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Objective To determine the current state of Rheumatology in Catalonia and to update the information regarding previous studies. Material and methods Design Observational, descriptive and cross-sectional study. Data collection from January to June 2017. Sample Rheumatologists practising public healthcare activity in Catalonia. An online questionnaire was sent to gather individual data and data from rheumatology services/sections. Results Information was obtained on 109 rheumatologists: 39 men and 70 women; mean age: 47 ± 9 years. The number of rheumatologists has increased by 8% over the past 5 years. One hundred and one (92.7%) doctors qualified as rheumatologists through the MIR. Rheumatology practice was mostly in a hospital setting: 68 (62.4%) physicians. Ninety-six (88.1%) rheumatologists were full-time practitioners. Fifty-four (50%) rheumatologists also practiced in the private sector. Clinical practice was predominant: 76% of daily time was devoted to this area. Of note, it was found that most of the rheumatology services, 24 (705), were dependent hierarchically on other services, namely internal medicine and orthopaedic surgery. There are still 6 hospitals in Catalonia without a rheumatologist. Conclusions The number of rheumatologists in the public health sector of Catalonia has increased over the past 5 years. The mean age of rheumatologists is advanced and there is a clear predominance of female practitioners in the specialty. Many rheumatology services depend on other services. Rheumatology activity is primarily focussed in the city of Barcelona.

Resumen Objetivo Determinar el estado actual de la reumatologia en Cataluna, y actualizar la informacion respecto a los estudios previos. Material y metodos Diseno Estudio observacional, descriptivo y transversal. Recogida de datos de enero a junio de 2017. Muestra Reumatologos que ejercen actividad asistencial publica en Cataluna. Se envio un cuestionario en linea recabando informacion tanto de forma individual como colectiva de los servicios de reumatologia. Resultados Se obtuvo informacion de 34 hospitales y de 109 reumatologos: 39 varones y 70 mujeres; edad media: 47 ± 9 anos. El numero de reumatologos aumento un 8% en los ultimos 5 anos. La obtencion del titulo fue en 101 (92,7%) casos por via MIR. Noventa y seis (88,1%) facultativos tenian dedicacion completa. Un 50% de los reumatologos ejercian ademas en el sector privado. La actividad asistencial suponia un 76% de la jornada laboral. Se constato que 24 (70%) servicios de reumatologia dependian jerarquicamente de otra especialidad. En 6 hospitales de Cataluna no disponen de reumatologo. Conclusiones El numero de reumatologos aumento respecto hace 5 anos. La edad media de los reumatologos es avanzada y existe un claro predominio femenino en la especialidad. Un gran numero de unidades de reumatologia dependen de otros servicios. La actividad reumatologica se centra en Barcelona.

Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed. (C) 2019 Elsevier Espana, S.L.U. and Sociedad Espanola de Reumatologia y Colegio Mexicano de Reumatologia. All rights reserved.

Objectives To assess the characteristics and risk of lymphoma in a large cohort of patients with SLE. Methods A case–cohort analysis was performed within a dynamic cohort of SLE patients from the Spanish Society of Rheumatology Lupus Registry (RELESSER). Clinical and analytical features were compared between the lymphoma SLE group and the control SLE group using an independent-sample Student’s t-test or Mann–Whitney test for continuous variables and the χ2 test for categorical variables with Fisher’s exact test if necessary. The multivariate analysis was based on a generalized linear model. Results Twenty-one patients with SLE and lymphoma and 3965 non-lymphoma controls with SLE were studied. Most lymphomas were of B cell origin (n = 15/21), with diffuse large B cell lymphoma being the most frequent histological type (8/21, 38.1%). As in the general population, the risk of lymphoma in SLE was higher in male than in female patients and increased with age. In the lymphoma SLE group, bivariate analysis showed a significantly higher percentage of pericarditis, organic brain syndrome, seizures, vasculitis, haemolytic anaemia, splenomegaly, venous thrombosis and mean modified (excluding lymphoma) SLICC/ACR damage index. In contrast, renal involvement, positive anti-dsDNA, and antimalarials ever were less frequent. Conclusions In this large multicentre Spanish cohort, we identified characteristics of SLE that are associated with a higher risk of lymphoma. Antimalarials were significantly negatively associated with risk of lymphoma in SLE patients. Nevertheless, further prospective studies are needed to clarify these findings.

To study retention of biologic disease-modifying anti-rheumatic drugs (bDMARDs) or apremilast and potential predictors of lack of response in patients with psoriatic arthritis (PsA). A single-center retrospective analysis of PsA patients who received ≥ 1 bDMARD or apremilast during 2000–2018. The main endpoint was lack of response (primary or secondary failure). Analyses included retention of DMARDs (Kaplan–Meier curves) and potential predictors of lack of response (bivariate and multivariate logistic regression models). A total of 159 patients with PsA received up to 8 DMARDs: etanercept (34%), adalimumab (30%), infliximab (9%), golimumab (9%), apremilast (7%), ustekinumab (5%), certolizumab (4%), and secukinumab (2%). Therapy was discontinued in 96 cases (60%), mainly owing to secondary failure (37%), followed by primary failure (25%) and adverse effects (24%). Retention was analyzed based on 313 units of analysis. Duration of follow-up was 846.1 treatment-years (maximum 14.8 years, median 2.75 years). A total of 172 DMARDs were discontinued. The probability of continuing the initial treatment was 37% at 5 years, 22% at 10 years, and 12% at 14 years. The longest medium retention time was observed for infliximab (6.2 years) and etanercept (4.5 years). Predictors of lack of response included male sex, number of swollen joints, and, especially, depression (OR = 35.2). The sensitivity and specificity of the model were 86.4% and 85.7%, respectively, with a coefficient of determination (R2) of 45.6 (ROC, 0.912). Rates of discontinuation due to primary and secondary failure are high in PsA. Retention is better for anti-TNF agents than for other agents.

