Management of non-renal non-neurologic persistent lupus activity in real world patients from Argentina.

Management of systemic lupus erythematosus patients is challenging because of disease heterogeneity. Although treatment of renal nephritis is more standardized, treating non-renal lupus activity remains controversial. Our objective was to identify non-renal, non-neurologic persistent active systemic lupus erythematosus patients in our cohort and described therapeutic behaviors in them. All systemic lupus erythematosus patients (American College of Rheumatology and/or Systemic Lupus Erythematosus International Collaborating Clinics criteria) seen at a university hospital between 2000 and 2017 were included and electronic medical records manually reviewed. Persistent lupus activity was defined as a patient with a Systemic Lupus Erythematosus Disease Activity Index score ≥ 6 (without renal and central nervous system manifestations) despite being on a stable treatment regimen for ≥ 30 days. Stable treatment could include prednisone alone (7.5-40 mg/d) or combined with antimalarial drugs and immunosuppressant therapies. A total of 257 lupus patients were included, 230 females (89.5%, 95% confidence interval 85.1-92.7), mean age at diagnosis 29.9 years (SD 16.4). After a median cohort follow-up of 5.7 years (interquartile range 2.4-10.2), 14 patients (5.4%, 95% confidence interval 3.2-9.0) showed persistent non-renal non neurologic lupus activity, with a median disease duration of 11.3 years (interquartile range 3.6-19.4). At that time, 12/14 (85.7 %, 95% confidence interval 52.6-97.0%) had low complement and 11/14 (78.6 %, 95% confidence interval 46.5-93.9%) had positive antiDNA antibodies. The main reasons for being refractory were mucocutaneous disease (50%, 95% confidence interval 23.5-76.5) and arthritis (42.9%, 95% confidence interval 18.5-71.2). Therapeutic choices after being refractory were: only increasing corticosteroid dose in one patient, starting rituximab in four, belimumab in eight, and in one mycophenolate and rituximab; with good response in all of them. In conclusion, 5.4% of systemic lupus erythematosus patients in our cohort were considered to have non-renal non neurologic persistent lupus activity, with mucocutaneous and arthritis the main manifestations. In total, 92.8% of these patients started a biologic treatment at this point (rituximab or belimumab).

Correction to: PANLAR consensus statement on biosimilars.

The two co-authors of the mentioned above article were incorrect. The correct are authors should have been "P. A. Beltrán" instead of "P. A. B. Roa" and "J. F. Diaz-Coto" instead of "L. Diaz Soto".

Causes of fetal third-degree atrioventricular block and use of hydroxychloroquine in pregnant women with Ro/La antibodies.

INTRODUCTION/OBJECTIVES: Complete congenital atrioventricular block (AVB) may be due to cardiac malformations or the presence of maternal antibodies (autoimmune AVB). Our objective was to estimate the prevalence of autoimmune AVB among all AVB in newborns treated at our hospital. Secondly, we estimated the prevalence of AVB among mothers with anti-Ro/La antibodies and examined the relationship of those fetal AVB with mother's use of hydroxychloroquine during pregnancy. METHODS: Retrospective cohort in which we reviewed electronic medical records from years 2000 to 2014 of (a) all mothers with children born with third degree AVB and (b) all pregnant women with anti-Ro/La-positive antibodies. RESULTS: Twenty-three AVBs were diagnosed. Ten (43.5%, 95% CI 23.2-65.5) were associated with maternal rheumatologic disease. The remaining 13 were associated with cardiac malformations. Sixty-two pregnancies in 47 mothers with Ro/La antibodies were identified; eight (12.9%, 95% CI 5.7-23.8) suffered AVB. Fourteen mothers consumed hydroxychloroquine during full pregnancy (one newborn (7.1%) suffered AVB) and 48 did not (7 newborns with AVB (14.6%); p = 0.5). CONCLUSIONS: All congenital AVB diagnosed at our hospital without cardiac malformations were associated with a maternal rheumatologic disease/antibodies. Therefore, if a AVB is diagnosed in a newborn without structural heart disease, the mother should be studied for an autoimmune disease. We found a high prevalence of AVB among mothers with anti-Ro/La antibodies. Although not statistically significant, AVBs in mothers with Ro/La antibodies were numerically more frequent in those not using hydroxychloroquine.Key Points• Although structural heart malformations were the predominant cause of third-degree AVB, autoimmune AVB was still a significant cause.• The distinction between structural or non-structural cause of AVB constitutes an essential issue since it determines the prognostic of these fetuses in terms of complications.• Although not statistically significant, AVBs in mothers with Ro/La antibodies were more frequent in those not using hydroxychloroquine.• If an AVB is diagnosed in a newborn without structural heart disease, the mother should be studied for an autoimmune disease.

