To evaluate the role of tumor necrosis factor-alpha (TNF-alpha) gene as susceptibility marker for... more To evaluate the role of tumor necrosis factor-alpha (TNF-alpha) gene as susceptibility marker for spondyloarthritis (SpA), two polymorphisms (-238 and -308 positions) were analyzed in 229 patients with SpA (113 with ankylosing spondylitis [AS], 92 with undifferentiated SpA [U-SpA], 24 with reactive arthritis), and 169 ethnically matched healthy control subjects. The HLA-B alleles were detected by PCR-SSP technique and the TNF-alpha polymorphism by PCR-RFLP. In comparison with healthy control subjects, the frequencies of TNF-238 in SpA were similar. In contrast, the analysis of -308 polymorphism showed increased frequencies of the T2(A) allele in the whole SpA group (p < 0.05, pC = NS, OR = 1.83) as well as the T2(A) allele (pC < 0.05, OR = 2.4) and T1T2(AG) genotype (p < 0.05, pC = NS, OR = 2.25) in U-SpA patients. Comparison of B27-negative patients and healthy control subjects yielded similar results. There was no significant correlation between TNF genotypes and clinical...
Chronic diseases have a great impact in the morbidity and mortality and in the health-related qua... more Chronic diseases have a great impact in the morbidity and mortality and in the health-related quality of life (HRQoL) of patients around the world. The impact of rheumatic diseases has not been fully recognized. We conducted a comparative study to evaluate the HRQoL in different chronic diseases. The aim of the present study was to assess the HRQoL and identify specific areas affected in patients with rheumatoid arthritis (RA), osteoarthritis (OA), diabetes mellitus, end-stage renal disease, geriatric subjects and a control group. We conducted a cross-sectional study, in a General Hospital in Morelia, Mexico. All patients met classification criteria for RA, OA, diabetes mellitus, end-stage renal disease; the geriatric subjects group was≥65 years, and the control group≥30 years. Demographic characteristics were recorded, different instruments were applied: SF-36, visual analogue scale for pain, patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s and physician&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s global assessments, Beck Depression Inventory and specific instruments (DAS-28, HAQ-Di, WOMAC, Diabetes Quality of Life [DQOL] and Kidney Disease Questionnaire of Life [KDQOL]). Biochemical measures: erythrocyte sedimentation rate, blood count, glucose, HbA1C, serum creatinine and urea. We evaluated 290 subjects (control group: 100; geriatric subjects: 30 and 160 for the rest of groups). Differences were detected in baseline characteristics (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.0001). The SF-36 scores were different between control group and others groups (P=0.007). The worst HRQoL was in end-stage renal disease group (±SD: 48.06±18.84 x/SD). The general health was the principal affected area in RA. The pain was higher in rheumatic diseases: OA (5.2±2.4) and RA (5.1±3). HAQ was higher in OA compared to RA (1.12±0.76 vs 0.82±0.82, respectively; P=.001). Forty five percent of all subjects had depression. The HRQoL in RA patients is poor and comparable to other chronic diseases (end-stage renal disease and diabetes mellitus). Rheumatic diseases should be considered high impact diseases and therefore should receive more attention.
To review background, pharmacological properties, mechanisms of action, and published clinical ex... more To review background, pharmacological properties, mechanisms of action, and published clinical experience using omega-3 fatty acids in rheumatoid arthritis. English language publications were identified through a computerized search (using MEDLINE) between 1979 and 1995 using the terms &quot;omega-3 fatty acids&quot; and &quot;fish oil&quot;. In addition, manual search and cross references were used to obtain published articles on the subject. Papers showing evidence of pharmacological properties and mechanisms of action were analyzed. For therapeutic efficacy, only randomized clinical trials are presented in this article. All papers were reviewed by a board certified rheumatologist with training in research methodology and critical appraisal skills. He was aware of study objectives. Main results are summarized in the text and presented in tables. Mean change from baseline is presented only for patients treated with omega-3 fatty acids. Omega-3 fatty acids are superior with respect to placebo in improving some outcome measures, and decrease the long-term requirements for nonsteroidal antiinflammatory drugs. Some of these effects are statistically significant, but their clinical significance remain to be established. Treatment with omega-3 fatty acids has been associated with improvement in some outcome measures in rheumatoid arthritis. Studies are needed to determine if they might represent an alternative to nonsteroidal antiinflammatory drugs in certain circumstances.
