An international study on starting tumour necrosis factor-blocking agents in ankylosing spondylitis

OBJECTIVES

To determine the type and proportion of patients with ankylosing spondylitis who rheumatologists consider to be candidates for treatment with tumour necrosis factor (TNF)-blocking agents, and to what extent this is in agreement with the ASsessment in Ankylosing Spondylitis (ASAS) international working group recommendations on initiation of treatment with anti-TNF agents.

METHODS

Participants were rheumatologists from 10 different countries, who were considered to be experts in treating patients with ankylosing spondylitis and in the use of anti-TNF treatment, but were unaware of the ASAS recommendations (unpublished at the time of study in 2003). The first 10 consecutive patients with ankylosing spondylitis seen by the rheumatologist were evaluated as to whether the patient was a candidate for anti-TNF treatment. Thereafter, a metrologist assessed the patient for disease activity and severity, and collected data on demographics and treatment.

RESULTS

Complete data were available for 1207 of the 1284 patients and were used for analysis. Overall, the rheumatologists indicated that they would initiate TNF-blocking agents in 49.3% of patients, ranging from 37.2% patients in Canada to 78.3% in Australia. These candidates had higher disease activity, higher levels of acute-phase reactants, worse spinal mobility, worse function, more often hip involvement and a higher prevalence of sick leave. Of all patients considered to be candidates, 40% did not fulfil ASAS recommendations with respect to previous use of non-steroidal anti-inflammatory drugs (NSAIDs; at least two NSAIDs) or Bath Ankylosing Spondylitis Disease Activity Index (>or=4). Conversely, 36% of patients who did not fulfil the NSAID or BASDAI recommendations were still considered to be candidates for TNF-blocking treatment.

OBJECTIVE

variables, such as C reactive protein, erythrocyte sedimentation rate or magnetic resonance activity, were considered less important than disease activity in the decision on starting TNF-blocking drugs. The only important objective criterion was rapid radiographic progression.

CONCLUSION

Rheumatologists wanted to initiate TNF-blocking drugs in roughly half of the patients with ankylosing spondylitis. However, there was a wide variation across countries and doctors. Rheumatologists considered both disease activity and severity to be determinants of starting TNF blockers, but their decision was often in disagreement with ASAS recommendations.

Tumor Necrosis Factor-α Promoter Polymorphisms in Mexican Patients With Spondyloarthritis

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 data. The present study demonstrates that TNF-alpha -308 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.

Health-related quality of life of patients with juvenile idiopathic arthritis coming from 3 different geographic areas. The PRINTO multinational quality of life cohort study

OBJECTIVES

To compare health-related quality of life (HRQL) and to identify clinical determinants for poor HRQL of patients with juvenile idiopathic arthritis (JIA) coming from three geographic areas.

METHODS

The HRQL was assessed through the Child Health Questionnaire (CHQ). A total of 30 countries were included grouped in three geographic areas: 16 countries in Western Europe; 10 in Eastern Europe; and four in Latin America. Potential determinants of poor HRQL included demographic data, physician's and parent's global assessments, measures of joint inflammation, disability as measured by Childhood Health Assessment Questionnaire (CHAQ) and erythrocyte sedimentation rate. Poor HRQL was defined as a CHQ physical summary score (PhS) or psychosocial summary score (PsS) <2 S.D. from that of healthy children.

RESULTS

A total of 3167 patients with JIA, younger than 18 yrs, were included in this study. The most affected health concepts (<2 S.D. from healthy children) that differentiate the three geographic areas include physical functioning, bodily pain/discomfort, global health, general health perception, change in health with respect to the previous year, self-esteem and family cohesion. Determinants for poor HRQL were similar across geographic areas with physical well-being mostly affected by the level of disability while the psychosocial well-being by the intensity of pain.

CONCLUSION

We found that patients with JIA have a significant impairment of their HRQL compared with healthy peers, particularly in the physical domain. Disability and pain are the most important determinants of physical and psychosocial well-being irrespective of the geographic area of origin.

Molecular analysis of the SLC22A12 (URAT1) gene in patients with primary gout

OBJECTIVE

To analyse the SLC22A12 (URAT1) gene in primary gout patients, first-grade relatives and healthy controls and the possible association of them with demographic and clinical data.

SUBJECTS AND METHODS

We included 69 consecutive patients with diagnosis of primary gout, as well as 29 first-grade relatives and 120 healthy volunteers. Demographic and clinical data were obtained from the patients and relatives. DNA was purified from peripheral blood and all 10 exons of the SLC22A12 (URAT1) gene were sequenced.

RESULTS

We found six different mutations in the SLC22A12 gene in 16 out of 69 (23%) patients with primary gout. Five mutations were in exon 5 and one in exon 4; five out of six mutations were heterozygous (one compound heterozygous) and one homozygous. The C850G mutation (exon 5) was found in 11 gout patients, these patients have lower levels of triglycerides than the rest of the group: 160 +/- 56 vs 292 +/- 203 mg/dl (P = 0.038). In one family, we found SLC22A12 mutations in three relatives within exon 5. We did not find mutations in the other exons studied (1-3 and 6-10), nor in any of the 10 exons of the 120 healthy volunteers.

CONCLUSIONS

We found several mutations in SLC22A12 gene associated with primary gout, the definite role of these mutations in URAT1 activity needs to be further studied.

Severe tophaceous gout. Characterization of low socioeconomic level patients from México

OBJECTIVE

To describe a group of patients with frequent tophaceous gout, the variables associated with severe tophaceous gout and to compare them with other patients with gout described elsewhere.

METHODS

We looked for 65 demographic clinical and paraclinical variables from patients with gout who attended our gout clinic from 1995-2000 and were evaluated by the same group of physicians.

RESULTS

Three hundred and sixteen patients were included, 98% males, 82% live in México city, the mean age at onset, educational level and disease duration were 37.5 +/- 12.4, 6.3 +/- 3.9 and 12.6 +/- 10.3 years respectively. Tophaceous gout was present in 62% of the patients with a mean tophi number of 4.7 +/- 6.3 and mean HAQ score 0.13 +/- 0.37. Severe tophaceous gout (>or= 5 tophi) was found in 34% and these patients had significantly: earlier age at onset, longer duration of the disease, lesser frequency of obesity and higher frequency of: intradermal tophi, HAQ > 0.5, hospitalizations, radiographic score III/IV, uric acid under-excretion, renal function impairment and previous (oral and parenteral) auto-prescribed chronic glucocorticoid treatment compared with patients with non-severe tophaceous gout. In the multiple logistic regression the significant variables were renal function impairment (p = 0.000) and previous chronic parenteral glucocorticoid treatment (p = 0.011) .

CONCLUSION

Our patients compared with those from other countries who have earlier age at onset, very low frequency of gout among females, frequent tophaceous gout and severe tophaceous gout. Severe tophaceous gout in this group is associated with renal function impairment and previous chronic parenteral glucocorticoid treatment.

Illness trajectories in Mexican children with juvenile idiopathic arthritis and their parents

BACKGROUND

We hypothesize that the qualitative approach of socio-cultural aspects in children with juvenile idiopathic arthritis (JIA) and their parents would improve the understanding of their illness.

OBJECTIVE

To explain the phenomenon of experiencing JIA within a specific cultural context.

METHODS

The theoretical position of this research was based on the substantive theories of suffering, explanatory models and illness experience. Its design was that of qualitative field, and its analysis followed the interpretative grounded theory methodology. Data were collected by in-depth interviews and notes; tape recordings were transcribed verbatim, read and imported into the ATLAS/ti 4.2 software. Data conceptualization, categorization and interpretation were based on the constant comparison method.

RESULTS

A total of 16 adults and six children from 10 families were interviewed. 'Pilgrimage' (metaphorically referred by some of the parents) was a major code in the study that reflected the religious reference to the trajectory of pain, faith and hope. For children, pilgrimage was conformed by immediate concepts; for parents, by historical and immediate experiences influenced by JIA subtype. Pilgrimage was consistent with the model of the illness trajectory theory, which conceptually relates to the idea that the course of chronic diseases is variable and modifiable throughout time.

