Polymorphisms CYP2R1 rs10766197 and CYP27B1 rs10877012 in Multiple Sclerosis: A Case-Control Study

BACKGROUND

Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease. Low vitamin D levels have been reported to be a risk factor for MS, and genetic variances could be implicated. The aim of this study was to evaluate the association of MS with rs10766197 polymorphism of CYP2R1 gene and rs10877012 polymorphism of CYP27B1 gene. The second aim was to analyse whether these polymorphisms are associated with the severity of the progression of MS. Material and Methods. In a case-control study, we included 116 MS patients and 226 controls, all of whom were Mexican Mestizo. MS was diagnosed by McDonald criteria (2017). A complete neurological evaluation was performed to evaluate the severity of disease progression. Serum 25-hydroxyvitamin D [25(OH) vitamin D] levels were measured by ELISA. Single nucleotide polymorphisms rs10766197 of CYP2R1 gene and rs10877012 SNP of CYP27B1 gene were genotyped by real-time PCR.

RESULTS

Serum 25(OH) vitamin D levels were lower in MS patients than in controls (p = 0.009). No differences were observed between serum 25(OH) vitamin D levels of MS patients with severe progression compared to low progression (p = 0.88). A higher frequency of the A allele of CYP2R1 rs10766197 was observed between MS patients and controls (p = 0.05). No differences were observed in the frequency of T allele of CYP27B1 rs10877012 (p = 0.65). In subanalysis, patients with GA + AA genotypes of CYP2R1 rs10766197 had an increased risk of MS compared to controls (p = 0.03). No increased risk was observed in GT + TT genotypes of CYP27B1 rs10877012 (p = 0.63). No differences were observed in allele frequencies of either polymorphism between patients with severe vs. low disease progression.

CONCLUSION

Lower serum 25(OH) vitamin D levels were observed in MS patients than in controls, although these levels were not associated with disease progression. Carriers of GA + AA genotypes of CYP2R1 rs10766197 had an increased risk of MS. None of these polymorphisms was associated with severe progression of MS.

Characterization of Permeability Barrier Dysfunction in a Murine Model of Cutaneous Field Cancerization Following Chronic UV-B Irradiation: Implications for the Pathogenesis of Skin Cancer

Simple Summary

In the present work, we developed an experimental preclinical model of skin with cutaneous field cancerization after chronic UV-B light exposure in an immunologically intact mouse model (SKH1 aged mice). We observed impairments in the transepidermal water loss, stratum corneum hydration, and surface pH. We also detected a marked hyperkeratotic hyperplasia of the epidermis, induction of keratinocyte hyperproliferation, incidental actinic keratosis, and in situ squamous cell carcinomas in the UV-B light-irradiated groups. In this context, the association between the permeability barrier impairment and keratinocyte hyperproliferation might be considered a new target in the management of skin with cutaneous field cancerization. As current therapeutic approaches to actinic keratosis and cutaneous field cancerization only focus on the direct antineoplastic, immunomodulatory, or photodynamic effects of approved topical drugs, this mouse model of skin with cutaneous field cancerization might be helpful for both the identification and screening of potentially new preventive strategies or treatments (e.g., skin barrier therapies).