Objective SLE can affect any part of the gastrointestinal (GI) tract. GI symptoms are reported to occur in >50% of SLE patients. To describe the GI manifestations of SLE in the RELESSER (Registry of SLE Patients of the Spanish Society of Rheumatology) cohort and to determine whether these are associated with a more severe disease, damage accrual and a worse prognosis. Methods We conducted a nationwide, retrospective, multicentre, cross-sectional cohort study of 3658 SLE patients who fulfil ≥4 ACR-97 criteria. Data on demographics, disease characteristics, activity (SLEDAI-2K or BILAG), damage (SLICC/ACR/DI) and therapies were collected. Demographic and clinical characteristics were compared between lupus patients with and without GI damage to establish whether GI damage is associated with a more severe disease. Results From 3654 lupus patients, 3.7% developed GI damage. Patients in this group (group 1) were older, they had longer disease duration, and were more likely to have vasculitis, renal disease and serositis than patients without GI damage (group 2). Hospitalizations and mortality were significantly higher in group 1. Patients in group 1 had higher modified SDI (SLICC Damage Index). The presence of oral ulcers reduced the risk of developing damage in 33% of patients. Conclusion Having GI damage is associated with a worse prognosis. Patients on a high dose of glucocorticoids are at higher risk of developing GI damage which reinforces the strategy of minimizing glucocorticoids. Oral ulcers appear to decrease the risk of GI damage.

Introduction Antiphospholipid antibodies (aPL) have been associated with organ damage and certain features in systemic lupus erythematosus(SLE) patients. Our aim was to investigate the differences between SLE patients according to the presence of aPL and/or clinical antiphospholipid syndrome (APS). Materials and methods Patients from the RELESSER-T registry were included. RELESSER-T is a Spanish multicenter, hospital-based, retrospective, SLE registry. Results We included 2398 SLE patients, 1372 of whom were positive for aPL. Overall 1026 patients were classified as SLE, 555 as SLE-APS and817 as SLE-aPL. Regarding cardiovascular risk factors, SLE-APS patients had higher rates of hypertension, dyslipidemia and diabetes than those with SLE-aPL and SLE ( p Conclusions SLE-APS patients exhibited more severe clinical profiles with higher frequencies of major organ involvement, greater damage accrual and higher mortality than SLE-aPL and SLE patients.

El diagnóstico y tratamiento de las enfermedades autoinmunes sistémicas (EAS) constituye un reto. Aunque infrecuentes, afectan a cientos de miles de pacientes en España. El médico de familia (MF) se enfrenta a síntomas o signos inespecíficos que hacen sospechar EAS al inicio del proceso, y tiene que decidir a quiénes debería derivar. Para facilitar su reconocimiento y mejorar su derivación, expertos de la Sociedad Española de Medicina de Familia y Comunitaria y de la Sociedad Española de Reumatología seleccionaron 26 síntomas/signos-guía y alteraciones analíticas. Se escogieron parejas de MF y reumatólogo para elaborar algoritmos diagnósticos y de derivación. Posteriormente se revisaron y adaptaron al formato de aplicación para móviles (app) descargable. El resultado es el presente documento de derivación de EAS para MF en formato de papel y app. Contiene algoritmos de fácil manejo utilizando datos de la anamnesis, exploración física y pruebas analíticas accesibles en atención primaria para orientar el diagnóstico y facilitar la derivación a reumatología o a otras especialidades. Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed. Sin financiación No data JCR 2020 0.271 SJR (2020) Q4, 50/58 Rheumatology No data IDR 2020 UEM

Objectives. This article estimates the frequency of polyautoimmunity and associated factors in a large retrospective cohort of patients with SLE. Methods. RELESSER (Spanish Society of Rheumatology Lupus Registry) is a nationwide multicentre, hospital-based registry of SLE patients. This is a cross-sectional study. The main variable was polyautoimmunity, which was defined as the co-occurrence of SLE and another autoimmune disease, such as autoimmune thyroiditis, RA, scleroderma, inflammatory myopathy and MCTD. We also recorded the presence of multiple autoimmune syndrome, secondary SS, secondary APS and a family history of autoimmune disease. Multiple logistic regression analysis was performed to investigate possible risk factors for polyautoimmunity. Results. Of the 3679 patients who fulfilled the criteria for SLE, 502 (13.6%) had polyautoimmunity. The most frequent types were autoimmune thyroiditis (7.9%), other systemic autoimmune diseases (6.2%), secondary SS (14.1%) and secondary APS (13.7%). Multiple autoimmune syndrome accounted for 10.2% of all cases of polyautoimmunity. A family history was recorded in 11.8%. According to the multivariate analysis, the factors associated with polyautoimmunity were female sex [odds ratio (95% CI), 1.72 (1.07, 2.72)], RP [1.63 (1.29, 2.05)], interstitial lung disease [3.35 (1.84, 6.01)], Jaccoud arthropathy [1.92 (1.40, 2.63)], anti-Ro/SSA and/or anti-La/SSB autoantibodies [2.03 (1.55, 2.67)], anti-RNP antibodies [1.48 (1.16, 1.90)], MTX [1.67 (1.26, 2.18)] and antimalarial drugs [0.50 (0.38, 0.67)]. Conclusion. Patients with SLE frequently present polyautoimmunity. We observed clinical and analytical characteristics associated with polyautoimmunity. Our finding that antimalarial drugs protected against polyautoimmunity should be verified in future studies., The RELESSER Registry was partially funded by GlaxoSmithKline (GSK), Roche, Union Chimique Belge (UCB), Lilly and Novartis. The sponsors had no role in the study design, data collection, analysis or interpretation, in writing the report, or in the decision to submit the article for publication. J.M.P.-R. is supported by grant 316265 (BIOCAPS) from the European Union 7th Framework Program (FP7/REGPOT-2012-2013.1). The study was supported by FIS Grant PI11/02857 (Instituto Carlos III, Fondos FEDER). Grant for medical researchers of the 'Fundacion Espanola de Reumatologia'.