PANLAR consensus statement on biosimilars.

INTRODUCTION: Biologics have improved the treatment of rheumatic diseases, resulting in better outcomes. However, their high cost limits access for many patients in both North America and Latin America. Following patent expiration for biologicals, the availability of biosimilars, which typically are less expensive due to lower development costs, provides additional treatment options for patients with rheumatic diseases. The availability of biosimilars in North American and Latin American countries is evolving, with differing regulations and clinical indications. OBJECTIVE: The objective of the study was to present the consensus statement on biosimilars in rheumatology developed by Pan American League of Associations for Rheumatology (PANLAR). METHODS: Using a modified Delphi process approach, the following topics were addressed: regulation, efficacy and safety, extrapolation of indications, interchangeability, automatic substitution, pharmacovigilance, risk management, naming, traceability, registries, economic aspects, and biomimics. Consensus was achieved when there was agreement among 80% or more of the panel members. Three Delphi rounds were conducted to reach consensus. Questionnaires were sent electronically to panel members and comments about each question were solicited. RESULTS: Eight recommendations were formulated regarding regulation, pharmacovigilance, risk management, naming, traceability, registries, economic aspects, and biomimics. CONCLUSION: The recommendations highlighted that, after receiving regulatory approval, pharmacovigilance is a fundamental strategy to ensure safety of all medications. Registries should be employed to monitor use of biosimilars and to identify potential adverse effects. The price of biosimilars should be significantly lower than that of reference products to enhance patient access. Biomimics are not biosimilars and, if they are to be marketed, they must first be evaluated and approved according to established regulatory pathways for novel biopharmaceuticals. KEY POINTS: • Biologics have improved the treatment of rheumatic diseases. • Their high cost limits access for many patients in both North America and Latin America. • Biosimilars typically are less expensive, providing additional treatment options for patients with rheumatic diseases. • PANLAR presents its consensus on biosimilars in rheumatology.

Evaluation of learned helplessness, self-efficacy and disease activity, functional capacity and pain in Argentinian patients with rheumatoid arthritis.

OBJECTIVES: To evaluate the association between learned helplessness (LH) and self-efficacy (SE) with disease activity, functional capacity, and level of pain in patients with rheumatoid arthritis (RA) and to compare LH and SE between patients in remission and patients with active disease. METHOD: This multicentre, cross-sectional study included consecutive patients (aged ≥ 18 years) with RA according to 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria. LH was measured by the Rheumatology Attitude Index (RAI), Spanish version; SE with the Arthritis Self-efficacy Scale (ASES), Spanish version; functional capacity with the Health Assessment Questionnaire, Argentinian version (HAQ-A); and perceived pain by the visual analogue scale (VAS). Disease activity was measured by the Clinical Disease Activity Index (CDAI). RESULTS: A total of 115 patients (82% females) with a mean (± sd) age of 58 ± 13 years were included. We found a significantly positive correlation between LH and perceived pain (p < 0.001), HAQ-A score (p < 0.001), and CDAI (p < 0.001) and a significantly negative correlation between SE and perceived pain (p < 0.001), HAQ-A score (p < 0.001), and CDAI (p < 0.001). We found greater levels of SE and lower grades of LH in patients in remission compared to those with active disease (median 76 vs. 58; p < 0.001 and 6 vs. 11; p < 0.001, respectively). CONCLUSIONS: LH and SE correlated significantly with disease activity, functional capacity, and perceived pain. Levels of SE were higher in patients in remission compared to those with active disease as opposed to levels of LH, which were lower in patients in remission compared to those with active disease. These results show that cognitive factors are related to disease activity and their modifications may have importance in the management of RA.