Painful shoulder syndrome (PSS) is a common problem in rheumatology and physiotherapy. Ultrasound... more Painful shoulder syndrome (PSS) is a common problem in rheumatology and physiotherapy. Ultrasound (US) and transcutaneous electrical nerve stimulation (TENS) have been advocated as potentially useful in pain management but this has not been adequately demonstrated. A randomised clinical trial was designed to compare their effectiveness in a package of treatment for PSS. Thirty patients with untreated PSS were randomly allocated to groups which received either U S to the glenohumeral joint for ten minutes or TENS on the anterior and posterior aspects of the joint for 20 minutes for 13 sessions. All patients performed Codman (pendular) and stretching exercises and received superficial heat treatment. Before-and-after measurements of range of movement and pain were collected and compared. A statistically significant and clinically important improvement in pain and range of flexion was shown for both packages of treatment but no statistically significant difference was found between them. It is concluded that packages of treatment including pendular exercises, superficial heat and either TENS or ultrasound are effective therapeutic alternatives for relief of PSS.
Clinical and laboratory manifestations and outcome of systemic lupus erythematosus (SLE) may vary... more Clinical and laboratory manifestations and outcome of systemic lupus erythematosus (SLE) may vary in different populations. A prospective multinational inception cohort should prove useful in identifying the influence of ethnicity on the clinical characteristics of SLE. We therefore analyzed clinical, laboratory, and prognostic variables in Latin American SLE patients with disease of recent onset who were entered into a prospective cohort, and compared these variables in the cohort's 3 major ethnic groups. Thirty-four centers from 9 Latin American countries participated by randomly incorporating SLE patients within 2 years of diagnosis into a standardized database. Participating centers were selected for their expertise in diagnosing and managing SLE. We were then able to evaluate prospectively socioeconomic variables, ethnicity, type of medical care, clinical and laboratory features, disease activity, damage, and mortality at each site. A coordinating center controlled the quality of the information submitted.
The objectives were to determine causes of consultation, hospitalization and outcome in a cohort ... more The objectives were to determine causes of consultation, hospitalization and outcome in a cohort of lupus patients in an emergency unit. Patients with systemic lupus erythematosus (SLE) who visited the emergency department for consultation from 1 September 1996 to 17 May 1997 were included in the study. They were evaluated during the visit by looking at 100 variables such as demographic, socioeconomic, clinical, therapeutical, behavioral, (compliance), emotional (Beck depression inventory), disease activity, (Mex-SLEDAI), disease severity (Lupus SDI), chronic damage (SLICC-ACR), and physician&#39;s and patient&#39;s global assessments of severity. All causes of consultation, hospitalization and outcome were registered. Descriptive statistics, univariate analysis and multiple logistic regression were used for analysis. Significance was set at the 0.05 level. 180 patients were included. 164 were female, mean age 31.7/11.39 y, mean Mex SLEDAI score 3.8, mean SLICC-ACR 1.3. Fever, poliarthralgia and abdominal pain were the main causes of consultation with 26, 25 and 18 cases each. 49 patients were hospitalized and these were statistically different than non-hospitalized patients in level of formal education (10.2 vs 11.8, P=0.03); compliance (7.6 vs 9, P=0.0001); malar rash (57% vs 82%, OR, 95% CI=0.28, 0.13-0.62, P=0.0008), chloroquine daily dose intake (45 vs 77 mg, P=0.04); disease severity in physician&#39;s global assessments (5.6 vs 2.1, P=0.0001) and Beck depression inventory (21 vs 16, P=0.01). Multiple logistic regression identified physician&#39;s global assessment, fewer ACR criteria and higher SLICC-ACR scores as the main variables associated with hospitalization. Five patients died; two with community acquired pneumonia, one with pancreatitis, multiple thromboses, and sepsis, one with pulmonary hemorrhage; and one with pulmonary thromboembolism. In conclusion, poor compliance, low level of formal education, severity, depression, lower ACR criteria and higher SLICC-ACR scores were important variables identified with hospitalization. Chloroquine use seemed to have a protective effect. Causes of death were related to infections and antiphospholipid syndrome.
a case-control study Factors associated with chronic renal failure in 121 patients with diffuse p... more a case-control study Factors associated with chronic renal failure in 121 patients with diffuse proliferative lupus nephritis:
Antimalarials are very useful drugs in the treatment of various rheumatic diseases. One of their ... more Antimalarials are very useful drugs in the treatment of various rheumatic diseases. One of their main side effects is ocular toxicity, specifically retinopathy. Our objective was to identify risk factors associated with chloroquine retinopathy. A single, trained evaluator reviewed patient records with rheumatic diseases. They were taking chloroquine and identified by the ophthalmology department as having retinopathy during their routine eye evaluation. These cases were classified according to clinical evaluation, visual fields and fluorangiographic study. Up to four controls were selected for each case, matched by age, gender, diagnosis and similar time on chloroquine. In all, 34 variables were studied, among these: weight, age, disease duration, keratopathy, total cumulative dose (TCD), mean daily dose (MDD), lean body weight adjusted daily dose (LBWDD) and laboratory tests. Descriptive and inferential statistics comparing cases and controls in all patients and subgroup analysis were carried out. Significance was set at the 0.05 level. Odds ratio and 95% confidence intervals were calculated. Sixteen cases of chloroquine retinopathy were identified, eight patients with rheumatoid arthritis (RA), seven with systemic lupus erythematosus (SLE) and one with dermatomyositis. All were female. Mean age was 47.3 +/- 12.2 years; weight 59.5 +/- 10.7 kg; disease duration 12.8 +/- 6.0 years; time on chloroquine 54.1 +/- 27.8 (min-max: 30-197) months. There was a significant difference in the following variables in all patients: MDD 212.3 +/- 52.6 versus 170 +/- 51.3, p = 0.009; and LBWDD 5 +/- 1 versus 4.2 +/- 1.5, p = 0.03, for cases and controls, respectively. In subgroup analysis the MDD remained significantly different (235.5 +/- 45.8 versus 169.7 +/- 46.1, p = 0.004) only in RA, whereas LBWDD was different both in SLE and RA. Keratopathy increased the risk for retinopathy: OR, 95% CI: 5, 1.4-17.6, p = 0.01. In conclusion, in accordance with previous studies, the MDD, LBWDD and keratopathy were risk factors associated with chloroquine retinopathy. Periodic ophthalmologic evaluations are mandatory.