Background OBJECTIVE: Estimate the frequency of the association of SLE with other autoimmune diseases in a large Spanish cohort of patients with systemic lupus erythematosus (SLE) and investigate the main risk factors for polyatoimmunity. Methods Design: RELESSER is a nationwide multicentre, hospital-based registry of SLE patients. This is a cross-sectional study. Patients: Unselected consecutive adult patients with SLE, classified according to the American College of Rheumatology (ACR) 1997 criteria. All patients had been attended upon and followed at Spanish rheumatology departments. The first patient was enrolled in October 2011 and the last in August 2012. Main outcome: Polyautoimmunity was defined as patients who fulfilled criteria for SLE and other autoimmune disease: (1) autoimmune thyroiditis (alteration of thyroid function with the presence of anti-thyroid autoantibodies), (2) other connective tissue disease (rheumatoid arthritis, systemic sclerosis or inflammatory myopathy) and (3) mixed connective tissue disease. Multiple autoimmune syndrome (MAS) was defined as patients who meet SLE criteria and at least two other autoimmune diseases. Other variables: Demographic and clinical variables, Sjogren’s syndrome, antiphospholipid syndrome and family history of autoimmune systemic disease were collected. Statistical analysis: Descriptive, Chi-square test and ANOVA or Kruskal-Wallis for comparison between groups of patients. Multiple logistic regression analysis was performed to investigate the possible risk factors for polyautoimmunity in patients with SLE. Results From all patients included in the registry, 3679 (91.4%) patients met 4 or more SLE criteria. Of these, 501 (13.6%) patients had Polyautoimmunity. The characteristics of this group are showed in table 1. The most frequent polyautoimmunity types associated with SLE were (in descending order over the total cohort of patients with SLE): autoimmune thyroiditis (7.5%), other connective tissue disorders (4.4%) and mixed connective tissue disease (2.7%). The percentage of patients a family history of SLE was 12.4%. Multiple autoimmune syndrome was observed in 10.2% of patients with Polyautoimmunity. The multivariate analysis identified age (odds ratio [95% confidence interval], 1.01 [1.00–1.02]), sex (3.00 [1.48–6.04]), Raynaud’s phenomenon (1.79 [1.34–2.39]), pulmonary fibrosis (2.88 [1.32–6.30]), Ro-La autoantibodies (1.68 [1.20–2.36]), antiRNP (1.79 [1.32–2.42]) and treatment with methotrexate (1.54 [1.08–2.18]) or with antimalarials (0.57 [0.41–0.78]) as factors associated with polyautoimmunity. Conclusions SLE patients frequently associate other autoimmune diseases, detecting poliautoimmunity in 14%, MAS in 2%, family history of SLE in 12.4% and others such as Sjogren’s syndrome and secondary SAF in 12.8% and 12.7% respectively. More studies are needed to better understand the increase of polyautoimmunity that seems to be observed in SLE. Funding Source(s): None

Background Antiphospholipid antibodies (aPL) have been associated with organ damage and certain features in systemic lupus erythematosus (SLE) patients. Our aim was to investigate the differences between SLE patients according to the presence of aPL and/or clinical antiphospholipid syndrome (APS). Methods Patients from the RELESSER-T registry were included. RELESSER-T is a multicenter, hospital-based registry, with retrospective cross-sectional collection of data from a large representative sample of adult non-selected patients with SLE attending Spanish rheumatology services from the public national health system. Results We included 3651 SLE patients and 1368 were positive for aPL (44.9% of patients were positive for anticardiolipin antibodies, 27.3% showed positivity for anti b2glycoprotein I and 24% for lupus anticoagulant). Overall 2283 patients were classified as SLE no aPL, 528 as SLE-APS and 840 as SLE-aPL. Demographic data, clinical and laboratory features in the different groups are showed in table 1. Regarding cardiovascular risk factors, SLE-APS patients had higher rates of hypertension, dyslipidemia and diabetes than SLE-aPL and SLE no aPL patients (p 0.5 grs), urinary cell casts, seizures and psychosis (p0.001). Overall, SLE-APS patients showed a lower rate of cutaneous manifestations and higher rates of neuropsychiatric, cardiac, pulmonary, renal, joint and ophthalmological manifestations (table 1). In accordance with a more severe clinical profile, higher frequency of anti-DNA antibodies and hypocomplementemia were observed in the SLE-APS group (p Conclusions SLE-APS patients show a more severe clinical profile with higher frequency of major organ involvement and more damage accrual than SLE-aPL and SLE no APL. Funding Source(s): None

Background Antiphospholipid antibodies (aPL) have been associated with organ damage and certain features in systemic lupus erythematosus (SLE) patients. Our aim is to investigate the association between the different aPL and SLE manifestations as well as to elucidate the influence of the load of antibodies. Methods Patients from the RELESSER-T registry were included. RELESSER-T is a multicenter, hospital-based registry, with retrospective cross-sectional collection of data from a large representative sample of adult non-selected patients with SLE attending Spanish rheumatology services from the public national health system. Results Out of a total of 3651 SLE patients, 1368 were positive for aPL (44.9% of patients were positive for anticardiolipin (aCL) antibodies, 27.3% for anti b2glycoprotein I (aB2GPI) and 24% for lupus anticoagulant (LA)). Regarding the load of antibodies, 20.6%, 12.1% and 4.8% were positive for one, two and three antibodies, respectively. The association between the different aPL, the number of positive antibodies and antiphospholipid syndrome related manifestations is showed in table 1. Overall, all types of aPL were associated with classic APS manifestations, although LA, IgG isotypes, and patients with more than one aPL display a higher risk to develop clinical APS. Regarding specific lupus manifestations, all aPL types showed a negative association with cutaneous manifestations, and was also significantly associated with the load of autoantibodies (p Conclusions The present study in a large SLE cohort confirm than there is a hierarchy for aPL and the risk of APS and lupus manifestations. aCL, and especially LA, confer a higher risk for major organ involvement in SLE patients. IgG isotypes and the load of aPL antibodies confer a higher risk for clinical APS and major lupus manifestations. Funding Source(s): None

Objective: Tocilizumab (TCZ) has shown efficacy in clinical trials on giant cell arteritis (GCA). Real-world data are scarce. Our objective was to assess efficacy and safety of TCZ in unselected patients with GCA in clinical practice Methods: Observational, open-label multicenter study from 40 national referral centers of GCA patients treated with TCZ due to inefficacy or adverse events of previous therapy. Outcomes variables were improvement of clinical features, acute phase reactants, glucocorticoid-sparing effect, prolonged remission and relapses. A comparative study was performed: (a) TCZ route (SC vs. IV); (b) GCA duration (6 months); (c) serious infections (with or without); (d) < 15 vs. >15 mg/day at TCZ onset. Results: 134 patients; mean age, 73.0 +/- 8.8 years. TCZ was started after a median [IQR] time from GCA diagnosis of 13.5 [5.0-33.5] months. Ninety-eight (73.1%) patients had received immunosuppressive agents. After 1 month of TCZ 93.9% experienced clinical improvement. Reduction of CRP from 1.7 [0.4-3.2] to 0.11 [0.05-0.5] mg/dL (p < 0.0001), ESR from 33 [14.5-61] to 6 [2-12] mm/1st hour (p < 0.0001) and decrease in patients with anemia from 16.4% to 3.8% (p < 0.0001) were observed. Regardless of administration route or disease duration, clinical improvement leading to remission at 6, 12, 18, 24 months was observed in 55.5%, 70.4%, 69.2% and 90% of patients. Most relevant adverse side-effect was serious infections (10.6/100 patients-year), associated with higher doses of prednisone during the first three months of therapy. Conclusion: In clinical practice, TCZ yields a rapid and maintained improvement of refractory GCA. Serious infections appear to be higher than in clinical trials. (C) 2019 Elsevier Inc. All rights reserved.