Abstract

Chronic ultraviolet B (UV-B) irradiation is known to be one of the most important hazards acting on the skin and poses a risk of developing photoaging, skin with cutaneous field cancerization (CFC), actinic keratosis (AKs), and squamous cell carcinomas (SCCs). Most of the UV-B light is absorbed in the epidermis, affecting the outermost cell layers, the stratum corneum, and the stratum granulosum, which protects against this radiation and tries to maintain the permeability barrier. In the present work, we show an impairment in the transepidermal water loss, stratum corneum hydration, and surface pH after chronic UV-B light exposure in an immunologically intact mouse model (SKH1 aged mice) of skin with CFC. Macroscopic lesions of AKs and SCCs may develop synchronically or over time on the same cutaneous surface due to both the presence of subclinical AKs and in situ SCC, but also the accumulation of different mutations in keratinocytes. Focusing on skin with CFC, yet without the pathological criteria of AKs or SCC, the presence of p53 immunopositive patches (PIPs) within the epidermis is associated with these UV-B-induced mutations. Reactive epidermis to chronic UV-B exposure correlated with a marked hyperkeratotic hyperplasia, hypergranulosis, and induction of keratinocyte hyperproliferation, while expressing an upregulation of filaggrin, loricrin, and involucrin immunostaining. However, incidental AKs and in situ SCC might show neither hypergranulosis nor upregulation of differentiation markers in the upper epidermis. Despite the overexpression of filaggrin, loricrin, involucrin, lipid enzymes, and ATP-binding cassette subfamily A member 12 (ABCA12) after chronic UV-B irradiation, the permeability barrier, stratum corneum hydration, and surface pH were severely compromised in the skin with CFC. We interpret these results as an attempt to restore the permeability barrier homeostasis by the reactive epidermis, which fails due to ultrastructural losses in stratum corneum integrity, higher pH on skin surface, abundant mast cells in the dermis, and the common presence of incidental AKs and in situ SCC. As far as we know, this is the first time that the permeability barrier has been studied in the skin with CFC in a murine model of SCC induced after chronic UV-B irradiation at high doses. The impairment in the permeability barrier and the consequent keratinocyte hyperproliferation in the skin of CFC might play a role in the physiopathology of AKs and SCCs.

The human olfactory system in two proteinopathies: Alzheimer's and Parkinson's diseases

Alzheimer's and Parkinson's diseases are the most prevalent neurodegenerative disorders. Their etiologies are idiopathic, and treatments are symptomatic and orientated towards cognitive or motor deficits. Neuropathologically, both are proteinopathies with pathological aggregates (plaques of amyloid-β peptide and neurofibrillary tangles of tau protein in Alzheimer's disease, and Lewy bodies mostly composed of α-synuclein in Parkinson's disease). These deposits appear in the nervous system in a predictable and accumulative sequence with six neuropathological stages. Both disorders present a long prodromal period, characterized by preclinical signs including hyposmia. Interestingly, the olfactory system, particularly the anterior olfactory nucleus, is initially and preferentially affected by the pathology. Cerebral atrophy revealed by magnetic resonance imaging must be complemented by histological analyses to ascertain whether neuronal and/or glial loss or neuropil remodeling are responsible for volumetric changes. It has been proposed that these proteinopathies could act in a prion-like manner in which a misfolded protein would be able to force native proteins into pathogenic folding (seeding), which then propagates through neurons and glia (spreading). Existing data have been examined to establish why some neuronal populations are vulnerable while others are resistant to pathology and to what extent glia prevent and/or facilitate proteinopathy spreading. Connectomic approaches reveal a number of hubs in the olfactory system (anterior olfactory nucleus, olfactory entorhinal cortex and cortical amygdala) that are key interconnectors with the main hubs (the entorhinal-hippocampal-cortical and amygdala-dorsal motor vagal nucleus) of network dysfunction in Alzheimer's and Parkinson's diseases.

Data for glomeruli characterization in histopathological images

The data presented in this article is part of the whole slide imaging (WSI) datasets generated in European project AIDPATH This data is also related to the research paper entitle "Glomerulosclerosis Identification in Whole Slide Images using Semantic Segmentation", published in Computer Methods and Programs in Biomedicine Journal [1]. In that article, different methods based on deep learning for glomeruli segmentation and their classification into normal and sclerotic glomerulous are presented and discussed. The raw data used is described and provided here. In addition, the detected glomeruli are also provided as individual image files. These data will encourage research on artificial intelligence (AI) methods, create and compare fresh algorithms, and measure their usability in quantitative nephropathology.

Glomerulosclerosis identification in whole slide images using semantic segmentation

BACKGROUND AND OBJECTIVE

Glomeruli identification, i.e., detection and characterization, is a key procedure in many nephropathology studies. In this paper, semantic segmentation based on convolutional neural networks (CNN) is proposed to detect glomeruli using Whole Slide Imaging (WSI) follows by a classification CNN to divide the glomeruli into normal and sclerosed.