To estimate the prevalence, burden of illness, and help-seeking behavior of patients with musculo... more To estimate the prevalence, burden of illness, and help-seeking behavior of patients with musculoskeletal complaints and provide point prevalence estimates of osteoarthritis, low back pain, fibromyalgia, rheumatoid arthritis, gout, and bone fractures not related to trauma among the adult population in a urban community in Havana City. Home survey of adults validated against physical examination. Forty-eight trained family doctors and 3 rheumatologists supervised the interviews and confirmed diagnoses. Family doctors applied a validated Community Oriented Program for the Control of Rheumatic Diseases core questionnaire. A diagnosis using American College of Rheumatology criteria was established. Analysis was based on descriptive statistics and point prevalence estimates with 95% confidence intervals (CIs) of most common diseases and associated disability rate. One thousand two hundred thirty-eight men and 1917 women were included. Prevalence of musculoskeletal pain was estimated in 43.9% (95% CI: 42.2-45.7). The knees were the most affected area (11.7%; 95% CI: 10.6-12) followed by low back pain (11.6%; 95% CI: 10.5-12.8). Point prevalence and 95% CI were as follows: osteoarthritis, 20.4% (95% CI: 19-21.8); gout, 0.38% (95% CI: 0.2-0.6); fibromyalgia, 0.22% (95% CI: 0.09-0.4); systemic lupus erythematosus, 0.06% (95% CI: 0.01-0.25); spondyloarthropathies, 0.19% (95% CI: 0.07-0.4); and rheumatoid arthritis,1.24% (95% CI: 0.8-1.7). Bone fractures not related to trauma were found in 1.14%, hip fracture being the most common (30.5%). Most patients were seen by the general practitioner (65.4%) and 6.2% described some disability. Musculoskeletal pain is highly prevalent in Cuba. Prevalence estimates are similar to those described in other surveys except for rheumatoid arthritis that seems more prevalent in Cuba and fibromyalgia less prevalent.
Treatment of rheumatoid arthritis (RA) has evolved dramatically in the last decade. However, litt... more Treatment of rheumatoid arthritis (RA) has evolved dramatically in the last decade. However, little is known about the way rheumatologists in Latin America treat their patients in clinical practice, outside the scope of clinical trials. The objective of this study was to describe treatment patterns at disease onset in early RA with data from a large, multicenter, multinational inception cohort of Latin American patients. Consecutive patients with early RA (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1 year of disease duration as diagnosed by a rheumatologist) from 46 centers in 14 Latin American countries were enrolled in the study. Clinical data, laboratory assessments, and a detailed registry on type of prescriptions were collected at baseline and at 3, 6, 12, 18, and 24 months of follow-up. Hands and feet x-rays were obtained at baseline and at 12 and 24 months. All data were captured in Arthros 6.1 database. Continuous variables were expressed as means and SDs, and categorical variables were expressed as percentages and 95% confidence intervals (95% CIs). Only therapeutic data at baseline are presented, corresponding to the period between disease onset and second visit (3 months). A total of 1093 patients were included. Eighty-five percent were female, and 76% had a positive rheumatoid factor. Mean age at diagnosis was 46.5 (SD, 14.2) years, and mean disease duration at the first visit was 5.8 (SD, 3.8) months. Between baseline and second visit (3 months), 75% of patients (95% CI, 72%-78%) received disease-modifying antirheumatic drugs. Methotrexate (MTX) alone or in combination was the most frequently used (60.5%), followed by antimalarials (chloroquine or hydroxychloroquine, 32.1%), sulfasalazine (7.1%), and leflunomide (LEF, 4%). In 474 patients (43%), initiation of disease-modifying antirheumatic drugs was within the first month after the first visit. In addition, 290 patients (26%; 95% CI, 23%-29%) received combination therapy as initial treatment. The most frequently used combinations were MTX + chloroquine (45%), MTX + hydroxychloroquine (25%), and MTX + sulfasalazine (16%). Eleven patients (1%; 95% CI, 0.5%-1.8%) received biologics. Sixty-four percent (95% CI, 60%-66%) received corticosteroids. Of those, 80% (95% CI, 77%-84%) received 10 mg of oral prednisone or less. In this cohort of Latin American patients with early RA, most patients received MTX very early in their disease course. Combination therapy was used approximately in 1 of every 4 patients as initial therapy. Biologics were rarely used at this early stage, and low-dose prednisone was commonly used.