CONCLUSION

The qualitative approach of JIA provides wide and deep information on the perception that children and parents have about the disease. The illness trajectory theory corresponds to pilgrimage, the theoretical model for JIA in this study.

A proposal for a pediatric version of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index based on the analysis of 1,015 patients with juvenile-onset systemic lupus erythematosus

OBJECTIVE

To devise a modified version of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) for use in children and adolescents with systemic lupus erythematosus (SLE), based on the frequency and distribution of damage in patients with juvenile-onset SLE and the sources of damage that are most suitable for inclusion in a pediatric damage index.

METHODS

In this cross-sectional study, damage was assessed through the SDI. Clinical assessments included evaluation of growth failure and delayed puberty, which were believed to be important sources of damage that are not incorporated in the SDI but should be included in a pediatric version of the instrument.

RESULTS

A total of 1,015 patients with juvenile-onset SLE in 39 countries were enrolled in the study. Of these, 405 patients (39.9%) had an SDI score of > or =1 (mean +/- SD score 0.8 +/- 1.4). Renal damage (13%), neuropsychiatric damage (10.7%), and musculoskeletal damage (10.7%) were observed most frequently, followed by ocular damage (8.2%) and skin damage (7.6%). Growth failure and delayed puberty were recorded in 15.3% and 11.3% of patients, respectively. A pediatric version of the SDI was devised, with inclusion of growth failure and delayed puberty as new domains.

CONCLUSION

We propose a modified version of the SDI for use in patients with juvenile-onset SLE. This new instrument warrants prospective validation in other populations of patients seen in different clinical or research settings.

Low grade radiographic sacroiliitis as prognostic factor in patients with undifferentiated spondyloarthritis fulfilling diagnostic criteria for ankylosing spondylitis throughout follow up

OBJECTIVE

To determine the rate and factors associated with ankylosing spondylitis in a cohort of patients with undifferentiated spondyloarthritides (SpA).

METHODS

62 consecutive patients with undifferentiated SpA seen between 1998 and 1999 underwent clinical and imaging evaluations throughout follow up. The main outcome measure was a diagnosis of ankylosing spondylitis.

RESULTS

50 patients with peripheral arthritis (n = 35) and inflammatory back pain (n = 24) (26 male; mean (SD) age at onset, 20.4 (8.8) years; disease duration 5.4 (5.7) years) were followed up for 3-5 years. At baseline, >90% of patients had axial and peripheral disease, while 38% had radiographic sacroiliitis below the cut off level for a diagnosis of ankylosing spondylitis (BASDAI 3.9, BASFI 2.9). At the most recent evaluation, 21 patients (42%) had ankylosing spondylitis. Two factors were associated with a diagnosis of ankylosing spondylitis in multivariate analysis: radiographic sacroiliitis grade <2 bilateral, or grade <3 unilateral (odds ratio (OR) = 11.18 (95% confidence interval, 2.59 to 48.16), p = 0.001), particularly grade 1 bilateral (OR = 12.58 (1.33 to 119.09), p = 0.027), and previous uveitis (OR = 19.25 (1.72 to 214.39), p = 0.001). Acute phase reactant levels, juvenile onset, and HLA-B27 showed a trend to linkage with ankylosing spondylitis (NS).

CONCLUSIONS

Low grade radiographic sacroiliitis is a prognostic factor for ankylosing spondylitis in patients originally classified as having undifferentiated SpA. Low grade radiographic sacroiliitis should be regarded as indicative of early ankylosing spondylitis in patients with undifferentiated SpA.

HLA antigens and juvenile onset spondyloarthritides: negative association with non-B27 alleles

OBJECTIVE

To describe the association between HLA-B and HLA-DR genes and juvenile onset spondyloarthritides (SpA) in Mexicans.

METHODS

The study included 66 consecutive patients with SpA (45 with ankylosing spondylitis (AS) and 21 with undifferentiated SpA) and 99 non-related healthy controls. The HLA-A, -B and DR alleles were detected by the polymerase chain reaction with the sequence-specific primers technique. Statistical methods included the Mantel-Haenzel chi2 test, Fisher's exact test, and Woolf method for odds ratio (OR).

RESULTS

The frequency of HLA-B27 was significantly increased in the whole group (pC < 10(-3), OR = 53.0, aetiological fraction = 51%), particularly in AS (pC < 10(-3), OR = 67.42, aetiological fraction 57%). In contrast, the frequencies of HLA-B44, and HLA-B14 were significantly decreased. Also, a weak negative association HLA-DR5 (p < 0.05) was found.

CONCLUSION

Apart from an expected significant association between HLA-B27 and juvenile-onset SpA, particularly AS, we found negative associations with HLA-B44, B14, and DR5. There was also a trend for HLA-B15 and DR1 associations with SpA.

ASAS/EULAR recommendations for the management of ankylosing spondylitis

OBJECTIVE

To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the 'ASsessment in AS' international working group and the European League Against Rheumatism.

METHODS

Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise.

RESULTS

The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I-IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion.

CONCLUSION

Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.

CD4 and CD8 T cell response to the rHSP60 from Klebsiella pneumoniae in peripheral blood mononuclear cells from patients with ankylosing spondylitis

OBJECTIVE

To determine the processing pathways used by peripheral blood mononuclear cells (PBMC) and present the rHSP60Kp, and the T cell subpopulations involved in the response, in patients with ankylosing spondylitis (AS) METHODS: The lymphoproliferative response to the rHSP60Kp in PBMC from 14 HLA-B27+ AS patients and 15 B27- healthy controls was assessed by 3H-TdR incorporation. The processing pathways for the rHSP60Kp were analyzed by 3H-TdR incorporation in fresh PBMC from patients using homologous PBMC preincubated with the antigen and specific inhibitors: chloroquine, N-acetyl-L-leucil-L-leucil-L-nor-leucinal (LLnL) or brefeldin A (BFA), fixed with p-formaldehyde (fixed APC). The CD4+/CD8+ T cell subpopulation activated with the antigen was determined by three colours flow cytometry in PBMC from patients.

RESULTS

Eight out of fourteen patients showed positive lymphoproliferative responses to the rHSP60Kp while none of the healthy controls responded (p < 0.012). In five patients S.I. was above 4.0. In these patients lymphoproliferation was lower when chloroquine and LLnL was used and it became negative with BFA, indicating that both pathways are used. CD4+ and CD8+ T cells populations expressed CD69 when activated by the rHSP60Kp.

CONCLUSIONS

Our results suggest that CD4 and CD8 T cells participate in the response to the rHSP60Kp in B27+ AS patients.

Pharmacokinetics of meloxicam in patients with juvenile rheumatoid arthritis

The pharmacokinetics of a meloxicam suspension were studied in 18 children with juvenile rheumatoid arthritis. Children received a single 0.25-mg/kg dose up to a maximum of 15 mg. Pharmacokinetic parameters after the first dose were calculated by noncompartmental methods. Geometric mean (percent coefficient of variation for geometric mean [gCV]) C(max), AUC(0- infinity ), apparent clearance, apparent volume of distribution, and elimination half-life values were 1.24 microg/mL (47% gCV), 25.6 microg x h/mL (81% gCV), 0.17 mL/min/kg (83% gCV), 0.19 L/kg (63% gCV), and 13.4 hours (54% gCV) in the younger group and 1.89 microg/mL (25% gCV), 35.8 microg x h/mL (21% gCV), 0.12 mL/min/kg (23% gCV), 0.13 L/kg (22% gCV), and 12.7 hours (21% gCV) for the older group, respectively. Area under the curve, volume of distribution, and clearance tended to be higher in the younger group, whereas elimination half-lives were similar. A post hoc comparison to pharmacokinetic data in adults revealed no relevant differences. Thus, a common body weight-normalized dose is considered appropriate for children older than 2 years.