ObjectivePsoriatic arthritis (PsA) is a chronic inflammatory arthritis affecting up to 30% of patients with psoriasis (Ps). To date, most of the known risk loci for PsA are shared with Ps, and identifying disease-specific variation has proven very challenging. The objective of the present study was to identify genetic variation specific for PsA.MethodsWe performed a genome-wide association study in a cohort of 835 patients with PsA and 1558 controls from Spain. Genetic association was tested at the single marker level and at the pathway level. Meta-analysis was performed with a case–control cohort of 2847 individuals from North America. To confirm the specificity of the genetic associations with PsA, we tested the associated variation using a purely cutaneous psoriasis cohort (PsC, n=614) and a rheumatoid arthritis cohort (RA, n=1191). Using network and drug-repurposing analyses, we further investigated the potential of the PsA-specific associations to guide the development of new drugs in PsA.ResultsWe identified a new PsA risk single-nucleotide polymorphism at B3GNT2 locus (p=1.10e-08). At the pathway level, we found 14 genetic pathways significantly associated with PsA (pFDRConclusionThese findings provide insights into the biological mechanisms that are specific for PsA and could contribute to develop more effective therapies.

We aimed to describe juvenile-onset systemic lupus erythematosus (jSLE) features and to establish its differences compared to adult-onset SLE (aSLE) from a large national database.Data from patients (≥4 ACR criteria) included in Spanish Society of Rheumatology Lupus Registry (RELESSER) were analysed. Sociodemographic, clinical, serological, activity, treatment, cumulative damage, comorbidities and severity data were collected. Patients with disease onset18 years were described and compared to those with disease onset ≥18 years.We reviewed 3,428 aSLE patients (89.6% women) and 484 jSLE patients (89.8% girls), 93% Caucasian (both groups). Mean age at diagnosis was 38.1±14 and 16.6±6.3 years (p0.001) and mean age at the end of follow-up was 48.8±14.3 and 31.5±30 years (p0.001), respectively. jSLE showed significantly more clinical (including lymphadenopathy, fever, malar rash, mucosal ulcers, pericarditis, pleuritis, Raynaud's phenomenon, lupus nephritis, recurrent nephritis, histologic nephritis changes, thrombocytopenia, haemolytic anaemia, thrombotic thrombocytopenic purpura, seizures, lupus headache and organic brain syndrome) and immunological (a-dsDNA and a-Sm antibodies, hypocomplementaemia) involvement than did aSLE, except for secondary Sjögren's syndrome, a-Ro antibodies, fibromyalgia and osteoporosis. jSLE also showed more SLE family history, longer diagnosis delay, higher SLEDAI and Katz scores, but lower Charlson scores than aSLE. Several specific domains were more frequently involved in SLICC/ACR DI in jSLE. jSLE patients more frequently underwent all SLE-related treatment and procedures, as well as dialysis and kidney transplantations.jSLE shares many clinical and serological features with aSLE. However, jSLE patients typically manifested more activity, severity, cumulative damage in certain areas, than their aSLE counterparts.

Objective To analyse the efficacy and safety of rituximab in the treatment of non-renal systemic lupus erythematosus (SLE). Methods We systematically searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials up to June 2013. The following were the selection criteria: (1) adult patients with SLE, (2) rituximab treatment, (3) placebo or active comparator, (4) outcome measures assessing efficacy and/or (5) safety. Meta-analysis, systematic literature reviews, randomised control trials (RCT), open clinical trials and cohort studies were included. Independent extraction of articles by 2 authors using predefined data fields was performed. The quality of each study was graded using the Oxford Levels of Evidence and Jadad׳s scale. Results A total of 26 articles met our inclusion criteria: one RCT and its exploratory analysis, 2 open studies and 22 cohort studies, which analysed 1,231 patients. Overall, patients had active disease refractory to steroids and/or immunosuppressant drugs. Acceptable evidence suggested improvements in disease activity, arthritis, thrombocytopaenia, complement and anti-dsDNA, with a steroid-sparing effect. But relapses of disease were demonstrated too. Weak evidence suggested a response in anaemia, cutaneous and neuropsychiatric manifestations. Available evidence revealed few major adverse events. Studies had medium methodological quality and in general were applicable to current practice. Conclusion Rituximab has been shown to be safe and effective in the treatment of non-renal SLE, especially in terms of disease activity, immunologic parameters and steroid-sparing effect. However, it can only be recommended for organ-specific manifestations such as arthritis and thrombocytopaenia. High-quality studies are needed in order to consider the long-term effects of re-treatment on different organ-specific manifestations.

a b s t r a c t Septic pyogenic arthritis of the acromioclavicular joint is a rare entity that occurs in immunosuppressed patients or those with discontinuity of defense barriers. There are only 15 cases described in the literature. The diagnosis is based on clinical features and the isolation of a microorganism in synovial fluid or blood cultures. The evidence of arthritis by imaging (MRI, ultrasound or scintigraphy) may be useful. Antibiotic treatment is the same as in septic arthritis in other locations. Staphylococcus aureus is the microorganism most frequently isolated. Our objective was to describe the clinical features, treatment and outcome of patients diagnosed with septic arthritis of the acromioclavicular joint at a Rheumatology Department. We developed a study with a retrospective design (1989–2012). The medical records of patients with septic arthritis were reviewed (101 patients). Those involving the acromioclavicular joint were selected (6 patients; 6%).

Resumen La artritis septica de la articulacion acromioclavicular (ACV) es una entidad poco frecuente que se presenta en pacientes inmunosuprimidos o con discontinuidad de las barreras de defensa. En la literatura unicamente se han descrito 15 casos hasta la fecha. El diagnostico se basa en la presencia de clinica compatible junto al aislamiento del germen en la articulacion o en los hemocultivos. Las tecnicas de imagen (resonancia magnetica, ecografia o gammagrafia) pueden ser utiles en la localizacion del proceso. El tratamiento antibiotico es el mismo que en la artritis septica de otra localizacion y Staphylococcus aureus es tambien el microorganismo aislado con mas frecuencia. Se describen las caracteristicas clinicas, el tratamiento y la evolucion de los pacientes diagnosticados de artritis septica de la articulacion ACV en un servicio de Reumatologia, mediante estudio retrospectivo de revision de historias clinicas de los pacientes atendidos por artritis septica en dicha unidad (101 pacientes) en el periodo de 1989-2012. Seis enfermos (6%) tuvieron infeccion en la articulacion ACV con confirmacion microbiologica.