The aim of this study was to determine the frequency and potential relevance of the promoter poly... more The aim of this study was to determine the frequency and potential relevance of the promoter polymorphisms of the tumor necrosis factor-alpha (TNF-a) in the severity of rheumatoid arthritis (RA) in Mexicans. HLA-DR and polymorphisms at positions ÿ238 and ÿ308 of TNF-a gene were determined in 137 Mexican RA patients (44 with severe and 93 with non-severe RA) as well as in 169 healthy controls (99 were typed for HLA-DR). We observed an increased frequency of HLA-DR4 in severe RA compared to healthy controls (pC Z 0.02, OR Z 2.33). TNF polymorphism analysis showed a significant increased frequency of TNF ÿ238 GG genotype in the whole group of RA patients when compared to healthy controls (pC Z 0.007, OR Z 4.71). When the analyses were carried out separately in severe and non-severe RA patients, the increased frequency of ÿ238 GG genotype only was observed in patients with non-severe forms of the disease. Analysis of ÿ308 polymorphism showed increased frequency of ÿ308 T2 (A) allele in severe RA when compared to non-severe disease (pC Z 0.011, OR Z 3.29) and to healthy controls (pC Z 0.002, OR Z 3.97). The data demonstrate that ÿ308 T2 (A) allele is associated with susceptibility to develop severe RA in Mexicans. This association could be independent from HLA-DR alleles and might be used as a prognostic marker for severe RA.
To evaluate the role of tumor necrosis factor-␣ (TNF-␣) gene as susceptibility marker for spondyl... more To evaluate the role of tumor necrosis factor-␣ (TNF-␣) gene as susceptibility marker for spondyloarthritis (SpA), two polymorphisms (Ϫ238 and Ϫ308 positions) were analyzed in 229 patients with SpA (113 with ankylosing spondylitis [AS], 92 with undifferentiated SpA [U-SpA], 24 with reactive arthritis), and 169 ethnically matched healthy control subjects. The HLA-B alleles were detected by PCR-SSP technique and the TNF-␣ polymorphism by PCR-RFLP. In comparison with healthy control subjects, the frequencies of TNF-238 in SpA were similar. In contrast, the analysis of Ϫ308 polymorphism showed increased frequencies of the T2(A) allele in the whole SpA group (p Ͻ 0.05, pC ϭ NS, OR ϭ 1.83) as well as the T2(A) allele (pC Ͻ 0.05, OR ϭ 2.4) and T1T2(AG) genotype (p Ͻ 0.05, pC ϭ NS, OR ϭ 2.25) in U-SpA patients. Comparison of B27-negative patients and healthy control subjects yielded similar results. There was no significant correlation between TNF genotypes and clinical data. The present study demonstrates that TNF-␣ Ϫ308 polymorphism appears to be associated with the genetic susceptibility U-SpA. The association seems independent of the susceptibility conferred by the HLA-B27 in this group of patients. Human Immunology 67, 826 -832 (2006).
GLADAR (Grupo Latino Americano de Estudio de Artritis Reumatoide) is a large group of Latin Ameri... more GLADAR (Grupo Latino Americano de Estudio de Artritis Reumatoide) is a large group of Latin American (LA) rheumatologists experienced in the diagnosis and treatment of RA. In 2006, PANLAR and GLADAR published the first LA position paper on the pharmacological treatment of RA [1]. Since then, new therapies have emerged to help achieve the ultimate goal to preserve the patient&amp;amp;#x27;s ability to function independently with an optimal quality of life.
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 2009
A consensus meeting of representatives of 18 Latin-American and Caribbean countries gathered in R... more A consensus meeting of representatives of 18 Latin-American and Caribbean countries gathered in Reñaca, Chile, for 2 days to identify problems and provide recommendations for the care of patients with rheumatoid arthritis (RA) in Latin America, a region where poverty and other health priorities make the efforts to provide effective and high quality care difficult. This report includes recommendations for health professionals, patients, and health authorities in Latin America, with an emphasis on education and therapeutic issues.
To conduct a systematic review to identify and describe the scope and nature of the research evid... more To conduct a systematic review to identify and describe the scope and nature of the research evidence on the effectiveness of interventions to improve health care quality or reduce disparities in the care of disadvantaged populations with osteoarthritis (OA) as an example of a common chronic disease.