Late-onset systemic lupus erythematosus in Latin Americans: a distinct subgroup?

OBJECTIVE: To examine the characteristics of patients who developed late onset systemic lupus erythematosus (SLE) in the GLADEL (Grupo Latino Americano de Estudio del Lupus) cohort of patients with SLE. METHODS: Patients with SLE of less than two years of disease duration, seen at 34 centers of nine Latin American countries, were included. Late-onset was defined as >50 years of age at time of first SLE-related symptom. Clinical and laboratory manifestations, activity index (SLEDAI), and damage index (SLICC/ACR- DI) were ascertained at time of entry and during the course (cumulative incidence). Features were compared between the two patient groups (<50 and ≥50) using descriptive statistics and hypothesis tests. Logistic regression was performed to examine the association of late-onset lupus, adjusting for other variables. RESULTS: Of the 1480 patients included, 102 patients (6.9 %) had late-onset SLE, 87% of which were female. Patients with late-onset SLE had a shorter follow-up (3.6 vs. 4.4 years, p < 0.002) and a longer time to diagnosis (10.1 vs. 5.8 months, p < 0.001) compared to the younger onset group. Malar rash, photosensitivity, and renal involvement were less prevalent while interstitial lung disease, pleural effusions, and sicca symptoms were more frequent in the older age group (p > 0.05). In multivariable analysis, late onset was independently associated with higher odds of ocular (OR = 3.66, 95% CI = 2.15-6.23), pulmonary (OR = 2.04, 95% CI = 1.01-4.11), and cardiovascular (OR = 1.76, 95% CI = 1.04-2.98) involvement and lower odds of cutaneous involvement (OR = 0.41, 95% CI = 0.21-0.80), number of cumulative SLE criteria (OR = 0.79, 95% CI = 0.64-0.97), use of cyclophosphamide (OR = 0.47, 95% CI = 0.24-0.95), and anti-RNP antibodies (OR = 0.43, 95% CI = 0.20-0.91). A Cox regression model revealed a higher risk of dying in older onset than the younger-onset SLE (OR = 2.61, 95% CI = 1.2-5.6). CONCLUSION: Late-onset SLE in Latin Americans had a distinct disease expression compared to the younger-onset group. The disease seems to be mild with lower cumulative SLE criteria, reduced renal/mucocutaneous involvements, and less use of cyclophosphamide. Nevertheless, these patients have a higher risk of death and of ocular, pulmonary, and cardiovascular involvements.

Value of repeat biopsy in lupus nephritis flares.

OBJECTIVES: Renal flares are common in lupus nephritis (LN), and class switch is thought to be characteristic. There is no agreement on indications for performing a repeat renal biopsy. Our objective was to retrospectively review patients who had more than one renal biopsy performed on clinical indications, and analyse clinical, pathological and treatment changes after successive biopsies. METHODS: Forty-five patients with LN and one or more repeat renal biopsies were included, with a total of 116 biopsies. RESULTS: Of the 71 repeat biopsies, pathological transition occurred in 39 (54.9%). When having a previous biopsy with a proliferative lesion, class switch occurred in 55.6%, with 24.4% evolving into non-proliferative classes. When previous biopsy was class V, transition to other classes occurred in 58.3% and changes were all into proliferative classes. Conversion from one pure proliferative form to another (class III to class IV or vice versa) happened in 11.3% of the rebiopsies, with 62 rebiopsies (87.3%) leading to a change in the treatment regimen. CONCLUSIONS: Histological transformations were common, and they occurred when the previous biopsy had non-proliferative lesions as well as when lesions were proliferative. Treatments were modified after repeat renal biopsy in the majority of patients. In this experience, kidney repeat biopsies were useful in guiding treatment of LN flares.

