequent in RA patients compared with controls (12.9 per 1000 PY, 95% CI 8.9-25.8, vs. 3.4, 95% CI 1.4-8.1, respectively, p = 0.01). CONCLUSION: Patients with RA didn't show an overall increased risk of osteoporotic fractures compared with matched controls, but vertebral fractures were more frequently observed in patients with RA.

Osteoporotic fractures in rheumatoid arthritis patients in Argentina: a matched retrospective cohort study

Abstract Background: To compare the incidence of osteoporotic fractures in patients with rheumatoid arthritis (RA) with matched controls from a university hospital. Methods: Consecutive RA patients (n = 100) were matched (age and sex) with controls (1:2). The follow-up period began at the index date, defined as the date of diagnosis for RA patients and the date of the first medical claim at the Health Management Organization (HMO) for non-RA patients. Fracture incidence rates per 1000 persons-years (PY) for distinct types of fractures were calculated. Multivariate cox regression analysis was performed to identify factors associated with fractures. Results: One hundred RA patients were followed for a total of 975.1 patients-years and 200 controls for 1485.7 patients-years. No difference was found in the overall fracture incidence rate per 1000 PY between RA and controls (19.5, 95% CI 12.7-28.6 vs 12.1, 95% CI 7.7-18.7, p =0.07). In the Cox regression analysis, only age (HR 1.06, 95% CI 1.02-1.11, p = 0.006) and history of a prior fracture (HR 9.85, 95% CI 2.97-32.64, p < 0.001) were associated with fractures after the index date. The stratified analysis of the fractures by location showed that only the vertebral fractures were more frequent in RA patients compared with controls (12.9 per 1000 PY, 95% CI 8.9-25.8, vs. 3.4, 95% CI 1.4-8.1, respectively, p =0.01). Conclusion: Patients with RA didn't show an overall increased risk of osteoporotic fractures compared with matched controls, but vertebral fractures were more frequently observed in patients with RA.

Performance of Ultrasonography Compared to Conventional Radiography for the Diagnosis of Osteoarthritis in Patients With Knee Pain.

Purpose: To investigate the performance of ultrasonography (US) for the detection of knee osteoarthritis (OA) in patients suffering from knee pain, compared to conventional radiographs. Methods: Cross-sectional study performed at a university teaching hospital. Consecutive patients complaining of unilateral or bilateral mechanical knee pain who signed an informed consent were included. All patients underwent simultaneously an ultrasonographic and a radiographic evaluation of the knee. Exclusion criteria were age under 18 years, prior diagnosis of knee OA, diagnosis of inflammatory arthritis, history of knee surgery or trauma, severe knee deformities, and corticosteroid injection within the last 2 months. The diagnostic properties of US for the detection of knee OA were evaluated using radiological data as the reference method. Evaluated test properties were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the positive and negative likelihood ratio (LR+ and LR-). Results: Three-hundred twenty-two knees (281 patients) were included. Radiographic degenerative changes were present in 56.8% (183) of the evaluated knees. Regarding the diagnostic properties of the US, the presence of either osteophytes or the compromise of the femoral hyaline cartilage had the best sensitivity to detect OA (95%), with a NPV of 92% and a LR- of 0,07, while the combined identification of osteophytes and compromise of the femoral hyaline cartilage had the best specificity (94%), with 94% PPV and a LR+ of 13. Conclusion: US demonstrated an excellent sensitivity with an adequate specificity for the detection of radiographic knee OA.

Rheumatoid Arthritis Patient's Journey: Delay in Diagnosis and Treatment.