To evaluate the role of tumor necrosis factor-alpha (TNF-alpha) gene as susceptibility marker for... more To evaluate the role of tumor necrosis factor-alpha (TNF-alpha) gene as susceptibility marker for spondyloarthritis (SpA), two polymorphisms (-238 and -308 positions) were analyzed in 229 patients with SpA (113 with ankylosing spondylitis [AS], 92 with undifferentiated SpA [U-SpA], 24 with reactive arthritis), and 169 ethnically matched healthy control subjects. The HLA-B alleles were detected by PCR-SSP technique and the TNF-alpha polymorphism by PCR-RFLP. In comparison with healthy control subjects, the frequencies of TNF-238 in SpA were similar. In contrast, the analysis of -308 polymorphism showed increased frequencies of the T2(A) allele in the whole SpA group (p < 0.05, pC = NS, OR = 1.83) as well as the T2(A) allele (pC < 0.05, OR = 2.4) and T1T2(AG) genotype (p < 0.05, pC = NS, OR = 2.25) in U-SpA patients. Comparison of B27-negative patients and healthy control subjects yielded similar results. There was no significant correlation between TNF genotypes and clinical...
Chronic diseases have a great impact in the morbidity and mortality and in the health-related qua... more Chronic diseases have a great impact in the morbidity and mortality and in the health-related quality of life (HRQoL) of patients around the world. The impact of rheumatic diseases has not been fully recognized. We conducted a comparative study to evaluate the HRQoL in different chronic diseases. The aim of the present study was to assess the HRQoL and identify specific areas affected in patients with rheumatoid arthritis (RA), osteoarthritis (OA), diabetes mellitus, end-stage renal disease, geriatric subjects and a control group. We conducted a cross-sectional study, in a General Hospital in Morelia, Mexico. All patients met classification criteria for RA, OA, diabetes mellitus, end-stage renal disease; the geriatric subjects group was≥65 years, and the control group≥30 years. Demographic characteristics were recorded, different instruments were applied: SF-36, visual analogue scale for pain, patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s and physician&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s global assessments, Beck Depression Inventory and specific instruments (DAS-28, HAQ-Di, WOMAC, Diabetes Quality of Life [DQOL] and Kidney Disease Questionnaire of Life [KDQOL]). Biochemical measures: erythrocyte sedimentation rate, blood count, glucose, HbA1C, serum creatinine and urea. We evaluated 290 subjects (control group: 100; geriatric subjects: 30 and 160 for the rest of groups). Differences were detected in baseline characteristics (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.0001). The SF-36 scores were different between control group and others groups (P=0.007). The worst HRQoL was in end-stage renal disease group (±SD: 48.06±18.84 x/SD). The general health was the principal affected area in RA. The pain was higher in rheumatic diseases: OA (5.2±2.4) and RA (5.1±3). HAQ was higher in OA compared to RA (1.12±0.76 vs 0.82±0.82, respectively; P=.001). Forty five percent of all subjects had depression. The HRQoL in RA patients is poor and comparable to other chronic diseases (end-stage renal disease and diabetes mellitus). Rheumatic diseases should be considered high impact diseases and therefore should receive more attention.
To review background, pharmacological properties, mechanisms of action, and published clinical ex... more To review background, pharmacological properties, mechanisms of action, and published clinical experience using omega-3 fatty acids in rheumatoid arthritis. English language publications were identified through a computerized search (using MEDLINE) between 1979 and 1995 using the terms &quot;omega-3 fatty acids&quot; and &quot;fish oil&quot;. In addition, manual search and cross references were used to obtain published articles on the subject. Papers showing evidence of pharmacological properties and mechanisms of action were analyzed. For therapeutic efficacy, only randomized clinical trials are presented in this article. All papers were reviewed by a board certified rheumatologist with training in research methodology and critical appraisal skills. He was aware of study objectives. Main results are summarized in the text and presented in tables. Mean change from baseline is presented only for patients treated with omega-3 fatty acids. Omega-3 fatty acids are superior with respect to placebo in improving some outcome measures, and decrease the long-term requirements for nonsteroidal antiinflammatory drugs. Some of these effects are statistically significant, but their clinical significance remain to be established. Treatment with omega-3 fatty acids has been associated with improvement in some outcome measures in rheumatoid arthritis. Studies are needed to determine if they might represent an alternative to nonsteroidal antiinflammatory drugs in certain circumstances.