Association study of LMP gene polymorphisms in Mexican patients with spondyloarthritis

To evaluate the role of LMP (low molecular weight protein) genes as susceptibility markers for spondyloarthritis (SpA), LMP gene polymorphisms were analyzed in 223 Mexican patients with SpA (81 undifferentiated SpA [U-SpA], 117 with ankylosing spondylitis [AS], 25 with reactive arthritis) and in 139 ethnically matched healthy individuals. LMP genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism. The LMP2 and LMP7 allele frequencies were similar in patients and healthy controls. Genotype analysis revealed an increased frequency of LMP2 R/R genotype in the whole group of SpA (pC = 0.003, OR = 2.06, 95%CI = 1.3-3.25) and in the clinical subgroups of AS (pC = 0.039, OR = 1.88, 95%CI = 1.1-3.22) and U-SpA (pC = 0.003, OR = 2.56, 95%CI = 1.37-4.8) compared with healthy controls. Analysis in the LMP7 did not reveal significant differences in patients and healthy controls. The HLA-B27-negative AS subgroup also showed an increased frequency of LMP2 R/R genotype (pC = 0.027, OR = 4.81, 95%CI = 1.21-22.13). The LMP2-R/R AS patients were younger than LMP2-H/R and H/H patients at onset of the disease (16.0 +/- 6.8 years for R/R, 22.0 +/- 11.2 years for H/R and 28.6 +/- 10.9 years for H/H) (p < 0.05). The data suggest that, besides HLA-B27, LMP2 genotypes are also involved in the genetic susceptibility to develop AS in Mexicans. Furthermore, the age at onset of this disease might also be influenced by genotypes of this gene.

Relationship between disease activity and infection in patients with spondyloarthropathies

OBJECTIVE

To assess the relationship between disease activity and signs and symptoms of infection in Mexican patients with spondyloarthropathies (SpA).

METHODS

A cross sectional study of 95 non-selected patients with SpA (62 men; mean age 26.4 years), who were examined for signs and symptoms of infection and their association with disease activity. 52 had ankylosing spondylitis (AS), 32 undifferentiated SpA (uSpA), 6 chronic reactive arthritis (ReA), and 5 psoriatic arthritis (PsA). Categorical data were analysed by chi(2) or Fisher's tests.

RESULTS

53 (56%) patients had infections: 41 (43%) upper respiratory tract (URT), 34 (36%) enteric, and 20 (21%) genitourinary infections. More infections occurred in HLA-B27 positive patients as a whole (39 v 5; p = 0.003) and in uSpA (12 v 2; p = 0.005). In AS and uSpA, infections occurred in approximately 50%. 30/39 (77%) patients with active disease (group A) and 23/56 (41%) (group B) (p = 0.001) had infection. There were more enteric infections in group A (47%; p<0.001) and more URT infections in group B (52%; p = NS). 22/30 (73%) patients attributed disease activity to infection.

CONCLUSION

Enteric, and less commonly, URT infections in Mexican patients with SpA, particularly those who were HLA-B27 positive, seem to have a role in the active phase of AS and uSpA.

Metabolic Syndrome and Ischemic Heart Disease in Gout

BACKGROUND

For decades, gout has been associated with several metabolic abnormalities and with ischemic heart disease (IHD).

OBJECTIVE

Our aim was to determine the prevalence of metabolic syndrome by Adult Treatment Panel III criteria (ATP III) and ischemic heart disease (IHD) by electrocardiogram (EKG) and/or single photon emission computed tomography (SPECT) in patients with gout.

METHODS

We included 64 consecutive outpatients with primary gout, but no history of IHD, attending our clinic for the first time. Demographic and clinical data were recorded and resting electrocardiogram, lipid profile, fasting insulin, and SPECT with Tc sestamibi were performed. Metabolic syndrome was defined according to ATP III criteria (> or =3 of the following data: 1) hyperglycemia (fasting glucose > or =110 mg/dL) or previous diagnosis of diabetes mellitus, 2) hypertension (> or =130/85 mm Hg) or previous diagnosis, 3) high-density lipoprotein (HDL) <40 mg/dL (men) or <50 mg/dL (women), 4) triglycerides > or =150 mg/dL, and 5) obesity.

RESULTS

IHD was diagnosed in 10 patients (16%); 2 had EKG changes compatible with previous silent myocardial necrosis and the other 8 had abnormal SPECT. The prevalence of metabolic syndrome was 82%, all patients had at least 1 metabolic abnormality, but all the patients with IHD had metabolic syndrome (3 criteria according with ATP III). Patients with IHD differed from those without IHD in the percentage of HDL levels <40 mg/dL (100% vs. 82%; P = 0.05) as well as glucose and insulin levels in the fasting state (129.3 +/- 6.1 mg/dL vs. 92.7 +/- 16.7 mg/dL; P = 0.000; and 21.1 +/- 6.0 vs. 17.5 +/- 8.6 UI/mL; P = 0.03) and low-density lipoproteins (143.9 +/- 21.3 mg/dL vs. 118.2 +/- 47.7 mg/dL; P = 0.014). In contrast, serum creatinine and urea (1.02 +/- 0.13 mg/dL vs. 1.5 +/- 1.5 mg/dL; P = 0.024; and 33.9 +/- 9.3 mg/dL vs. 48.7 +/- 46.1 mg/dL; P = 0.039) and creatinine clearance <50 mL/min (10% vs. 37%; P = 0.06) were higher in patients without IHD.

CONCLUSIONS

In this work, metabolic syndrome was very common among patients with gout. Sixteen percent of the patients, although previously asymptomatic, had IHD, they all had metabolic syndrome. Gouty patients frequently first seek medical care from a rheumatologist. The rheumatologist can have an important role in detecting metabolic syndrome and risk factors for cardiovascular disease.

Primary prevention in rheumatology: the importance of hyperuricemia

Hyperuricemia (HU) is present in 5-30% of the general population, although the prevalence is higher among some ethnic groups and seems to be increasing worldwide. Classically, chronic HU has been considered a risk factor for gout or lithiasis and is associated with alcoholism, obesity, hypertension, dyslipidemia, hyperglycemia/diabetes mellitus, renal failure and intake of certain drugs. HU is also associated with cardiovascular diseases such as hypertension, vascular disease, pre-eclampsia, pulmonary arterial hypertension, stroke, heart failure, ischemic heart disease and also metabolic syndrome, renal disease and increased mortality. It is uncertain if these associations are dependent or not, especially cardiovascular and renal diseases. Patients with chronic HU and also those with gout require both medical investigation for associated diseases or drugs as well as nutritional counseling and life-style changes. HU should alert physicians to possible complications.

[Diagnosis and treatment of gout in Mexico City. Results from a physicians survey]

The diagnosis and proper treatment for gout were described decades ago but these guides are not always realized in all the patients.

OBJECTIVES

To evaluate by a mail survey sent to general physicians (GP), internal medicine physicians (IM), orthopedists (OP) and rheumatologists (RP) from Mexico city, the way they diagnose and treat gouty patients.

SUBJECTS AND METHODS

The survey was anonymous and included 20 questions, it was sent by mail to 1,836 physicians (640 GP, 640 OP, 423 IM and 133 RP) living in Mexico city.

RESULTS

The response was 6.8% OP, 10.4% IM, 10.8% GP and 41.4% RP. Eighty two to 95% of them attend gouty patients. Diclofenac was the drug most frequently used as the treatment for acute attacks, although a high frequency of glucocorticoids and allopurinol prescription for acute gout attacks was detected (28% OP and 49% GP respectively). Allopurinol is the drug more frequently used for the chronic treatment, it is also used for asymptomatic hyperuricemia by 43-84% of the physicians. Twenty five percent do not adjust initial allopurinol doses to glomerular filtration rate. The prophylactic treatment is used in only some cases and the dietetic restrictions were variable. Some points regarding the treatment of these patients are not according those recommended in the literature.

CONCLUSIONS

We need to increase the knowledge between physicians about gout diagnosis and proper treatment. The adequate treatment is in most of the cases safe, cheap and effective.