OBJECTIVES: To estimate the incidence of severe infection and investigate the associated factors and clinical impact in a large systemic lupus erythematosus (SLE) retrospective cohort. METHODS: All patients in the Spanish Rheumatology Society Lupus Registry (RELESSER) who meet ?4 ACR-97 SLE criteria were retrospectively investigated for severe infections. Patients with and without infections were compared in terms of SLE severity, damage, comorbidities, and demographic characteristics. A multivariable Cox regression model was built to calculate hazard ratios (HRs) for the first infection. RESULTS: A total of 3658 SLE patients were included: 90% female, median age 32.9 years (DQ 9.7), and mean follow-up (months) 120.2 (±87.6). A total of 705 (19.3%) patients suffered ?1 severe infection. Total severe infections recorded in these patients numbered 1227. The incidence rate was 29.2 (95% CI: 27.6-30.9) infections per 1000 patient years. Time from first infection to second infection was significantly shorter than time from diagnosis to first infection (p < 0.000). Although respiratory infections were the most common (35.5%), bloodstream infections were the most frequent cause of mortality by infection (42.0%). In the Cox regression analysis, the following were all associated with infection: age at diagnosis (HR = 1.016, 95% CI: 1.009-1.023), Latin-American (Amerindian-Mestizo) ethnicity (HR = 2.151, 95% CI: 1.539-3.005), corticosteroids (?10mg/day) (HR = 1.271, 95% CI: 1.034-1.561), immunosuppressors (HR = 1.348, 95% CI: 1.079-1.684), hospitalization by SLE (HR = 2.567, 95% CI: 1.905-3.459), Katz severity index (HR = 1.160, 95% CI: 1.105-1.217), SLICC/ACR damage index (HR = 1.069, 95% CI: 1.031-1.108), and smoking (HR = 1.332, 95% CI: 1.121-1.583). Duration of antimalarial use (months) proved protective (HR = 0.998, 95% CI: 0.997-0.999). CONCLUSIONS: Severe infection constitutes a predictor of poor prognosis in SLE patients, is more common in Latin-Americans and is associated with age, previous infection, and smoking. Antimalarials exerted a protective effect. Spanish Foundation of Rheumatology. FIS/ISCIII (grant number PI11/02857). Dr. Pego-Reigosa is supported by Grant 316265 (BIOCAPS) from the European Union 7th Framework Programme (FP7/REGPOT-2012–2013.1).

Resumen Los tratamientos biologicos pueden ser el heraldo de la curacion de la artritis reumatoide. Estos tratamientos dirigidos a dianas terapeuticas han cambiado el pronostico de la enfermedad. El tocilizumab es un anticuerpo monoclonal humanizado contra el receptor de la interleucina 6. El tocilizumab se ha aprobado en diferentes paises para el tratamiento de la artritis reumatoide moderada o grave. Se han publicado diferentes trabajos que han puesto de manifiesto la eficacia de tocilizumab en el tratamiento de la artritis reumatoide activa. Esta revision versa sobre la seguridad y la dosificacion del tocilizumab.

Resumen Introduccion El sindrome de Churg-Strauss (SCS) es una vasculitis que afecta a vasos de pequeno y mediano calibre, caracterizandose clinicamente por afectacion predominante del aparato respiratorio, asma y eosinofilia periferica y anatomopatologicamente por la presencia de granulomas y la infiltracion tisular por eosinofilos. Objetivos En el presente trabajo se detallan las caracteristicas de una serie de 9 pacientes con SCS diagnosticados en un centro universitario de referencia. Pacientes y metodos Estudio retrospectivo: entre 1984 y 2007 se diagnosticaron 9 pacientes con SCS en nuestro centro. De todos ellos se obtuvieron de forma retrospectiva datos epidemiologicos, clinicos, analiticos, estudios anatomopatologicos y tratamiento recibido. Resultados De estos 9 pacientes, 7 eran hombres. La edad media en el momento del diagnostico fue de 51 anos (rango 23–76 anos). Ocho de los pacientes tenian antecedente de asma bronquial. Las manifestaciones clinicas mas frecuentes fueron las cutaneas (66%), musculoesqueleticas (66%), del sistema nervioso periferico (55%) y las pulmonares (55%). Todos presentaban eosinofilia periferica. Los anticuerpos anticitoplasma de neutrofilo (ANCA) fueron positivos en 6 pacientes (66%), la mayor parte de ellos con patron perinuclear en inmunofluorescencia (p-ANCA). Todos los pacientes recibieron tratamiento con glucocorticoides y 8 de ellos requirieron, ademas, tratamiento inmunosupresor, principalmente ciclofosfamida. Conclusiones En este trabajo se presentan 9 pacientes diagnosticados de SCS. Las manifestaciones clinicas no difieren de las observadas en el resto de series publicadas. Sin embargo, en esta serie se observa una mayor positividad de ANCA. La mayoria de los pacientes fueron tratados con glucocorticoides e inmunosupresores, debiendose individualizar el tratamiento de cada paciente segun el grado de afectacion.

Resumen La lumbalgia se define como dolor producido entre la ultima costilla y la zona glutea que puede irradiarse a las extremidades inferiores. Es un problema de salud importante, sobre todo en paises industrializados, con una prevalencia que gira alrededor del 70%. Generalmente se trata de un dolor musculoesqueletico que se autolimitara en un plazo de tiempo determinado. A pesar de ello, ante un paciente con lumbalgia, es conveniente realizar una correcta anamnesis y exploracion fisica para descartar otras patologias graves (como por ejemplo neoplasias, osteomielitis, fracturas vertebrales, sindrome de la cauda equina, estenosis del canal lumbar, espondiloartropatias, etc.), ya que de ello depende su pronostico y tratamiento. Por este motivo, en la mayoria de las guias clinicas se habla de los signos de alarma o «red flags» de la lumbalgia. Se define como signo de alarma aquel factor de riesgo que puede presentar un paciente con lumbalgia y que podria relacionarse con el desarrollo de alguna enfermedad grave respecto a otros pacientes con lumbalgia que no presentan ese factor. No existen suficientes estudios basados en la evidencia sobre los distintos signos de alarma, pero ante un paciente con lumbalgia y fiebre, sindrome toxico, antecedente de neoplasia, dolor de caracteristicas inflamatorias, antecedente de traumatismo, retencion aguda de orina, entre otros, convendria ampliar el estudio, ya que podriamos encontrarnos ante una lumbalgia secundaria. En el texto que viene a continuacion se hablara sobre los signos de alarma de la lumbalgia aguda.