Painful shoulder syndrome (PSS) is a common problem in rheumatology and physiotherapy. Ultrasound... more Painful shoulder syndrome (PSS) is a common problem in rheumatology and physiotherapy. Ultrasound (US) and transcutaneous electrical nerve stimulation (TENS) have been advocated as potentially useful in pain management but this has not been adequately demonstrated. A randomised clinical trial was designed to compare their effectiveness in a package of treatment for PSS. Thirty patients with untreated PSS were randomly allocated to groups which received either U S to the glenohumeral joint for ten minutes or TENS on the anterior and posterior aspects of the joint for 20 minutes for 13 sessions. All patients performed Codman (pendular) and stretching exercises and received superficial heat treatment. Before-and-after measurements of range of movement and pain were collected and compared. A statistically significant and clinically important improvement in pain and range of flexion was shown for both packages of treatment but no statistically significant difference was found between them. It is concluded that packages of treatment including pendular exercises, superficial heat and either TENS or ultrasound are effective therapeutic alternatives for relief of PSS.
Clinical and laboratory manifestations and outcome of systemic lupus erythematosus (SLE) may vary... more Clinical and laboratory manifestations and outcome of systemic lupus erythematosus (SLE) may vary in different populations. A prospective multinational inception cohort should prove useful in identifying the influence of ethnicity on the clinical characteristics of SLE. We therefore analyzed clinical, laboratory, and prognostic variables in Latin American SLE patients with disease of recent onset who were entered into a prospective cohort, and compared these variables in the cohort's 3 major ethnic groups. Thirty-four centers from 9 Latin American countries participated by randomly incorporating SLE patients within 2 years of diagnosis into a standardized database. Participating centers were selected for their expertise in diagnosing and managing SLE. We were then able to evaluate prospectively socioeconomic variables, ethnicity, type of medical care, clinical and laboratory features, disease activity, damage, and mortality at each site. A coordinating center controlled the quality of the information submitted.
The objectives were to determine causes of consultation, hospitalization and outcome in a cohort ... more The objectives were to determine causes of consultation, hospitalization and outcome in a cohort of lupus patients in an emergency unit. Patients with systemic lupus erythematosus (SLE) who visited the emergency department for consultation from 1 September 1996 to 17 May 1997 were included in the study. They were evaluated during the visit by looking at 100 variables such as demographic, socioeconomic, clinical, therapeutical, behavioral, (compliance), emotional (Beck depression inventory), disease activity, (Mex-SLEDAI), disease severity (Lupus SDI), chronic damage (SLICC-ACR), and physician&#39;s and patient&#39;s global assessments of severity. All causes of consultation, hospitalization and outcome were registered. Descriptive statistics, univariate analysis and multiple logistic regression were used for analysis. Significance was set at the 0.05 level. 180 patients were included. 164 were female, mean age 31.7/11.39 y, mean Mex SLEDAI score 3.8, mean SLICC-ACR 1.3. Fever, poliarthralgia and abdominal pain were the main causes of consultation with 26, 25 and 18 cases each. 49 patients were hospitalized and these were statistically different than non-hospitalized patients in level of formal education (10.2 vs 11.8, P=0.03); compliance (7.6 vs 9, P=0.0001); malar rash (57% vs 82%, OR, 95% CI=0.28, 0.13-0.62, P=0.0008), chloroquine daily dose intake (45 vs 77 mg, P=0.04); disease severity in physician&#39;s global assessments (5.6 vs 2.1, P=0.0001) and Beck depression inventory (21 vs 16, P=0.01). Multiple logistic regression identified physician&#39;s global assessment, fewer ACR criteria and higher SLICC-ACR scores as the main variables associated with hospitalization. Five patients died; two with community acquired pneumonia, one with pancreatitis, multiple thromboses, and sepsis, one with pulmonary hemorrhage; and one with pulmonary thromboembolism. In conclusion, poor compliance, low level of formal education, severity, depression, lower ACR criteria and higher SLICC-ACR scores were important variables identified with hospitalization. Chloroquine use seemed to have a protective effect. Causes of death were related to infections and antiphospholipid syndrome.
a case-control study Factors associated with chronic renal failure in 121 patients with diffuse p... more a case-control study Factors associated with chronic renal failure in 121 patients with diffuse proliferative lupus nephritis:
Antimalarials are very useful drugs in the treatment of various rheumatic diseases. One of their ... more Antimalarials are very useful drugs in the treatment of various rheumatic diseases. One of their main side effects is ocular toxicity, specifically retinopathy. Our objective was to identify risk factors associated with chloroquine retinopathy. A single, trained evaluator reviewed patient records with rheumatic diseases. They were taking chloroquine and identified by the ophthalmology department as having retinopathy during their routine eye evaluation. These cases were classified according to clinical evaluation, visual fields and fluorangiographic study. Up to four controls were selected for each case, matched by age, gender, diagnosis and similar time on chloroquine. In all, 34 variables were studied, among these: weight, age, disease duration, keratopathy, total cumulative dose (TCD), mean daily dose (MDD), lean body weight adjusted daily dose (LBWDD) and laboratory tests. Descriptive and inferential statistics comparing cases and controls in all patients and subgroup analysis were carried out. Significance was set at the 0.05 level. Odds ratio and 95% confidence intervals were calculated. Sixteen cases of chloroquine retinopathy were identified, eight patients with rheumatoid arthritis (RA), seven with systemic lupus erythematosus (SLE) and one with dermatomyositis. All were female. Mean age was 47.3 +/- 12.2 years; weight 59.5 +/- 10.7 kg; disease duration 12.8 +/- 6.0 years; time on chloroquine 54.1 +/- 27.8 (min-max: 30-197) months. There was a significant difference in the following variables in all patients: MDD 212.3 +/- 52.6 versus 170 +/- 51.3, p = 0.009; and LBWDD 5 +/- 1 versus 4.2 +/- 1.5, p = 0.03, for cases and controls, respectively. In subgroup analysis the MDD remained significantly different (235.5 +/- 45.8 versus 169.7 +/- 46.1, p = 0.004) only in RA, whereas LBWDD was different both in SLE and RA. Keratopathy increased the risk for retinopathy: OR, 95% CI: 5, 1.4-17.6, p = 0.01. In conclusion, in accordance with previous studies, the MDD, LBWDD and keratopathy were risk factors associated with chloroquine retinopathy. Periodic ophthalmologic evaluations are mandatory.