Translation, cross-cultural adaptation, and validation of the Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Dougados Functional Index (DFI) in a Spanish speaking population with spondyloarthropathies

OBJECTIVES

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI) and the Dougados Functional Index (DFI) are the most commonly used instruments to measure disease activity and functioning in ankylosing spondylitis (AS). The aim of this study was to translate, adapt and validate these instruments into the Spanish language.

METHODS

The BASDAI, BASFI, and DFI questionnaires were translated into Spanish by three independent bilingual physicians who were familiar with the medical aspects of AS and by one professional translator. Two rheumatologists familiar with instrument validation, and who were aware of the purpose of the study, examined semantic, idiomatic and conceptual issues and produced by consensus unified versions of each instrument. English back-translations from the Spanish were done by a professional translator unaware of the original version. Both English versions were compared, and where needed, modifications to the Spanish versions were made. The Spanish versions were administered to 61 ambulatory patients with AS and to 80 patients with undifferentiated spondyloarthropathy for validation purposes. Reliability and responsiveness were measured in 28 patients participating in a physiotherapy program.

RESULTS

Reliability showed an acceptable 24-hour test-retest intraclass correlation coefficient (ICC)--BASFI ICC: 0.68, 95% CI: 0.29-0.85; BASDAI ICC: 0.74, 95% CI: 0.52-0.88 and DFI ICC: 0.87, 95% CI: 0.73-0.94. The construct validity of the instruments was evaluated, and BASDAI was correlated with disease activity measured by the total enthesis count (rs: 0.34); general well being in the last week (rs: 0.7); spinal pain (rs: 0.53) and duration of morning stiffness (rs: 0.64). BASFI correlated with Schöber's test (rs: -0.4); occipital-wall distance (rs: 0.38) and thoracic expansion (rs: -0.3). DFI correlated with Schöber's test (rs: -0.36); occipital-wall distance (rs: 0.29) and chest expansion (rs: -0.3). The correlation among DFI and BASFI was rs: 0.83. All instruments showed clinical responsiveness in the physiotherapy program (baseline and end of program; mean +/- SD): BASDAI: 6.25 +/- 1.97 and 3.07 +/- 2.04 (p = 0.0001); BASFI: 5.68 +/- 2.29 and 2.88 +/- 1.77 (p = 0.0001); DFI: 16 +/- 7.6 and 8.0 +/- 5.5 (p = 0.001) with effect sizes and standardized effect sizes > 1.

CONCLUSIONS

The Mexican Spanish versions of the BASDAI, BASFI, and DFI showed adequate reliability, validity and responsiveness to clinical change. These instruments can be used in the clinical evaluation of Spanish-speaking patients with AS.

IgG antibodies to enterobacteria 60 kDa heat shock proteins in the sera of HLA-B27 positive ankylosing spondylitis patients

OBJECTIVE

To study the association of HLA-B27 and the IgG response to the 60 kDa HSPs of Klebsiella pneumoniae, Yersinia enterocolitica, Shigella flexneri, Escherichia coli and Salmonella typhi.

METHODS

IgG against the 60 kDa HSPs of enterobacteria was determined by ELISA in the sera from 49 HLA-B27+ ankylosing spondylitis (AS) patients; 41 HLA-B27+ healthy relatives of AS patients and 101 HLA-B27-unrelated healthy individuals.

RESULTS

HLA-B27+ patients and healthy individuals, showed significantly higher IgG antibody levels to the Klebsiella, Yersinia and Salmonella HSPs than HLA-B27- healthy controls. B27+ patients had a significantly higher response to E. coli HSP than the two other groups. IgG response anti-Shigella HSP was similar in the three groups.

CONCLUSIONS

There is a relationship between HLA-B27 and the response to HSPs 60 from Klebsiella, Yersinia, Escherichia and Salmonella, that may be important in the initiation of AS.

Juvenile onset spondyloarthropathies: therapeutic aspects

Juvenile onset spondyloarthropathy (SpA) is a term that refers to a group of human leucocyte antigen (HLA)-B27 associated inflammatory disorders affecting children under the age of 16 years, producing a continuum of clinical symptoms through adulthood. This disease is characterised by enthesopathy and arthropathy affecting the joints of the lower extremities and seronegativity for IgM rheumatoid factor and antinuclear antibodies. Children usually present with undifferentiated SpA and progress to differentiated forms over time. Except for the prevalence of some clinical features at onset, the pathogenic and clinical aspects of juvenile onset SpAs resemble those of the adult disease. Thus application of the same or similar therapeutic measures for both juvenile and adult onset SpAs seems logical. Current treatments for juvenile onset SpA provide symptomatic improvement, but do not alter disease progression. The increased expression of tumour necrosis factor alpha (TNFalpha) in synovial tissue of patients with adult and juvenile onset SpA and its correlation with infiltration of inflammatory mediators into the synovia suggest a significant pathogenic role of this cytokine. Clinical trials of anti-TNFalpha antibody (infliximab) therapy in patients with adult onset SpA have demonstrated significant clinical improvement in inflammatory pain, function, disease activity, and quality of life in correlation with histological and immunohistochemical evidence of modulation of synovial inflammatory processes. These promising findings suggest that anti-TNFalpha therapy may confer similar benefits in patients with juvenile onset SpA.

TNF-alpha antagonists for the treatment of juvenile-onset spondyloarthritides

Juvenile-onset spondyloarthritides (SpA) is a term for a group of HLA-B27 related disorders. The hallmark signs and symptoms of this group of disorders include peripheral arthritis and enthesitis while sacroiliitis and spondylitis develop in some cases later on and extrarticular manifestations such as anterior uveitis occurs occasionally. Conventional medical therapy in children consists of non-steroidal anti-inflammatory drugs and corticosteroids that are administered intraarticulary, even in the sacroiliac joints. Sulfasalazine and methotrexate are given in cases of chronic synovitis or enthesitis. Unfortunately, these forms of therapy have limited efficacy in many cases and disease activity and damage may lead to various degrees of functional impairment. Recently, experience with TNFalpha-antagonists in adults has opened new perspectives for treating patients with refractory SpA, particularly ankylosing spondylitis (AS). So far there is only little experience in the treatment of juvenile-onset SpA, consisting of case reports and case series where etanercept or infliximab have been given to children suffering from refractory juvenile-onset AS and psoriatic arthritis. From these observations there is evidence that treatment seems to be as effective as in adults. Risks are likely to be the same as in patients suffering from other forms of juvenile idiopathic arthritides. However, without further studies no recommendations can be provided for indication for treatment, dosing, intervals and duration of treatment.

A short-term follow-up of enthesitis and arthritis in the active phase of juvenile onset spondyloarthropathies

OBJECTIVE

To describe the characteristics of enthesitis and arthritis in the active inflammatory stage of juvenile onset spondyloarthropathies (SpA) during a short-term follow-up.

PATIENTS AND METHODS

The study group included data of 33 patients with juvenile-onset SpA with enthesitis in > or = 3 sites, arthritis in > or = 4 joints, and erythrocyte sedimentation rate (ESR) of > or = 25 mm/h despite treatment, who participated in a 26-week, double-blind, sulfasalazine versus placebo trial that showed no significant differences between groups in regard to enthesitis and arthritis.

RESULTS

Twenty-seven boys and 6 girls (mean age: 15.3 +/- 3.5 years; mean disease duration: 4.1 +/- 2.7 years) with the seronegative enthesopathy and arthropathy (SEA) syndrome (n = 20) or ankylosing spondylitis (AS; n = 13) comprised the group. Throughout the study, the mean (+/- SD) number of swollen joints and tender entheses were 4.6 +/- 2.5 and 8.3 +/- 5.4. The entheses and joints most frequently involved were the calcaneal attachments of the plantar fascia (87.9%) and Achilles tendon (81.8%) and the ankle (87.9%) and knee (72.7%), respectively. There was pain in the cervical, thoracic, and lumbar spine in 39.4%, 69.7%, and 63.6% of patients and in the sacroiliac joints in 48.5%. Mid-foot involvement (or tarsitis) occurred in 29 patients (87.9%). Except for the feet, the simultaneous occurrence of enthesitis and arthritis in other sites was rare. Overall, there were no significant differences between SEA syndrome and AS patients.