The phenomenon of pathergia is characterized by an erythematous induration, a papule or aseptic pustule in the site of minor trauma. This phenomenon is a peculiar characteristic of patients with Behcet's disease. Nevertheless, other diseases may induce pathergia. Pathergia is more frequent in males than in females and bears no relation to the severity of the disease. Patients with pathergia are more prone to have vascular involvement.

Objetivo: el 15% de las artritis septicas corresponde a formas poliarticulares, si bien son escasas las series publicadas. Evaluamos las caracteristicas de los enfermos con artritis septica poliarticular recogidos en un servicio de reumatologia. Material y metodo: analisis retrospectivo de las artritis piogenas con afeccion oligoarticular o poliarticular. Se incluye unicamente a los enfermos con aislamiento del germen en el liquido articular. Se analizan las variables clinicas, analiticas y radiologicas de la serie. Resultados: se registraron 19 casos (14 varones y 5 mujeres) con una media de edad de 55 anos. La media del tiempo hasta el diagnostico fue 6 dias. La articulacion afectada con mayor frecuencia fue la rodilla, seguida del tobillo. La media de focos infecciosos por paciente fue 3 (intervalo, 2-6). Los factores de riesgo mas frecuentes fueron la diabetes mellitus, la insuficiencia renal cronica, la hepatopatia cronica, la gota y la artritis reumatoide. Los germenes aislados fueron Staphylococcus aureus (47%), S. agalactiae (21%) y bacilos gramnegativos. Los hemocultivos fueron positivos en el 52,6%, y el 15,8% presento shock septico. La gammagrafia con 99Tc mostro la afeccion politopica cuando fue realizada. La duracion media del tratamiento antibiotico fue 46 ± 27 dias. La evolucion fue satisfactoria en el 52,6% y torpida en el 26%, con mortalidad del 15,8% (3 casos). Se realizo artrotomia en el 21%. Conclusiones: la presencia de oligoartritis o poliartritis no excluye el diagnostico de artritis infecciosa. Entre los factores de riesgo destacan las artropatias inflamatorias previas. S. aureus es el microorganismo causal mas frecuente. La morbilidad y la mortalidad de esta forma de infeccion articular son importantes, por lo que debe mantenerse un alto indice de sospecha y realizar una exploracion sistematica de todas las articulaciones. © 2008 Elsevier Espana, S.L. Todos los derechos reservados.

Objective Polyarticular septic arthritis accounts for 15% of all septic arthritis, but there are few references in the literature. We describe characteristics of patients with polyarticular septic arthritis in a rheumatology service. Patients and method Retrospective analysis of patients with septic arthritis involving more than one joint. Only patients with positive culture of synovial fluid were included. Clinical, analytical, and radiological variables are reviewed. Results Nineteen patients (14 male) had a polyarticular infection. Mean age was 55 years. Mean time from onset to diagnosis was 6 days. The knee was the most commonly involved joint, followed by ankle. The mean number of joints involved per patient was 3. Risk factors included diabetes, chronic renal, or hepatic disease, gout, and rheumatoid arthritis. Most commonly isolated agents were S aureus (47%) and S agalactiae (21%). Blood cultures were positive in 52.6% and 15.8% had septic shock. Scintygraphic bone scan showed a polyarticular uptake. Mean duration of antibiotic therapy was 46 (27) days. Clinical outcome was good in 52.6%, complicated in 26%, and mortality rate was 15.8% (3 cases). Joint debridement was performed in 21%. Conclusions Multiple joint involvement does not exclude the diagnosis of septic arthritis. Inflammatory arthritis is an important risk factor. S aureus in the main infectious agent. The morbidity and mortality of this condition are important, so we need to maintain a high index of suspicion for the condition.

Cryoglobulins are immunoglobulins that precipitate at temperatures below 37 °C and redissolve on rewarming. These immunoglobulins can form immune complexes that precipitate in blood vessels, activate complement and cause cryoglobulinemic vasculitis. Cryoglobulinemia is classified intro three serological subsets; of these, type II, or mixed cryoglobulinemia, is associated with hepatitis C virus (HCV) infection in more than 80% of cases. The discovery of this association has changed therapeutic strategies in cryoglobulinemic vasculitis, which is now considered an extrahepatic manifestation of HCV infection. Therefore, the main therapeutic approach currently consists of antiviral therapies such as interferon or ribavirin. In patients refractory to these treatments, new agents such as rituximab, infliximab and mycophenolate mofetil are being used. The development of an effective vaccine against HCV would drastically reduce the number of cases of this form of vasculitis.

Fundamento y objetivo Describir las caracteristicas clinicas, el tratamiento y la evolucion de una serie de pacientes con enfermedad de Still del adulto. Pacientes y metodo Se revisaron de forma retrospectiva las historias clinicas de los pacientes con esta enfermedad desde 1984 hasta 2004. Resultados Se incluyo a 26 pacientes. Las manifestaciones clinicas mas frecuentes fueron las siguientes: fiebre (100%), artritis (81%), exantema (92%), odinofagia (92%) y adenopatias (42%). El 27% de los pacientes respondio al acido acetilsalicilico, el 70% preciso glucocorticoides y el 50%, un inmunodepresor ahorrador de glucocorticoides. En el 54% el curso fue monociclico y en el 46% restante, policiclico. Conclusiones Las manifestaciones clinicas fueron similares a las de series previamente descritas. La poliartritis febril es la forma mas frecuente de presentacion de la enfermedad. El 58% tuvo un curso policiclico, dato que parece relacionarse con un peor pronostico y necesidad de un tratamiento mas agresivo.