To estimate the prevalence, burden of illness, and help-seeking behavior of patients with musculo... more To estimate the prevalence, burden of illness, and help-seeking behavior of patients with musculoskeletal complaints and provide point prevalence estimates of osteoarthritis, low back pain, fibromyalgia, rheumatoid arthritis, gout, and bone fractures not related to trauma among the adult population in a urban community in Havana City. Home survey of adults validated against physical examination. Forty-eight trained family doctors and 3 rheumatologists supervised the interviews and confirmed diagnoses. Family doctors applied a validated Community Oriented Program for the Control of Rheumatic Diseases core questionnaire. A diagnosis using American College of Rheumatology criteria was established. Analysis was based on descriptive statistics and point prevalence estimates with 95% confidence intervals (CIs) of most common diseases and associated disability rate. One thousand two hundred thirty-eight men and 1917 women were included. Prevalence of musculoskeletal pain was estimated in 43.9% (95% CI: 42.2-45.7). The knees were the most affected area (11.7%; 95% CI: 10.6-12) followed by low back pain (11.6%; 95% CI: 10.5-12.8). Point prevalence and 95% CI were as follows: osteoarthritis, 20.4% (95% CI: 19-21.8); gout, 0.38% (95% CI: 0.2-0.6); fibromyalgia, 0.22% (95% CI: 0.09-0.4); systemic lupus erythematosus, 0.06% (95% CI: 0.01-0.25); spondyloarthropathies, 0.19% (95% CI: 0.07-0.4); and rheumatoid arthritis,1.24% (95% CI: 0.8-1.7). Bone fractures not related to trauma were found in 1.14%, hip fracture being the most common (30.5%). Most patients were seen by the general practitioner (65.4%) and 6.2% described some disability. Musculoskeletal pain is highly prevalent in Cuba. Prevalence estimates are similar to those described in other surveys except for rheumatoid arthritis that seems more prevalent in Cuba and fibromyalgia less prevalent.
Treatment of rheumatoid arthritis (RA) has evolved dramatically in the last decade. However, litt... more Treatment of rheumatoid arthritis (RA) has evolved dramatically in the last decade. However, little is known about the way rheumatologists in Latin America treat their patients in clinical practice, outside the scope of clinical trials. The objective of this study was to describe treatment patterns at disease onset in early RA with data from a large, multicenter, multinational inception cohort of Latin American patients. Consecutive patients with early RA (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1 year of disease duration as diagnosed by a rheumatologist) from 46 centers in 14 Latin American countries were enrolled in the study. Clinical data, laboratory assessments, and a detailed registry on type of prescriptions were collected at baseline and at 3, 6, 12, 18, and 24 months of follow-up. Hands and feet x-rays were obtained at baseline and at 12 and 24 months. All data were captured in Arthros 6.1 database. Continuous variables were expressed as means and SDs, and categorical variables were expressed as percentages and 95% confidence intervals (95% CIs). Only therapeutic data at baseline are presented, corresponding to the period between disease onset and second visit (3 months). A total of 1093 patients were included. Eighty-five percent were female, and 76% had a positive rheumatoid factor. Mean age at diagnosis was 46.5 (SD, 14.2) years, and mean disease duration at the first visit was 5.8 (SD, 3.8) months. Between baseline and second visit (3 months), 75% of patients (95% CI, 72%-78%) received disease-modifying antirheumatic drugs. Methotrexate (MTX) alone or in combination was the most frequently used (60.5%), followed by antimalarials (chloroquine or hydroxychloroquine, 32.1%), sulfasalazine (7.1%), and leflunomide (LEF, 4%). In 474 patients (43%), initiation of disease-modifying antirheumatic drugs was within the first month after the first visit. In addition, 290 patients (26%; 95% CI, 23%-29%) received combination therapy as initial treatment. The most frequently used combinations were MTX + chloroquine (45%), MTX + hydroxychloroquine (25%), and MTX + sulfasalazine (16%). Eleven patients (1%; 95% CI, 0.5%-1.8%) received biologics. Sixty-four percent (95% CI, 60%-66%) received corticosteroids. Of those, 80% (95% CI, 77%-84%) received 10 mg of oral prednisone or less. In this cohort of Latin American patients with early RA, most patients received MTX very early in their disease course. Combination therapy was used approximately in 1 of every 4 patients as initial therapy. Biologics were rarely used at this early stage, and low-dose prednisone was commonly used.