Incidence and prevalence of lupus in Buenos Aires, Argentina: a 11-year health management organisation-based study.

OBJECTIVES: Studies regarding the epidemiology of systemic lupus erythematosus (SLE) are lacking in Argentina. Our purpose was to estimate the incidence and prevalence of SLE in a university hospital-based health management organisation in Buenos Aires (HIMCP). METHODS: For incidence calculation, the population at risk included all adult members of the HIMCP, with continuous affiliation for at least 1 year from January 1998 to January 2009. Each person was followed until he/she voluntarily left the HIMCP, death or finalisation of the study. Multiple methods for case finding were used to ensure complete ascertainment: (a) patients with problem SLE, undifferentiated autoimmune disease or mixed connective tissue disease in the Computer-based Patient Record System, (b) patients with positive antinuclear antibody test, anti-Sm antibodies and/or anti-dsDNA antibodies in the laboratory database and (c) patients who consumed hydroxichloroquine, chloroquine, azathioprine, cyclophosphamide, mycophenolate, cyclosporine or rituximab, from the administrative HIMCP drugs database. Medical records of all patients found were reviewed, and only patients fulfilling ACR criteria for SLE were included. Global and gender incidence rate (IR) was calculated. Prevalence was estimated on 1 January 2009, and the denominator population was the number of active members >18 years at that date (n=127 959). RESULTS: In the study period, 68 patients developed SLE. The observed IR (per 100 000 person-years, (CI 95%)) was 6.3 (4.9 to 7.7) for total population; 8.9 (CI 6.6 to 11.2) for women and 2.6 (1.2 to 3.9) for men. On 1 January 2009, 75 prevalent cases were identified. Prevalence rates (cases per 100 000 habitants, (CI 95%)) were 58.6 (46.1 to 73.5) for total population; 83.2 (63.9 to 106.4) for women and 23 (CI 11.9 to 40.1) for men. CONCLUSIONS: SLE incidence and prevalence rates in Argentina are in agreement with those of other studies from different parts of the world.

Systemic sclerosis in Argentina: evaluation of a large cohort from a single centre and comparison with other international series.

OBJECTIVES: Prevalence of systemic sclerosis (SSc) and different clinical subsets varies across the world. Few data have been published on SSc patients in Latin America. Our objective was to describe a SSc cohort in Argentina and to compare clinical findings, disease subsets and antibodies with other international SSc populations. METHODS: Patients with SSc (n=234) seen at the Rheumatology section of the Hospital Italiano de Buenos Aires between 2000-2011 were retrospectively analysed. Data on clinical manifestations, disease subsets and antibodies were obtained. Patients were classified into diffuse cutaneous (dc) and limited cutaneous (lc) subsets. Comparison with other cohorts (France, United States, Germany, Italy, Mexico, EUSTAR and Brazil) was made based on published information. RESULTS: A higher female:male ratio (12:1) and a higher limited subset prevalence (76.1%) was found in this Argentine cohort comparing with others. We also found a lower prevalence of diffuse disease, anti Scl-70 (antitopoisomerase) and nucleolar pattern antinuclear antibodies. Within each subset, clinical findings were similar with other SSc populations except for a very low prevalence in renal crisis (0.02% of dc SS). CONCLUSIONS: With slight variations perhaps due to genetic, environmental or referral factors, SSc in this cohort appears to be similar to that described in other parts of the world.

Remission criteria and activity indices in psoriatic arthritis.