OBJECTIVES: The aims of this study were to establish delay times from articular symptoms onset to first rheumatologist consultation, rheumatoid arthritis (RA) diagnosis, and treatment initiation with disease-modifying antirheumatic drug (DMARD) therapy and to assess the impact of delayed diagnosis on structural damage. METHODS: This was an observational cohort study. Rheumatoid arthritis adult patients treated in a private health system between January 1, 1996, and December 31, 2016, were included. Electronic medical records were reviewed to obtain clinical and demographic data, dates of first disease symptom, diagnosis, and date of first treatment with DMARDs. Physical function (Health Assessment Questionnaire) and structural damage (Sharp score modified by van der Heijde) were also assessed. RESULTS: Two hundred forty-six patients (81% female), with a mean age of 67.25 (standard deviation [SD], 14.53) years, were included. At the end of follow-up period, median Health Assessment Questionnaire (n = 145) and radiological scores (n = 171) were 0.125 (interquartile range, 0-0.87) and 15 (interquartile range, 6-33), respectively. A mean of 9.2 (SD, 20) months (median, 3 months) elapsed from the first disease symptom to rheumatologist consultation, 14.2 (SD, 24) months (median, 4.8 months) to RA diagnosis, and 16.9 (SD, 25.4) months (median, 7 months) to treatment initiation with DMARDs. Significantly greater structural damage was found in patients with a diagnosis delay of more than 12 months (n = 70) (p = 0.0325). CONCLUSIONS: Despite good access to medical consultation in a private health system, there is still a delay to RA diagnosis and to start pharmacological therapy. A delay of more than 12 months was significantly associated with greater radiological damage after 5 years of follow-up.

Value of Color Doppler Ultrasound Assessment of Sacroiliac Joints in Patients with Inflammatory Low Back Pain.

OBJECTIVE: To evaluate the diagnostic value of color Doppler ultrasound (CDUS) for the detection of sacroiliitis, in patients with inflammatory back pain (IBP). METHODS: Consecutive patients with IBP and suspected axial spondyloarthritis (SpA), but without a definitive diagnosis, were included. Consecutive patients with defined SpA and axial involvement were included as a control group. All patients underwent clinical evaluation, magnetic resonance imaging (MRI), and CDUS of sacroiliac joints (SIJ) within the same week. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of sacroiliitis by CDUS were calculated, using MRI as the gold standard. RESULTS: There were 198 SIJ evaluated in 99 patients (36 with previous SpA). There were 61 men (61.6%), with a mean age of 39.8 years (SD 11.3) and median disease duration of 24 months (IQR 12-84). At the patient level, CDUS had a sensitivity of 63% (95% CI 48.7-75.7%) and a specificity of 89% (95% CI 76-96%). The PPV was 87.2% (95% CI 72.6-95.7%) and the NPV was 66.7% (95% CI 53.3-78.3%). At joint level, CDUS had a sensitivity of 60% (95% CI 49-70%) and a specificity of 93% (95% CI 88-98%). The PPV was 83% (95% CI 78-95%) and the NPV was 43% (95% CI 33-56%). The sensitivity of CDUS for the diagnosis of axial SpA was 54% (95% CI 36.6-71.2%), specificity was 82% (95% CI 63.1-93.9%), PPV was 79% (95% CI 57.8-92.9%), and NPV was 59% (95% CI 42.1-74.4%). CONCLUSION: CDUS showed adequate diagnostic properties for detection of sacroiliitis and is a useful tool in patients with IBP.

Por "Estudio multicéntrico no intervencional en pacientes con artritis reumatoidea tratados con tocilizumab" / For "Non-interventional multicenter study in patients with arthritis rheumatoid treated with tocilizumab"

Estimado Editor: uno de los paradigmas en el tratamiento de la Artritis Reumatoidea(AR) ha sido la introducción de los agentes biológicos. Los primeros disponibles fueron los inhibidores del TNF (iTNF); sin embargo, un 20 a un 40% de los pacientes tienen una respuesta parcial con el uso de estas drogas. Desde el año 2010, tocilizumab(TCZ), un anticuerpo monoclonal humanizado contra el receptor de interleuquina (IL), está disponible para su uso en AR endiferentes países del mundo. La efectividad clínica de TCZ fue demostrada como monoterapia y como terapia combinada con metotrexato (MTX); en pacientes no respondedores a drogas modificadoras de la enfermedad (DMARs) convencionales ya Itnf

Validation in Spanish of a screening questionnaire for the detection of psoriatic arthritis in patients with psoriasis.