CONCLUSIONS

Disease activity shows a significant trend for entheses and joints of the feet and a significant prevalence of axial enthesitis in juvenile onset SpA. Mid-foot involvement appears to be the most characteristic and potentially, the most severe form of disease in these patients.

The juvenile-onset spondyloarthritides: rationale for clinical evaluation

This chapter reviews the clinical events that occur in patients with juvenile-onset spondyloarthritides (SpA) with the purpose of developing core sets, domains and instruments to evaluate disease activity and disease damage. We discuss several aspects, from concept and classification to clinical features and instruments already in use for measuring adult-onset SpA and childhood arthritides. Similarly, comparisons between juvenile-onset SpA, its adult counterpart, and other forms of juvenile arthritis are made to consider the adaptation of existing instruments or to develop specific ones.

Effect of HLA-B and HLA-DR genes on susceptibility to and severity of spondyloarthropathies in Mexican patients

OBJECTIVE

To investigate the role of HLA-B and HLA-DR genes as contributors to genetic susceptibility and clinical expression of the spondyloarthropathies (SpA) in the Mexican population.

METHODS

The study included 172 patients with SpA (undifferentiated SpA 83, ankylosing spondylitis (AS) 64, and reactive arthritis 25) and 99 healthy controls. The HLA-B and HLA-DR alleles were detected by the polymerase chain reaction with sequence-specific primers technique. Patient assessment included demographic data, diagnostic categories, and disease patterns. Statistical methods included the Mantel-Haenzel chi(2) test, Fisher's exact test, and Woolf method for odds ratio (OR). Differences of continuous variables between HLA allele groups were calculated by Student's t test.

RESULTS

Increased frequencies of HLA-B27 (pCh10(-3), OR=28.7), HLA-DR1 (pC=0.045, OR=2.77), and HLA-B15 (p=0.034, pC=NS, OR=2.04) alleles in the whole group were found. HLA-B27 strength of association (OR) was 41.4 in AS; 20.9 in undifferentiated SpA; 27.2 in reactive arthritis. HLA-DR1 and HLA-B15 were increased in undifferentiated SpA (pC=0.045, OR=2.98 and p=0.004, pC=NS, OR=2.75). By analysing 58 HLA-B27 negative patients it was found that HLA-B15 and HLA-DR1 associations with SpA were independent of HLA-B27; increased frequencies of HLA-B15 were found in the whole SpA group and in patients with undifferentiated SpA (pC=0.03, OR=3.09 and pCh0.01, OR=3.77) and of HLA-DR1 in the latter (p=0.04, pC=NS, OR=3.15). HLA-B27 positive patients were younger than HLA-B27 negative patients at onset (p=0.03), but HLA-DR1 positive patients were older than HLA-DR1 negative patients (p=0.03). Bath indices for disease activity and functioning were higher in HLA-B27 positive patients (p=0.006 and p=0.004 v HLA-B27 negative patients). In contrast, neither HLA-DR1 nor HLA-B15 influenced these indices.

CONCLUSION

Apart from HLA-B27, there is a significant association of HLA-DR1 and HLA-B15 with SpA in Mexicans which is independent of B27. HLA-B27 is associated with younger age at onset and increased disease severity and HLA-DR1 with older age at onset. The strength of HLA-B15, HLA-B27, and HLA-DR1 associations varied in different forms of SpA.

The juvenile-onset spondyloarthritides

The juvenile-onset spondyloarthritides comprise a group of HLA-B27-associated disorders, which are mainly characterized by enthesitis and arthritis affecting the lower extremities, and in a variable proportion of cases, the sacroiliac and spinal joints. Additional features include a variety of extra-articular manifestations, and in some cases, bacterial infections as triggers. Except for the prevalence of some clinical features at onset and severity throughout the course of the disease, juvenile-onset SpA resemble their adult counterpart in most clinical aspects, strength of HLA-B27 association, and the role of arthritogenic bacteria in their pathogenesis. Not surprisingly, several aspects, from nomenclature to classification, and diagnostic criteria reflect to some extent those developed in the adult onset populations.

Development of a radiographic index to assess the tarsal involvement in patients with spondyloarthropathies

OBJECTIVE

To develop and test an index to evaluate the radiographic changes that occur in the tarsus and adjacent areas of the foot in patients with spondyloarthropathies (SpA).

METHODS

The spondyloarthropathy tarsal radiographic index (SpA-TRI) was developed in three consecutive steps: (a) detection of descriptors after reviewing 70 radiographic files; (b) descriptor gradation and subsequent modifications performed by a consensus committee, and (c) interobserver variability assessed by three blinded and independent observers on 272 radiographs: anteroposterior 118, lateral 90, oblique 64 from 121 patients with SpA, and intraobserver variability on 75 radiographs from 25 patients with SpA. Statistical analysis included percentage of agreement and kappa test. SpA-TRI score ranges from 0 to 4 (0=normal; 1=osteopenia or suspicious findings; 2=definite joint space narrowing, bony erosion(s), periosteal whiskering, or enthesophyte(s) in the plantar fascia or Achilleal tendon attachments; 3=para-articular enthesophyte(s); 4=bony ankylosis (joint space fusion or complete bridging)).

RESULTS

Complete agreement for every evaluation was >40%, and discordance >1 grade was <15%. The kappa scores among the three observers were acceptable for all the single projections: oblique (0.52, 0.36, 0.35), lateral (0.50, 0.42, 0.56), and anteroposterior (0.40, 0.41, 0.21) views. The combination of lateral and oblique views achieved the highest concordance rates (0.72, 0.33, 0.66), surpassing that of the three projections altogether (0.34, 0.58, 0.37). In every case the concordance was comparable with that of sacroiliac joints (0.47, 0.41, 0.34); intraobserver concordance showed a similar trend.

CONCLUSION

The SpA-TRI is an index that includes the most prominent features of tarsal disease and adjacent areas of the foot in SpA and grades them accordingly, it has an adequate reproducibility, and is suitable for use with two or more projections, preferably the combination of oblique and lateral.

Heat shock protein 70 gene polymorphisms in Mexican patients with spondyloarthropathies

OBJECTIVE

To investigate the role of HSP70 genes as contributors to genetic susceptibility of the spondyloarthropathies (SpA) in the Mexican population.

METHODS

The study included 150 patients with SpA (undifferentiated spondyloarthropathy (uSpA) 68, ankylosing spondylitis (AS) 60, and reactive arthritis 22) and 158 healthy controls. HSP70-1, HSP70-2 and HSP70-hom genotypes were analysed by the polymerase chain reaction-restriction fragment length polymorphism technique. Statistical methods included the Mantel-Haenzel, chi(2), Fisher's exact test, and Woolf's method for odds ratio (OR).

RESULTS

HSP70-2 B/B genotype frequency was increased in the whole group of patients with SpA (pC<0.05, OR=4.3), as well as in the different clinical subgroups (pC<0.05, OR=4.2 for AS; pC<0.05, OR=4.4 for uSpA; and pC<0.05, OR=4.1 for ReA). This frequency remained significantly increased when the patients with B27 negative SpA were analysed. On the other hand, HSP70-hom locus analysis showed significantly increased frequency of A allele in the whole group of SpA (pC<0.05, OR=3.4), as well as in the groups with AS (pC<0.05, OR=5.6) and with uSpA (pC<0.05, OR=3.1), when compared with healthy controls. In this case, also, the genotype A/A was increased in the whole group of SpA (pC<0.05, OR=4.5), as well as in patients with AS (pC<0.05, OR=6.4) and with uSpA (pC<0.05, OR=3.7). When the patients with B27 negative SpA were analysed the frequencies of HSP70-hom A allele and A/A genotype remained significantly increased in the whole group of SpA (pC<0.05, OR=3.2 for the A allele and pC<0.05, OR=4.2 for the A/A genotype) and in the uSpA subgroup (pC<0.05, OR=3.8 for the A allele and pC<0.05, OR=4.3 for the A/A genotype).