Remission criteria and activity indices used in rheumatoid arthritis (RA) are often applied in psoriatic arthritis (PsA). Some new indices have been specifically developed for PsA. Our objective was to evaluate the performance of different remission criteria and activity indices in PsA. This is a cross-sectional study that includes consecutive patients with PsA. Information necessary to complete the following indices was captured: Composite Psoriatic Disease Activity Index (CPDAI), Psoriatic Arthritis Screening and Evaluation (PASE), Disease Activity Index for Psoriatic Arthritis (DAPSA), Disease Activity Score in 28 Joints (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), and American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) Boolean RA remission criteria. Patients were classified according to activity categories (remission, low, medium, or high disease activity). Correlation between indices was established. Fifty-five patients were included. Mean age was 53 years (SD = 12), and 35 (63.6 %) were males. Mean PsA disease duration was 5.9 years (SD = 8.5), and mean psoriasis duration was 15.9 (SD = 12.6). We found important differences in the percentage of patients classified as in remission by applying different remission criteria: DAS28 = 33 % (95 % confidence interval (CI) 20-45) vs ACR/EULAR = 4 % (95 % CI 1-17). Particularly, DAS28 and minimal disease activity seemed to be less stringent in PsA than the other indices. Of the specific PsA indices evaluated, CPDAI showed the poorest correlation with all the other activity measurements, although differences were not statistically significant in most cases. Disease activity in PsA is measured by many different indices. In spite they all showed good correlations between them, they classified different patients in different disease status.

Prevalencia de la enfermedad de Pompe entre pacientes con elevación de creatinin-kinasa (CK) / Prevalence of Pompe diseases among patients with elevated phosphocreatine kinase

Introducción: La prevalencia exacta de la enfermedad de Pompe en lapoblación general es desconocida, y la frecuencia estimada varía entrelas diferentes formas clínicas y grupos étnicos. Existe un gran númerode pacientes con elevación de enzimas musculares que no tienen undiagnóstico definitivo. Un porcentaje de ese grupo de pacientes podríatener enfermedad de Pompe. Objetivos: 1) Determinar la prevalencia de la enfermedad de Pompeentre pacientes mayores de un año de edad, con elevación persistente de creatin-kinasa (CK) de causa desconocida. 2) Describir las manifestaciones clínicas y demográficas de los pacientes con CPK elevada. Materiales y métodos: Se incluyeron a todos los pacientes con aumentode CK en sangre, definida como la detección de al menos un valor >500 UI/L y otro mayor de 200 UI/L, durante un período mínimode 1 año, entre los años 2010-2013, tomados de la base de datos dellaboratorio del Hospital Italiano de Buenos Aires. Se excluyeron a lospacientes bajo tratamiento actual con agentes hipolipemiantes; pacientestratados con agentes hipolipemiantes, en quienes la CK no senormalizó luego de suspender el tratamiento; pacientes tratados conagentes hipolipemiantes que interrumpieron el tratamiento durante untiempo menor de 9 meses antes del período de inclusión y pacientescon enfermedad muscular inflamatoria (pacientes con criterios diagnósticos probables o definidos de Bohan & Peter). Los pacientes condiagnóstico probable de miositis por cuerpo de inclusión (biopsia notípica) podían ser incluidos. Se les realizó evaluación clínica (mediciónde la fuerza muscular), cuestionario sobre síntomas musculares y se lesextrajo sangre para test enzimático en papel de filtro para enfermedadde Pompe.