OBJECTIVE: A patient self-administered questionnaire [PsA Screening and Evaluation (PASE)] has been developed and validated in English, but has not been tried in Spanish speaking populations. This study aimed to adapt and validate PASE in Spanish to screen Spanish speaking psoriasis patients for signs and symptoms of inflammatory arthritis. METHODS: Initial translation from English to Spanish (forward translation) was performed by two independent translators and the resulting versions were synthesized during a consensus meeting. The questionnaire was tried in a pilot study and resulted in a change in the agreement scale for a frequency scale with wording adaptation [Spanish PASE (PASE-S)]. RESULTS: One hundred and eleven patients were screened with PASE-S; 25 with PsA (without previous treatments), 23 with psoriasis, 22 with psoriasis and OA and 41 with OA without psoriasis. The diagnosis of psoriasis was performed by a dermatologist, and a rheumatologist determined the diagnosis of PsA or OA. Patients with PsA had statistically significant higher symptoms, function and total PASE-S scores compared with those without PsA. Receiver operator curves showed an area under the curve of 0.79 (95% CI 0.69, 0.89) for the total score. A cut-off value ≥34 showed sensitivity of 76%, and specificity of 74.4% for the diagnosis of PsA. CONCLUSION: The validated PASE questionnaire is a self-administered tool that can be used to screen for PsA among patients with psoriasis in a Spanish speaking population. PASE was able to distinguish between symptoms of PsA and OA.

Cost of rheumatoid arthritis in a selected population from Argentina in the prebiologic therapy era.

BACKGROUND: The present study aimed to estimate the cost of rheumatoid arthritis and its components in a university hospital-based health management organization in Argentina, during the prebiologic era. METHODS: A one-year (2002) observational prevalence, cost-of illness study of patients with rheumatoid arthritis from the societal perspective was performed in a hospital-based health management organization population. Direct medical costs were obtained using administrative databases. Direct nonmedical and indirect costs were obtained from a semistructured questionnaire. Indirect costs included work absenteeism, permanent work disability, and housework lost for housewives, using the human capital approach. Costs are expressed in 2002 US dollars per patient per year. RESULTS: A total of 165 patients (84% females), of mean age 61 ± 15 years and with a mean disease duration of 8.5 ± 8.3 years were included. Mean total direct medical costs were US$1862 (95% confidence interval [CI] 828-2899). Mean direct nonmedical costs were US$222 (95% CI 149-294). Mean indirect costs were US$1008 (95% CI 606-1412). The annual mean total cost was US$3093 without biologics. Hospitalizations represented 73% of total direct medical costs while drugs and outpatient procedures represented 16% and 8% of total direct medical costs, respectively. Sixty percent of the total costs were related to direct medical costs, while indirect costs represented 33% of total costs. CONCLUSION: In our population, annual mean total costs in the prebiologic therapy era were mainly driven by direct medical costs. Even without the use of biologic agents, rheumatoid arthritis represents an important burden for society in developing countries.

Quality of life of patients with rheumatoid arthritis in Argentina: reliability, validity, and sensitivity to change of a Spanish version of the Rheumatoid Arthritis Quality of Life questionnaire.

The Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire is the first needs-based instrument specifically designed to measure quality of life (QoL) of patients with rheumatoid arthritis (RA). The aims of our study were to develop an Argentinean version of the RAQoL and to determine its reproducibility, validity, and sensitivity to change in patients with RA. Translation process was performed according to internationally accepted methodology. Internal consistency and test-retest reliability were calculated. Criterion and construct validity were assessed by comparing the RAQoL with parameters of disease activity, the Health Assessment Questionnaire (HAQ), and the Medical Outcomes Study 36-item health survey (SF-36) questionnaire. Sensitivity to change was measured at 6-12 months using standardized response mean (SRM). The minimal important change was defined as a change of 1 or 1.96 times the standard error of measurement. A total of 97 patients with RA were included. Cronbach's α was 0.93, and test-retest reliability was 0.95. The RAQoL showed moderate to strong correlation with parameters of disease activity, the HAQ, and the SF-36. Functional status was the main determinant of patients' level of QoL. The SRM of the RAQoL was 0.24. Agreement between 20 % improvement in RAQoL and ACR20 response was moderate. Minimal important change was 2.2 (1 SEM) or 4.3 (1.96 SEM). The Argentinean version of the RAQoL is the first Spanish translation of this questionnaire. Our findings show it to be valid, reliable, and sensitive to changes in RA clinical status.

Incidence and prevalence of systemic sclerosis in a healthcare plan in Buenos Aires.