CONCLUSION

In addition to the association of SpA with HLA-B27, there is a significant association of HSP70-2 and HSP70-hom alleles with SpA in Mexicans. This association seems to be independent of the susceptibility conferred by HLA-B27 in the group of patients with uSpA.

Relation between adverse events associated with allopurinol and renal function in patients with gout

BACKGROUND

Because serious adverse reactions to allopurinol have been related to a reduce creatinine clearance rate and prolonged half life of oxypurinol, it has been recommended that the dose should be adjusted according to the rate of creatinine clearance. However, in some patients with gout the dose is not sufficient to reduce serum levels of uric acid (< or =390 micromol/l) and to halt disease progression.

OBJECTIVE

To determine the prevalence of adverse reactions attributable to allopurinol in patients with primary gout according to dose and creatinine clearance rate.

METHODS

Data on 120 patients with gout receiving allopurinol, in whom the starting dose was adjusted according to creatinine clearance rate and later increased in some patients to control the disease, were retrospectively reviewed. Two groups were compared: group A, 52 patients receiving creatinine clearance adjusted maintenance doses of allopurinol and group B, 68 patients receiving non-adjusted higher maintenance doses of allopurinol.

RESULTS

During follow up 57% required higher allopurinol doses than those recommended according to their creatinine clearance rate. Only five (4%) of 120 consecutive patients developed allopurinol related adverse reactions: four minor skin reactions and one allopurinol hypersensitivity syndrome (AHS). Three of these (including the case of AHS) occurred in group A and two in group B (p=NS). The duration of allopurinol treatment was the same in both groups (group A: 2.3 (3.3) years; group B: 3.7 (4.8) years). No patient in group A, but 44% in group B had a creatinine clearance rate of <50 ml/min. None of the patients received concomitant diuretics, ampicillin, or azathioprine.

CONCLUSIONS

No increase was seen in the prevalence of adverse reactions to allopurinol in patients who received higher allopurinol maintenance doses than those recommended according to creatinine clearance rate.

Bacterial DNA in synovial fluid cells of patients with juvenile onset spondyloarthropathies

OBJECTIVE

To identify bacterial DNA in synovial fluid cells of patients with active juvenile onset spondyloarthropathy (SpA).

METHODS

The main group of study constituted 22 patients with juvenile onset SpA. In addition, five patients with adult onset SpA and nine with rheumatoid arthritis (RA) were studied. Polymerase chain reaction (PCR) with either genus- or species-specific primers was performed on synovial fluid cells to detect DNA sequences of Chlamydia trachomatis, Yersinia enterocolitica, Salmonella sp., Shigella sp., Campylobacter sp. and Mycobacterium tuberculosis. The presence of antibacterial antibodies in sera and synovial fluid was also determined by enzyme-linked immunoassay.

RESULTS

The synovial fluid of nine patients with juvenile onset SpA, three with adult onset SpA and one with RA contained bacterial DNA. Five juvenile onset SpA samples had DNA of one single bacterium; two juvenile onset SpA and three adult onset SpA had DNA of two bacteria and two juvenile onset SpA had DNA of three bacteria. Overall, Salmonella sp. DNA was detected in seven synovial fluid samples, Shigella sp., Campylobacter sp. and M. tuberculosis were found in four samples each, and C. trachomatis was found in two. The bacterial DNA findings correlated with neither diagnosis nor disease duration. One RA synovial fluid had DNA of Campylobacter sp. Neither serum nor synovial fluid antibacterial antibodies correlated with DNA findings or clinical diagnosis.

CONCLUSION

In this study, single and several combinations of bacterial DNA were identified in the synovial fluid of patients with long-term undifferentiated and definite juvenile onset SpA and adult onset SpA. Of relevance is that bacterial DNA corresponds to bacteria producing endemic disease in our population.

The Mexican version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report herein the results of the cross-cultural adaptation and validation into the Mexican language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Mexican CHAQ was already published and therefore it was revalidated while the Mexican CHQ was derived from the European Spanish version with changing of the few words whose use is different in the 2 countries. A total of 182 subjects were enrolled: 89 patients with JIA (26% systemic onset, 47% polyarticular onset, 13.5% extended oligoarticular subtype, and 13.5% persistent oligoarticular subtype) and 93 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, and polyarticular onset subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, and polyarticular onset having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Mexican version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.

Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. VIGOR Study Group

BACKGROUND

Each year, clinical upper gastrointestinal events occur in 2 to 4 percent of patients who are taking nonselective nonsteroidal antiinflammatory drugs (NSAIDs). We assessed whether rofecoxib, a selective inhibitor of cyclooxygenase-2, would be associated with a lower incidence of clinically important upper gastrointestinal events than is the nonselective NSAID naproxen among patients with rheumatoid arthritis.

METHODS

We randomly assigned 8076 patients who were at least 50 years of age (or at least 40 years of age and receiving long-term glucocorticoid therapy) and who had rheumatoid arthritis to receive either 50 mg of rofecoxib daily or 500 mg of naproxen twice daily. The primary end point was confirmed clinical upper gastrointestinal events (gastroduodenal perforation or obstruction, upper gastrointestinal bleeding, and symptomatic gastroduodenal ulcers).

RESULTS

Rofecoxib and naproxen had similar efficacy against rheumatoid arthritis. During a median follow-up of 9.0 months, 2.1 confirmed gastrointestinal events per 100 patient-years occurred with rofecoxib, as compared with 4.5 per 100 patient-years with naproxen (relative risk, 0.5; 95 percent confidence interval, 0.3 to 0.6; P<0.001). The respective rates of complicated confirmed events (perforation, obstruction, and severe upper gastrointestinal bleeding) were 0.6 per 100 patient-years and 1.4 per 100 patient-years (relative risk, 0.4; 95 percent confidence interval, 0.2 to 0.8; P=0.005). The incidence of myocardial infarction was lower among patients in the naproxen group than among those in the rofecoxib group (0.1 percent vs. 0.4 percent; relative risk, 0.2; 95 percent confidence interval, 0.1 to 0.7); the overall mortality rate and the rate of death from cardiovascular causes were similar in the two groups.

CONCLUSIONS

In patients with rheumatoid arthritis, treatment with rofecoxib, a selective inhibitor of cyclooxygenase-2, is associated with significantly fewer clinically important upper gastrointestinal events than treatment with naproxen, a nonselective inhibitor.

Cellular immune response to Klebsiella pneumoniae antigens in patients with HLA-B27+ ankylosing spondylitis

OBJECTIVE

To study the reactivity of peripheral blood mononuclear cells (PBMC) of patients with ankylosing spondylitis (AS) and rheumatoid arthritis (RA) and healthy controls to Klebsiella pneumoniae antigens and to the GroEL-like proteins from K. pneumoniae (HSP60Kp) and Mycobacterium leprae recombinant heat shock protein 65 (rHSP65Ml).

METHODS

PBMC of 13 patients with AS and 9 with RA and 10 controls were stimulated in vitro by heat shock induced K. pneumoniae antigens in a cell blot assay, by insolubilized HSP60Kp, by cytosolic proteins (CP) from K. pneumoniae cultivated at 37 degrees C or 45 degrees C, by soluble HSP60Kp, or by rHSP65Ml.

RESULTS

In the cell blot assay 7/13 AS and 3/9 RA patients responded to fraction 4, which contains mainly HSP60Kp, and no controls responded (AS vs. controls: p = 0.007). The response to the insolubilized HSP60Kp was positive in 6/13 AS patients but negative in RA patients and controls (p = 0.004). The response to CP45 degrees C was positive in 7/13 AS, in 2/9 RA, and no controls (AS vs controls: p<0.015). Response to the soluble HSP60Kp was found in 7/13 AS and 5/9 RA patients, but no controls (AS vs. controls: p = 0.0075). Response to rHSP65Ml was positive in 3/13 AS, 7/9 RA patients, and 1/10 controls (AS vs RA: p = 0.027; RA vs. controls: p = 0.005; AS vs. controls: nonsignificant).