Introduction: The exact prevalence of Pompe disease in the generalpopulation is unknown, and the estimated frequency varies among differentethnic groups and clinical forms. A large number of patients withelevated muscle enzymes do not have a definitive diagnosis. A significant percentage of these patients may have a Pompe disease. Objectives: To determine the prevalence of Pompe disease among patients with persistently elevated CK (over one year) of unknown cause.To describe the demographic and clinical manifestations of the patients with elevated CK. Patients and methods: We included all patients with increased bloodCK, defined as a value >500 IU/L and another greater than 200 IU/L forat least 1 year between 2010 and 2013. Patients were selected fromthe database of the laboratory of the Italian Hospital of Buenos Aires. Weexcluded patients under current treatment with lipid-lowering agents; patients who have been treated with lipid-lowering agents, in whom CPK has not normalized after discontinuation of therapy; patients whohave been treated with lipid-lowering agents and discontinued for atime less than 9 months before the inclusion period and patients with inflammatory muscle disease: patients with probable or definite criteriadiagnoses (Bohan & Peter criteria). Patients with a diagnosis of probableinclusion body myositis (not typical biopsy) were included. Patients underwent clinical evaluation (measurement of muscle strength), muscle symptoms questionnaire and had blood taken for enzyme test on filter paper for Pompe disease.

Tercer reporte de eventos adversos con tratamientos biológicos en Argentina. Informe de registro biobadasar / Thrid report of adverse events with biologics in Argentina. Report from biobadasar registry

Introducción: BIOBADASAR (Registro Argentino de Eventos Adversos con Tratamientos Biológicos en Reumatología) comenzó en agosto de 2010. La importancia de este registro es mostrar datos locales que, probablemente, puedan diferir de otros registros. El objetivo es comunicar los resultados del tercer reporte de BIOBADASAR. Métodos: Todos los pacientes con enfermedades reumáticas que requirieron tratamiento con agentes biológicos y pacientes controles sin estos tratamientos fueron incluidos en la base de datos provenientes de 32 centros participando a lo largo de la Argentina. Tres áreas de datos son analizados: características de los pacientes, tratamientos y eventos adversos...

Introduction: BIOBADASAR (Argentine Registry of Adverse Events with Biological Treatments in Rheumatology) began in August 2010. The importance of this registry is to show local data that may probably differ from other registries. The objective is to communicate the results of the third BIOBADASAR report. Methods: All patients with rheumatic diseases who required treatment with biological agents and control patients without these treatments were included in the database from 32 participating centers throughout Argentina. Three areas of data are analyzed: patient characteristics, treatments and adverse events...

Incidence of multiple sclerosis in Buenos Aires: a 16-year health maintenance organization-based study.

OBJECTIVE: The present study was undertaken to determine the incidence of MS in a health maintenance organization from Buenos Aires, the largest populated area in Argentina. METHODS: Population was all members of a hospital-based health maintenance organization who were affiliated since January 1992 up to December 2007. Each person was followed contributing time at risk since January 1992 or enrollment date to the final date. Patients with definite diagnosis according to Poser's criteria were included. Incidence density was calculated with 95% confidence intervals. RESULTS: A total of 145,000 patients were followed for a total of 1,021,515 person-years, of whom 18 developed the disease. Incidence density (ID): 1.76 /100 000 person-years (95% CI: 1.1-2.8/100,000 person-years). CONCLUSION: The incidence density of 1.76 per 100,000 suggests a low-median risk area for MS. This study constitutes the first of its kind to cover data of MS incidence in Argentina.

Gait velocity in senior people. An easy test for detecting mobility impairment in community elderly.