The objective of this study is to determine the prevalence of fibromyalgia (FM) in systemic lupus erythematosus (SLE) patients and to study its relationship to depression and other SLE-related factors.A cross-sectional data analysis from the RELESSER-Transversal Spanish Registry, which includes SLE patients in a national multicentre retrospective charts review, was performed.patients who fulfilled ≥4 ACR 1997 SLE criteria. Main variables were disease duration, depression, sociodemographics, comorbidities, SLE activity symptoms, serological findings, therapies and different disease status indices. Statistical analyses included a descriptive, associative and logistic regression analyses. A literature review was performed.3,591 SLE patients were included, 90.1% women, 34.6 years of age at diagnosis (SD 14.6 years) and 93.1% Caucasians. FM prevalence was 6.2%. SLE patients with disease duration5 years showed more FM than those with duration5 years: 6.9% vs. 4.0%, respectively (p0.05). SLE-FM patients showed higher prevalence of depression compared to non-FM-SLE patients: 53.1% vs. 14.6%, respectively (p0.001). After adjusting by risk factors, the OR (CI) of suffering depression in FM-SLE patients was 6.779 (4.770-9.636), p0.001. The OR of having secondary Sjögren's 2.447 (1.662-3.604), p0.001, photosensitivity 2.184 (1.431-3.334), p0.001, and oral ulcers 1.436 (1.005-2.051), p=0.047.Prevalence of FM in Caucasian SLE patients was high compared to the general population, and was significantly higher in those in later stages of disease. SLE patients with depression showed a strong risk of developing FM. Photosensitivity, oral ulcers and secondary Sjögren's were the only SLE-related factors associated with FM.

This article estimates the frequency of cardiovascular (CV) events that occurred after diagnosis in a large Spanish cohort of patients with systemic lupus erythematosus (SLE) and investigates the main risk factors for atherosclerosis. RELESSER is a nationwide multicenter, hospital-based registry of SLE patients. This is a cross-sectional study. Demographic and clinical variables, the presence of traditional risk factors, and CV events were collected. A CV event was defined as a myocardial infarction, angina, stroke, and/or peripheral artery disease. Multiple logistic regression analysis was performed to investigate the possible risk factors for atherosclerosis. From 2011 to 2012, 3658 SLE patients were enrolled. Of these, 374 (10.9%) patients suffered at least a CV event. In 269 (7.4%) patients, the CV events occurred after SLE diagnosis (86.2% women, median [interquartile range] age 54.9 years [43.2-66.1], and SLE duration of 212.0 months [120.8-289.0]). Strokes (5.7%) were the most frequent CV event, followed by ischemic heart disease (3.8%) and peripheral artery disease (2.2%). Multivariate analysis identified age (odds ratio [95% confidence interval], 1.03 [1.02-1.04]), hypertension (1.71 [1.20-2.44]), smoking (1.48 [1.06-2.07]), diabetes (2.2 [1.32-3.74]), dyslipidemia (2.18 [1.54-3.09]), neurolupus (2.42 [1.56-3.75]), valvulopathy (2.44 [1.34-4.26]), serositis (1.54 [1.09-2.18]), antiphospholipid antibodies (1.57 [1.13-2.17]), low complement (1.81 [1.12-2.93]), and azathioprine (1.47 [1.04-2.07]) as risk factors for CV events. We have confirmed that SLE patients suffer a high prevalence of premature CV disease. Both traditional and nontraditional risk factors contribute to this higher prevalence. Although it needs to be verified with future studies, our study also shows-for the first time-an association between diabetes and CV events in SLE patients.

The ivory vertebra is an osteoblastic spine lesion. It is defined as a solitary homogeneously radiodense vertebral body with normal size and limits and with no change in adjacent intervertebral discs. The ivory vertebra is seen in a conventional radiography in patients with low back pain or as a casual finding in asymptomatic patients. The differential diagnosis of ivory vertebra is wide and include benign disorders and sometimes cancer with an ominous prognosis. That is why is a diagnostic challenge for clinicians and radiologists.

Resumen El tratamiento de la artrosis de manos es actualmente insuficiente. Se utilizan los programas de educacion, el paracetamol, los antiinflamatorios no esteroideos y la capsaicina. Existe una falta de estudios del condroitin sulfato en la artrosis de manos. El presente estudio examina la utilidad del condroitin sulfato en la artrosis de manos. Estudio prospectivo, aleatorizado y con grupo controlado con placebo. Todos los pacientes cumplian los criterios diagnosticos del Colegio Americano de Reumatologia. Se reclutaron 162 pacientes y se aleatorizaron en dos brazos: 82 pacientes al grupo placebo y 80 al grupo condrointin sulfato (800 mg cada dia). Las medidas de desenlace primarias fueron: la escala analogica visual y el indice funcional; las medidas de desenlace secundarias fueron: fuerza de agarre, rigidez matutina, opinion del investigador y consumo semanal de paracetamol. El estudio tuvo una duracion de 6 meses. Al finalizar el estudio existia una diferencia significativa entre el grupo tratado con condroitin sulfato respecto a placebo en la escala analogica visual (diferencia en la EAV 2,14; p = 0,008), indice funcional (FIHOA:2,14; p = 0,008), rigidez matutina (diferencia de 5’ 1 minutos; p = 0,031) y opinion global del investigador (44% versus 33%; p = 0,043). Las reacciones adversas fueron similares en ambos grupos. Los autores remarcan la utilidad del condroitin sulfato en la artrosis de manos, destacando su perfil de seguridad.

Un problema fundamental en las vasculitis es la falta de una clasificacion unificada. A pesar de los ultimos intentos realizados, la mayoria de clasificaciones continuan basandose en las caracteristicas clinicas e histologicas, pero no en su etiologia. Esto provoca un solapamiento entre categorias. Respecto al tratamiento, existen pocos trabajos controlados y aleatorios. Muchas de las decisiones terapeuticas derivan de estudios prospectivos con muestras reducidas o de estudios con muestras mas amplias pero retrospectivos 1,2 . Por todo ello, en la actualidad, grupos internacionales de consenso intentan disenar pautas de tratamiento segun la gravedad de la enfermedad y no tanto segun la clase de vasculitis. Aquellos pacientes con una presentacion clinica mas grave tienen un peor pronostico y, por tanto, los tratamientos deberian ser mas agresivos, a pesar de que conlleven mas reacciones adversas 3-5 . Este enfoque frente a las vasculitis es empirico y requiere mas estudios para confirmar su valor. Esta revision trata de ofrecer una vision de esta perspectiva, detallando en un principio diferentes subgrupos clinicos segun la gravedad y finalizando con algunas caracteristicas particulares de cada una de las vasculitis.