CONCLUSION

In PBMC of the majority of patients with AS and in some with RA, but not in healthy controls, there are cells that proliferate in the presence of HSP60 of K. pneumoniae.

Update on functional assessment tools

In recent years, there has been a tremendous growth in the development of measurement instruments that evaluate health status, functional status, disability, and quality of life in adults with rheumatic diseases. In the past decade, similar measures have been developed for application in children with rheumatic diseases. These include the Childhood Arthritis Impact Measurement Scales (CHAIMS), the Childhood Health Assessment Questionnaire (CHAQ), the Juvenile Arthritis Functional Assessment Report (JAFAR), the Juvenile Arthritis Self-report Index (JASI), the Juvenile Arthritis Quality of Life Questionnaire (JAQQ), and the Childhood Arthritis Health Profile (CAHP). The latter 2 instruments assess health related quality of life (HRQOL) and they are discussed here. The need to adapt this kind of instrument for use in an international climate creates an interesting dilemma and this is discussed.

Recognition of B cells epitopes of the Klebsiella pneumoniae GroEL-like protein by HLA-B27 positive subjects

The presence of antibodies against antigens of K. pneumoniae in HLA-B27 positive patients with ankylosing spondylitis (AS), has been well documented. We have previously reported that sera from HLA-B27 positive subjects react with the K. pneumoniae GroEL-like protein (HSP60Kp) and have higher titers than HLA-B27 negative individuals. We cloned the gene that codes for this protein, determined hydrophilic regions by computer analysis of the predicted amino acid sequence and found that residues 389-397, 360-368 and 282-290, were possible B cell epitopes. To test this prediction, and to determine if the HLA-B27 positive and negative AS patients recognize the same or different epitopes, we truncated the hsp60Kp gene, from the 3; terminal nucleotide, to obtain fragments having or not the predicted epitopes. Four polypeptides of 40, 37, 30 and 18 kDa were obtained and analysed, by ELISA and inhibition of ELISA, for their reactivity with IgG antibodies from three high responders HLA-B27 positive AS patients and three HLA-B27 negative subjects who recognized the rHSP60Kp. Sera from both HLA-B27 positive and negative subjects reacted equally well with rHSP60Kp or with the 40 and 37 kDa peptides, which do not have residues 389-397 and 360-368, respectively, but reactivity was lost with the 30 kDa peptide, which also lacks residues 282-290. Contrary to what we expected, antibodies from HLA-B27 negative and positive individuals recognized the same epitope of the HSP60Kp. Our results indicate that the important epitope for B cells could be the 282-290 region and that the contribution of the two other predicted regions is minimal. We also conclude that the differences in response to the HSP60Kp in HLA-B27 positive AS patients and HLA-B27 negative individuals is not qualitative, but only quantitative.

Comparison of two schedules for administering oral low-dose methotrexate (weekly versus every-other-week) in patients with rheumatoid arthritis in remission: a twenty-four week, single blind, randomized study

OBJECTIVE

To compare the efficacy of 2 low-dose oral methotrexate (MTX) schedules in maintaining remission in patients with rheumatoid arthritis (RA).

METHODS

Patients with RA were included if they were receiving treatment with weekly MTX for at least 9 months and the RA was in remission (defined by American College of Rheumatology [ACR] criteria) for at least 6 months. Patients were stratified by treatment and randomly assigned to weekly or every-other-weekly (EOW; reducing their monthly dose by half) treatment with MTX. Patients were evaluated by a rheumatologist (blinded to the treatment schedule) at baseline and at 6, 12, and 24 weeks. The evaluations included joint counts, Ritchie Articular Index, Health Assessment Questionnaire Disability Index, physician's and patient's global health assessments, visual analog scale for pain, and incidence of adverse effects. Laboratory evaluations were done at baseline and at week 24.

RESULTS

Fifty-one patients were included (26 taking weekly MTX, 25 taking EOW MTX). Baseline comparisons showed no differences between the groups. The mean duration of RA was <3 years in both groups, and they had been started on weekly MTX treatment early after diagnosis. After 24 weeks, >90% of the patients in both groups continued in remission. Evaluations of disease activity at 6 and 12 weeks showed no between-group differences. EOW MTX patients who experienced relapse were switched back to weekly MTX, and after a few weeks, their RA was again controlled. The incidence of adverse effects was slightly higher in the weekly MTX group, although the difference did not reach statistical significance. The observed laboratory values were very similar for both groups, except for the serum aspartate aminotransferase and alanine aminotransferase levels, which decreased in the EOW MTX group and were statistically significant at week 24 (P = 0.04 and P = 0.006, respectively).

CONCLUSION

EOW MTX represents a valid therapeutic alternative for a specific subgroup of RA patients, as outlined by the ACR remission criteria. Patients with a short disease duration who were treated early after disease onset with weekly MTX and who achieve sustained remission have a higher probability of success with the EOW MTX schedule.

A proposal for the classification of patients for clinical and experimental studies on reactive arthritis

OBJECTIVE

To propose classification criteria for patients entering clinical and basic studies on reactive arthritis (ReA).

METHODS

From a MEDLINE search of articles published between 1980 and 1996, we identified reports on HLA-B27 related ReA and Reiter's syndrome as study groups and analyzed the items that constituted the diagnostic, classification, and inclusion (or entry) criteria of patients. We developed disease categories that constituted our classification proposal.

RESULTS

We reviewed 175 articles containing 110 study groups of patients with ReA and 94 with Reiter's syndrome. Most articles (89.7%) relied on arthritis for diagnosis, but only 48.0% relied on infection. Only 22.5% of articles used published criteria for diagnosis. Articles including a bacterial name to further describe a group of patients with ReA relied on cultures at the site of infection, serum antibodies, or both to confirm the diagnosis. There were inter/intra-group variations and overlapping of diagnostic criteria, at least 32 different terms referring to ReA or Reiter's syndrome, and 6 patterns of disease. According to these data, we propose 3 categories of disease for patients entering clinical and basic studies on ReA: probable ReA (2 subgroups); definite ReA triggered by bacteria (2 subgroups); and bacterial-associated undifferentiated oligoarthritis or spondyloarthropathy.

CONCLUSION

This proposal provides a rationale for reducing the heterogeneity found in criteria for including patients with ReA in research and to facilitate scientific communication. In contrast to diagnostic criteria, this proposal does not restrict the study population to a minority of patients, but allows the investigator to include several forms of disease and to analyze results according to different categories.

Intradermal tophi in gout: a case-control study

OBJECTIVE

To describe the characteristics of intradermal tophi in patients with gout and search for factors associated with their development.

METHODS

This is a case-control study of patients with gout: cases (Group A, n = 21) had intradermal (not subcutaneous) plaques of monosodium urate (MSU) crystals located in sites distant to articular or paraarticular structures, and controls (Group B, n = 42) had gout but no intradermal tophi. Both Group A and Group B were paired by sex, age (+/-5 years), and duration of the disease (+/-3 years). Analysis included serum and urinary uric acid levels at first visit, radiographic stage of gout, the presence of associated diseases, and previous therapy, specifically, chronic glucocorticoid and diuretic usage.

RESULTS

Intradermal tophi were located in the legs, forearms, buttocks, thighs, arms, and abdominal wall. Patients in Group A had a greater number of nonintradermal tophi in common sites (11.9+/-12.5 vs. 4.2+/-7.9, mean +/- SD; p = 0.018), decreased glomerular filtration rate (46.74+/-25.11 vs. 70.87+/-30.18 ml/min; p = 0.042), advanced radiographic changes (57.2 vs. 7.1%; p = 0.0001), and longterm glucocorticoid self-medication (76 vs. 36%; p = 0.006). We found no differences in other associated diseases between groups.

CONCLUSION

Intradermal tophi were commonly found in the legs and forearms, and less frequently in the buttocks, thighs, and abdominal wall of gouty patients, and were associated with longterm self-prescribed glucocorticoids and chronic renal failure. The occurrence of intradermal tophi in these patients appeared to correlate with advanced disease.