The aim of this study was to determine the frequency and potential relevance of the promoter poly... more The aim of this study was to determine the frequency and potential relevance of the promoter polymorphisms of the tumor necrosis factor-alpha (TNF-a) in the severity of rheumatoid arthritis (RA) in Mexicans. HLA-DR and polymorphisms at positions ÿ238 and ÿ308 of TNF-a gene were determined in 137 Mexican RA patients (44 with severe and 93 with non-severe RA) as well as in 169 healthy controls (99 were typed for HLA-DR). We observed an increased frequency of HLA-DR4 in severe RA compared to healthy controls (pC Z 0.02, OR Z 2.33). TNF polymorphism analysis showed a significant increased frequency of TNF ÿ238 GG genotype in the whole group of RA patients when compared to healthy controls (pC Z 0.007, OR Z 4.71). When the analyses were carried out separately in severe and non-severe RA patients, the increased frequency of ÿ238 GG genotype only was observed in patients with non-severe forms of the disease. Analysis of ÿ308 polymorphism showed increased frequency of ÿ308 T2 (A) allele in severe RA when compared to non-severe disease (pC Z 0.011, OR Z 3.29) and to healthy controls (pC Z 0.002, OR Z 3.97). The data demonstrate that ÿ308 T2 (A) allele is associated with susceptibility to develop severe RA in Mexicans. This association could be independent from HLA-DR alleles and might be used as a prognostic marker for severe RA.
To evaluate the role of tumor necrosis factor-␣ (TNF-␣) gene as susceptibility marker for spondyl... more To evaluate the role of tumor necrosis factor-␣ (TNF-␣) gene as susceptibility marker for spondyloarthritis (SpA), two polymorphisms (Ϫ238 and Ϫ308 positions) were analyzed in 229 patients with SpA (113 with ankylosing spondylitis [AS], 92 with undifferentiated SpA [U-SpA], 24 with reactive arthritis), and 169 ethnically matched healthy control subjects. The HLA-B alleles were detected by PCR-SSP technique and the TNF-␣ polymorphism by PCR-RFLP. In comparison with healthy control subjects, the frequencies of TNF-238 in SpA were similar. In contrast, the analysis of Ϫ308 polymorphism showed increased frequencies of the T2(A) allele in the whole SpA group (p Ͻ 0.05, pC ϭ NS, OR ϭ 1.83) as well as the T2(A) allele (pC Ͻ 0.05, OR ϭ 2.4) and T1T2(AG) genotype (p Ͻ 0.05, pC ϭ NS, OR ϭ 2.25) in U-SpA patients. Comparison of B27-negative patients and healthy control subjects yielded similar results. There was no significant correlation between TNF genotypes and clinical data. The present study demonstrates that TNF-␣ Ϫ308 polymorphism appears to be associated with the genetic susceptibility U-SpA. The association seems independent of the susceptibility conferred by the HLA-B27 in this group of patients. Human Immunology 67, 826 -832 (2006).
GLADAR (Grupo Latino Americano de Estudio de Artritis Reumatoide) is a large group of Latin Ameri... more GLADAR (Grupo Latino Americano de Estudio de Artritis Reumatoide) is a large group of Latin American (LA) rheumatologists experienced in the diagnosis and treatment of RA. In 2006, PANLAR and GLADAR published the first LA position paper on the pharmacological treatment of RA [1]. Since then, new therapies have emerged to help achieve the ultimate goal to preserve the patient&amp;amp;#x27;s ability to function independently with an optimal quality of life.
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 2009
A consensus meeting of representatives of 18 Latin-American and Caribbean countries gathered in R... more A consensus meeting of representatives of 18 Latin-American and Caribbean countries gathered in Reñaca, Chile, for 2 days to identify problems and provide recommendations for the care of patients with rheumatoid arthritis (RA) in Latin America, a region where poverty and other health priorities make the efforts to provide effective and high quality care difficult. This report includes recommendations for health professionals, patients, and health authorities in Latin America, with an emphasis on education and therapeutic issues.
To conduct a systematic review to identify and describe the scope and nature of the research evid... more To conduct a systematic review to identify and describe the scope and nature of the research evidence on the effectiveness of interventions to improve health care quality or reduce disparities in the care of disadvantaged populations with osteoarthritis (OA) as an example of a common chronic disease.
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