a b s t r a c t Introduction: Churg-Strauss Syndrome (CSS) is a necrotizing vasculitis affecting small to medium-sized vessels, characterized by lung involvement, asthma and peripheral blood eosinophilia, and pathologically by the presence of granulomas and eosinophilic infiltrates. Objectives: This report analizes the characteristics of 9 patients with SCS diagnosed in an university referral center. Patients and methods: Retrospective study. Between 1984 and 2007 nine patients with SCS were diagnosed in our center. Epidemiological, clinical, laboratory test as well as pathologic studies and treatment required were retrospectively analyzed. Results: Nine patients (7 males). The mean age at the time of diagnosis was 51 years (range 23-76 years). Eight of these patients had history of asthma. The more frequent organs involved were the skin (66%), musculoesqueletical system (66%), peripheral nervous system (55%) and the lung (55%). All patients presented peripheral eosinophilia. ANCA positivity was demonstrated in 6 patients (66%), most of the patients with the p-ANCA pattern. All patients were treated with corticosteroids, and in 8 immunosupressant treatment was required, mainly cyclophosphamide. Conclusions: In this report, 9 patients with SCS are presented. Clinical characteristics are similar with the observed in other reports. We observed a major positivity of ANCA. Most of the patients were treated with corticosteroids and inmunosupresants, but the treatment should be tailored depending on the involvement of the patient.

We intended to describe the clinical characteristics, treatment and evolution of 26 patients with adult onset Still's disease.This was a retrospective study (1984-2004). The clinical records of patients with adult onset Still's disease were reviewed.Twenty six patients were included. Most frequent clinical characteristics were: fever (100%), arthritis (81%), rash (92%) sore throat (92%) and lymphadenopathy (42%). Aspirin controlled the disease in 27% of patients, prednisone was needed in 70% and methotrexate was added in 50% cases. A monocyclic course was seen in 54% and polycyclic in 46% patients.The clinical characteristics were similar to previous series. A febrile polyarthritis was the most frequent presentation form. A polycyclic course was found in 58% of cases and it seems to be associated with poor prognosis and need for aggressive treatment.

Correo electronico: aolive.germanstrias@gencat.cat Alan S Dixon –reumatologo ingles y uno de los pioneros de la reumatologia– contaba en la decada de los ochenta que si un extraterrestre aterrizaba en la tierra y hacia un estudio de las enfermedades reumaticas segun lo publicado en las revistas biomedicas, se llevaria la idea que la artritis reumatoide y el lupus eritematoso sistemico eran las enfermedades mas frecuentes. Nada mas cierto, en aquella epoca; los congresos tambien daban fe de la poca atencion que se daba a la artrosis, sin lugar a dudas la enfermedad ostearticular mas prevalente. Estos pensamientos los plasmo en varios editoriales que causaron una sana polemica1,2. Si se realiza una busqueda en PubMed con la palabra “ostearthritis”, se vera que esta enfermedad ha recuperado su terreno durante estos ultimos anos (fig. 1). La investigacion en la artrosis forma parte fundamental de la reumatologia y hoy dia no solo llena los congresos de reumatologia, sino que tambien tiene congresos y revistas biomedicas propias. En el estado espanol tenemos varios grupos asentados y con una investigacion de excelencia. El concepto de la artrosis tambien ha sufrido un giro copernicano. Se consideraba como una enfermedad del cartilago articular. Actualmente, se define la artrosis como una enfermedad de organo: la articulacion. Este concepto engloba la degradacion del cartilago, la inflamacion de la membrana sinovial y la remodelacion del hueso subcondral. En efecto, en el cartilago tiene lugar un extenso proceso de degradacion, implicando a mediadores de la inflamacion producidos por la membrana sinovial, y por los condrocitos. Es mas, en el hueso subcondral tiene lugar un remodelaje que conlleva la formacion de una matriz osea anormal. Una verdadera enfermedad de la articulacion. Comentaba que la artrosis es una enfermedad de organo, pero lo que es todavia poco conocido es el caracter metabolico y sistemico de la enfermedad. Las comorbilidades estan presentes en la artrosis. El riesgo cardiovascular, la diabetes y la dislipemia estan asociados a la artrosis. Lo cual da una idea de la magnitud de la enfermedad. Los tratamientos para la artrosis no cumplen con los objetivos que los galenos nos marcamos. Pueden aliviar pero no frenan el avance de la enfermedad. Durante estos ultimos anos se han puesto en evidencia nuevos farmacos que han llevado a cabo un cambio en la terminologia de los tratamientos en la artrosis: SYSADOA (farmacos modificadores lentos de los sintomas) y DMOAD (farmacos modificadores de la estructura en la artrosis). El condroitin sulfato pertenece a este grupo de farmacos que estan tratando de cambiar el rumbo de la artrosis. En poco tiempo se han publicado 2 trabajos que sugieren que el condroitin sulfato puede ser efectivo en el tratamiento de la artrosis. Wildi et al comunico que el condrointin sulfato reduce la perdida de volumen del cartilago y las lesiones de la medula osea subcondral en la artrosis de rodilla3. Asimismo, investigadores suizos han puesto de manifiesto la utilidad de este farmaco en la artrosis de manos4. Ambos articulos se comentan en este numero. Recientemente, en el congreso OARSI de Barcelona, investigadores espanoles presentaron el efecto del condrointin sulfato en la sinovitis que acontece en la artrosis de rodilla. En un trabajo aleatorizado y controlado con placebo pusieron de manifiesto mediante pruebas de imagen (ultrasonido) que este farmaco reducia la sinovitis frente a paracetamol de forma significativa5. Asimismo, el grupo canadiense de Pelletier sugeria en un estudio que aquellos pacientes tratados con condroitin sulfato y seguidos durante 4 anos presentaban un menor numero de artroplastias de rodilla que los tratados con placebo6. Las implicaciones economicas de este ultimo estudio –caso de confirmarse– serian enormes. Este numero monografico dedicado a la artrosis es una puesta al dia de los cambios que estan ocurriendo en esta enfermedad. Cam50.000

Cardiac involvement in vasculitis syndromes is uncommon. We describe a 50-year-old male who presented with progressive dyspnea and myalgies. Echocardiogram revealed significant thickening of aortic root, aortic cusps, and anterior mitral valve leaflet, with severe aortic regurgitation that required aortic valve replacement. Furthermore, this patient suffered progressive atrioventricular block that needed implantation of a pacemaker. The study performed disclosed the presence of necrotizing vasculitis positive for perinuclear antineutrophil cytoplasmic antibody. (ECHOCARDIOGRAPHY, Volume 20, October 2003)