BACKGROUND: Functional assessment is an important part of the evaluation of elderly patients. Mobility problems detected by functional tests predict the development of more severe disability and injurious events such as falls and hip fractures. Several tests to evaluate mobility have been described, but most of them are difficult to perform by a primary care physicians or take much time in the ambulatory setting. PURPOSE: To evaluate different mobility test to detect mobility impairment in community senior people. Select an easier test to perform on the ambulatory ward by a GP with the hypothesis that gait velocity could be an easier test to detect early mobility impairment. METHODS: A cohort of 100 elderly subjects of 75 year and older were selected from our database and contacted by phone. The subjects were appointed and assessed by three geriatricians from January to May 2000. The measures including MMSE, Yesavage Test, ADL (Barhtel) and IADL (Lawton), the Get Up and Go test, the POMA, one leg balance test and the Gait Velocity (GV). A gait velocity of 0.8 m/s or lower was defined as a pathological gait velocity (PGV). RESULTS: 95 subjects, mean age 79.63 (+/- 4) ranged form 75 to 95. Women in 71.3%. The ADLs were normal on 85% of the patients and the MMSE was normal on 78%. There was a significant association between pathological gait velocity (<0.8m/sec) and impairment on Get up and Go (OR 2.20; 95% CI 1.44-3.34), incapacity to perform the one leg balance test (OR 2.20; 95%CI: 1.43 - 4.71) and abnormal POMA test (OR 4.60; 95 %CI 1.5-14.7). Only 15% of the subjects with normal gait velocity reported recurrent falls in the previous 6 months while 35% of subjects with pathological gait velocity did. (OR 0.32 CI95% 010-099 p < 0.044). CONCLUSION: The pathological gait velocity (<0.8m/sec) correlates with a pathologic performance of Get Up and Go test and POMA and with the incapacity to perform the One Leg Balance test. Also correlate with previous repeated falls in the last 6 (p <0.04). The gait velocity could be a test easy to perform, no time consuming, and an operative tool to apply in the ambulatory care to detect elderly patients with mobility impairment.

Inflammatory muscle disease: therapeutic aspects.

The present treatment of the inflammatory myopathies remains unsatisfactory in several areas, perhaps due in part to our incomplete knowledge of their aetiology. These conditions have been grouped together for practical purposes and because of a similar approach to treatment. However, recent data regarding pathological findings, serological patterns and different outcomes, suggest that some of these myopathies may be distinct, and perhaps approaches to treatment should be tailored according to these findings. This chapter will attempt to update our current management, offer an analysis of recent data regarding newer treatment modalities and highlight areas lacking solid data that need to be further addressed. Although corticosteroids are still considered to be the mainstay of treatment, the earlier use of immunosuppressive therapy will be discussed, as will the use of autoantibody profiles for tailoring treatment. Newer modalities for the monitoring of therapeutic response and their current place in clinical practice will be analysed. The management of refractory cases will be addressed as will the current management of calcinosis, a problem more frequently encountered in children.

Streptococcus pyomyositis occurring in a patient with dermatomyositis in a country with temperate climate.

We describe a man in whom pyomyositis developed in a temperate climate. Three facts make this case unique. First the pyomyositis developed in someone with underlying dermatomyositis, this being the second reported case to our knowledge. Second, the organism involved was a Streptococcus and not a Staphylococcus as in most cases described, and the course of the disease was acute and not subacute as is usually reported. Finally, contrary to most described cases, surgical drainage was not necessary, probably because of the early diagnosis. Pyomyositis should be considered a possible cause of localized pain in patients with underlying inflammatory muscle disease.

Baker's cysts, pseudothrombophlebitis, pseudo-pseudothrombophlebitis: where do we stand?

The diagnostic approach and therapeutic attitudes to be assumed when facing the dilemma of deep vein thrombosis versus a complicated Baker's cyst remain unclear. We examined our own approach with 16 Baker's cysts [11 presenting with a "thrombophlebitis picture" (TP)] recently diagnosed in our services, and reviewed the literature. All of our patients had an underlying joint disorder and previous knee effusions. The diagnostic approach (i.e., the request or not for venography) was related to the specialty of the physician who saw the patient first. The results of the venography led to anticoagulation treatment in 5 of the 6 patients on whom it was performed, although these patients did not otherwise differ from those with a similar clinical picture in whom no venogram was obtained. Arthrograms performed early after onset of the TP were more likely to reveal cyst rupture. The recent literature does not mention serious venous complications (in particular, pulmonary embolism) in patients in whom only the cyst was treated, without knowledge of possible coexisting venous occlusions. The need to perform venography, the importance of the localisation of the occlusions and the therapeutic consequences are discussed and a proposal is made to study these patients in a systematic way in order to better understand the inter-relationship between complicated popliteal cysts and venous alterations, and to decide the best approach to assume in the future.