Features of spondyloarthritis around the world

This article elucidates the prevalence and pathogenic roles of the MHC and microbial infections and clinical features and treatment of SpA across different populations from the arctic and subarctic regions to Central America, Asia, and Africa. Preliminary evidence suggests significant genetic and environmental influences on the onset and presentation of SpA, particularly AS, in these populations, which are different than those reported in white Caucasians; however, community surveys and longitudinal and case control studies are difficult to undertake in many of the developing countries. Thus, most of the currently available data have been devised from short-term and retrospective studies and should be treated with caution. Differences in referral and follow-up practices and the availability of rheumatology expertise and relevant resources may explain some of the differences observed in the populations discussed in this article. Furthermore, widely accepted criteria for the classification of SpA may not be applicable to non-Caucasians and need to be evaluated in these subjects. With gradual improvement in the economic status in many of the developing countries in Asia and Africa, it is hoped that with improvement in medical services, more physicians and specialty clinics in rheumatology, and changing referral patterns, better documentation of the various aspects of different SpA can be achieved. Future research should focus on the evaluation of specific risk or protective factors in population groups to better delineate the relative importance of genetic and environmental effects in the pathogenesis of SpA.

Prevalence of fibromyalgia in children: a clinical study of Mexican children

OBJECTIVE

To determine the prevalence of fibromyalgia (FM) in schoolchildren according to the 2 stage classification process proposed by the 1990 American College of Rheumatology (ACR) Multicenter Criteria Committee on Fibromyalgia.

METHODS

Stage 1: we administered a pain questionnaire to a sample of 548 schoolchildren (264 boys, 284 girls; mean age 11.9 yrs, range 9-15). Stage 2: two rheumatologists examined all children with diffuse pain. Using thumb palpation, they examined 18 fibromyalgia tender points and 3 pairs of controls points followed by dolorimetry. Additionally, a random sample of 79 children with no pain were selected as controls, following the same procedures (thumb palpation and dolorimetry). The Wilcoxon test was used to compare the distribution of tenderness thresholds between FM and non-FM groups. Kappa statistics for multiple raters was used to assess interobserver agreement.

RESULTS

Seven children, all girls, fulfilled the ACR diagnostic criteria for FM. Thus, the prevalence of FM in this group of schoolchildren reached only 1.2%. The girls with FM had a mean of 14 tender points, whereas controls (n = 79) had 2.4. Pain thresholds were 3.4 kg in children with FM and 5.1 kg in controls (p = 0.004).

CONCLUSION

The prevalence of FM in our study was 5-fold lower than a previous report. This variance may be due to (1) racial and sociocultural differences between populations; and (2) differences in methodological approach. The difficulties of making accurate estimates of FM across different studies are highlighted.

Antibody response to Klebsiella pneumoniae 60 kDa protein in familial and sporadic ankylosing spondylitis: role of HLA-B27 and characterization as a GroEL-like protein

OBJECTIVE

To study the antibody response of HLA-B27+ patients with ankylosing spondylitis (AS) and their first degree relatives to the 60 kDa protein of Klebsiella pneumoniae and to characterize this protein.

METHODS

Sera from 84 individuals were analyzed by ELISA to determine the titer of antibodies against the 60 kDa protein of K. pneumoniae. Subjects were divided into 3 categories: Group 1: 44 HLA-B27+ AS related individuals (35 patients, 9 healthy controls); Group 2: 28 healthy B27- AS related individuals; and Group 3: 12 healthy B27- non-AS related subjects. The 60 kDa protein of K. pneumoniae was induced at 45 degrees C and purified by electroelution from sodium dodecyl sulfate-polyacrylamide gel electrophoresis. It was characterized as a GroEL-like heat shock protein (HSP). The recognition of GroEL-like protein was confirmed by immunoblot of 2 dimension electrophoresis. The response to GroEL-like protein from other bacteria and the response to lipopolysaccharide (LPS) was also analyzed by immunoblot.

RESULTS

HLA-B27+ individuals (Group 1), independent of their disease status, showed a significant higher response to the 60 kDa protein of K. pneumoniae than HLA-B27- subjects from Groups 2 and 3 (p < 0.0001). This protein was characterized as a HSP of the GroEL family and designated HSP60Kp. The GroEL of other enterobacteria as well as that of Mycobacterium leprae were recognized by HLA-B27+ individuals by immunoblot, whereas HLA-B27- individuals did not. LPS was not recognized by HLA-B27 positive or negative subjects.

CONCLUSION

These findings suggest a relationship between HLA-B27 and the response to a GroEL-like protein that could have implications in AS.

Ossification of the posterior longitudinal ligament in three geographically and genetically different populations of ankylosing spondylitis and other spondyloarthropathies

STUDY DESIGN

Cross sectional.

RESEARCH QUESTIONS

(a) Is any clinical variable of ankylosing spondylitis (AS) associated with the presence of ossification of the posterior longitudinal ligament (OPLL)? and (b) Is OPLL present in patients with AS from different geographical or genetic backgrounds?

METHODS

Three groups were assembled: (1) a prospective group of 103 consecutive AS patients from two community based rheumatology clinics from Guadalajara, who were evaluated using: a questionnaire with disease characteristics variables; clinical assessment by a neurologist; lateral radiographic views of the cervical spine and somatosensory evoked potentials (SSEP). (2) Fifty one spondyloarthropathies (SpA) patients from Mexico city whose cervical spine films were retrospectively reviewed. (3) Thirty nine AS patients from Edmonton, Canada whose cervical spine films were retrospectively reviewed and compared with 72 controls.

RESULTS

Group 1: 74% of the 103 patients were men and 86% were HLA-B27 positive. The mean age was 35 years, and mean (SD) disease duration 10 (8) years. OPLL was reported in 16 patients (15.5%; 95% CI 9, 22). OPLL was statistically associated with older age (p = 0.001), longer disease duration (p = 0.001), clinical myelopathy (p = 0.03), worst functional index (p = 0.042), restricted axial movement measurements (all p < 0.001), radiological sacroilitis (p < 0.001 for linear association), osteitis pubis (p = 0.009), hip involvement (p = 0.006 for linear association), and abnormal SSEP (p = 0.008). Group 2: 92% of 51 patients were men; the mean age was 30 years and the mean (SD) disease duration 11 (7) years. OPLL was reported in 15 (29%, 95% CI 17, 41) patients (nine AS, two psoriatic arthritis, three juvenile AS, and one Reiter's syndrome). Group 3: 95% of the 39 patients were men; the mean of age was 46 years and disease duration of 18 (10) years. OPLL was reported in nine (23%; 95% CI 10, 36) patients, including one with psoriatic arthritis, and two with Crohn's disease. OPLL was observed in two of the control group.

CONCLUSIONS

The prevalence of OPLL in AS and SpA is higher than previously recognised and seems to be associated with variables identifying more severe axial disease.

Validation of a Spanish version of the Childhood Health Assessment Questionnaire

OBJECTIVE

To determine the reliability and validity of a Spanish version of the Childhood Health Assessment Questionnaire (CHAQ).

METHODS

Fifty-five patients with juvenile rheumatoid arthritis (JRA) [35 girls, 20 boys; mean age at onset (+/- SD) 11 +/- 3.3 yrs, mean disease duration 3.3 +/- 2.2 yrs] were included in an observational and cross sectional study that evaluated translation validity, cross sectional construct validity, and test-retest reliability of the Spanish version of the CHAQ. The questionnaire was administered to either patients or one of their parents, and results were correlated with the Steinbrocker functional class, the Juvenile Arthritis Functional Assessment Scale (JAFAS), and disease activity.

RESULTS

The mean CHAQ score (mean 0.77, range 0.01-2.25) was found to correlate at different levels with Steinbrocker functional class (r = 0.62, p < 0.0001), JAFAS (r = 0.65, p < 0.0001), and disease activity score (r = 0.40, p < 0.0001). Test-retest and interobserver agreement had good correlations.

CONCLUSION

The Spanish version of the CHAQ we studied is a reliable and valid tool for assessment of health status in Spanish speaking children with JRA.