BACKGROUND: Systemic sclerosis (scleroderma) is an infrequent disease. Data on incidence and prevalence are scarce and conflictive. There are no such data in Latin America or in Argentina in particular. OBJECTIVES: We undertook to examine the incidence and prevalence of systemic sclerosis in the prepaid health maintenance organization of our hospital, in the city of Buenos Aires. METHODS: Members of the plan between 1999 and 2004 were followed up for incident cases, and prevalence was calculated at the end of the period. RESULTS: A total of 98,642 persons were followed up for a total of 32,9534 person-years. Density of incidence overall was 21.2 per million person-years (95% confidence interval [CI], 5.4-37). Density of incidence for diffuse disease was 6.1 per million person-years (95% CI, 2.3-14.5), and for limited disease, it was 15.2 per million person-years (95% CI, 2-28). Prevalence was 296 per million people (95% CI, 193-434); females, 477 per million people (95% CI, 309-704); and males, 28 per million people (95% CI, 7-157). Prevalence for diffuse disease was 57 per million people (95% CI, 18-133), and for limited disease, it was 240 per million people (95% CI, 148-365). CONCLUSIONS: Despite potential biases, these data are in agreement with others from different parts of the world and the first obtained in Argentina and, to our knowledge, in Latin America.

Tratamiento y pronóstico / Treatment and prognosis

El diagnóstico preciso es esencial y la biopsia muscular mandatoria para identificar miositis por cuerpos de inclusión. La mayoría de las miopatías inflamatorias se tratan de manera similar, aunque el manejo ha sido empírico en la mayoría de los casos y los estudios controlados escasos. La fuerza muscular y los niveles de enzimas musculares siguen siendo las medidas más útiles en el seguimiento. Los glucocorticoides siguen siendo el pilar del tratamiento aunque no existen estudios controlados. El uso de drogas inmunosupresoras desde el inicio podría ser útil como ahorrador de esteroides. Las drogas más utilizadas son el metotrexato y la azatioprina, y los antipalúdicos en casos de compromiso cutáneo. En casos refractarios a estos tratamientos, el rituximab parecería ser efectivo en algunos (aunque no hay estudios controlados) y hay cierto consenso en usar esta droga antes que la inmunoglobulina endovenosa. Los anticuerpos anti–TNF no han sido efectivos en estas enfermedades. La ciclosporina y el micofenolato de mofetilo han demostrado cierta utilidad, especialmente la ciclosporina en pacientes con compromiso pulmonar. El tratamiento de la miositis por cuerpos de inclusión sigue siendo insatisfactorio (AU)

Diagnosis should include mandatory muscle biopsy to identify inclusion body myositis. Most forms of inflammatory myopathies are still treated similarly, although treatment strategies remain empirical and controlled trials are few. Muscle strength and CPK levels remain the most frequently used measures to monitor disease activity and response to therapy. Corticosteroids are the main pillar of drug therapy but simultaneous use of corticosteroid-sparing drugs may be considered from the start. The most frequently used drugs for combined therapy are methotrexate, azathioprine and antimalarials in cases of dermatomyositis. In refractory cases, especially if life threatening, rituximab has appeared to be effective although there are no controlled trials, and there is some consensus that this should be used prior to Immunoglobulin. Anti TNF antibodies have not been useful in these diseases. Cyclosporin (especially with lung involvement) and Mofetil mycophenolate may also have a role in non-responding cases. Treatment of inclusion body myositis remains unsatisfactory (AU)

[Treatment and prognosis]. / Tratamiento y pronóstico.

Diagnosis should include mandatory muscle biopsy to identify inclusion body myositis. Most forms of inflammatory myopathies are still treated similarly, although treatment strategies remain empirical and controlled trials are few. Muscle strength and CPK levels remain the most frequently used measures to monitor disease activity and response to therapy. Corticosteroids are the main pillar of drug therapy but simultaneous use of corticosteroid-sparing drugs may be considered from the start. The most frequently used drugs for combined therapy are methotrexate, azathioprine and antimalarials in cases of dermatomyositis. In refractory cases, especially if life threatening, rituximab has appeared to be effective although there are no controlled trials, and there is some consensus that this should be used prior to Immunoglobulin. Anti TNF antibodies have not been useful in these diseases. Cyclosporin (especially with lung involvement) and Mofetil mycophenolate may also have a role in non responding cases. Treatment of inclusion body myositis remains unsatisfactory.