METHODS

Comparison between U-Net and SegNet CNNs is performed for pixel-level segmentation considering both a two and three class problem, that is, a) non-glomerular and glomerular structures and b) non-glomerular normal glomerular and sclerotic structures. The two class semantic segmentation result is then used for a CNN classification where glomerular regions are divided into normal and global sclerosed glomeruli.

RESULTS

These methods were tested on a dataset composed of 47 WSIs belonging to human kidney sections stained with Periodic Acid Schiff (PAS). The best approach was the SegNet for two class segmentation follows by a fine-tuned AlexNet network to characterize the glomeruli. 98.16% of accuracy was obtained with this process of consecutive CNNs (SegNet-AlexNet) for segmentation and classification.

CONCLUSION

The results obtained demonstrate that the sequential CNN segmentation-classification strategy achieves higher accuracy reducing misclassified cases and therefore being the methodology proposed for glomerulosclerosis detection.

Serum P-glycoprotein level: a potential biomarker of DMARD failure in patients with rheumatoid arthritis

OBJECTIVES

To evaluate the utility of elevated serum P-glycoprotein (P-gp) as a risk marker of therapeutic response failure in rheumatoid arthritis (RA) patients treated with disease-modifying antirheumatic drugs (DMARDs).

METHODS

A cross-sectional study was conducted in 151 RA patients. Patients were classified into two groups according to the response achieved in terms of the disease activity score (DAS)28 after ≥ 6 months: (1) patients with a therapeutic response to DMARDs, with DAS28 < 3.2; and (2) patients without a response to DMARDs, with persistent DAS28 ≥ 3.2. We explored a wide group of clinical factors associated with therapeutic resistance. Serum P-gp levels were measured by ELISA. The risk of P-gp elevation as a marker of failure to achieve a therapeutic response to DMARDs was computed using multivariate logistic regression.

RESULTS

Serum P-gp levels were significantly higher in RA patients (n = 151) than in the controls (n = 30) (158.70 ± 182.71 ng/mL vs. 14.12 ± 8.97 ng/mL, p < 0.001). The P-gp level was correlated with the DAS28 score (r = 0.39, p < 0.001). RA patients with DMARD failure had higher serum P-gp levels than patients with a therapeutic response (206 ± 21.47 ng/mL vs 120.60 ± 15.70 ng/mL; p = 0.001). High P-gp levels increased the risk of DMARD failure (OR 3.36, 95% CI 1.54-7.27, p = 0.001). After adjusting for confounding variables, elevated P-gp remained associated with DMARD failure (OR 2.64, 95% CI 1.29-5.40, p = 0.01).

CONCLUSION

Elevated serum P-gp is associated with DMARD failure. The P-gp level can be considered a clinical tool for evaluating the risk of DMARD failure in patients; however, future prospective studies should be performed to evaluate the utility of this marker in predicting long-term responses.

Association between -174G/C and -572G/C interleukin 6 gene polymorphisms and severe radiographic damage to the hands of Mexican patients with rheumatoid arthritis: a preliminary report

Several interleukin 6 gene (IL6) polymorphisms are implicated in susceptibility to rheumatoid arthritis (RA). It has not yet been established with certainty if these polymorphisms are associated with the severe radiographic damage observed in some RA patients, particularly those with the development of joint bone ankylosis (JBA). The objective of the present study was to evaluate the association between severe radiographic damage in hands and the -174G/C and -572G/C IL6 polymorphisms in Mexican Mestizo people with RA. Mestizo adults with RA and long disease duration (>5 years) were classified into two groups according to the radiographic damage in their hands: a) severe radiographic damage (JBA and/or joint bone subluxations) and b) mild or moderate radiographic damage. We compared the differences in genotype and allele frequencies of -174G/C and -572G/C IL6 polymorphisms (genotyped using polymerase chain reaction-restriction fragment length polymorphism) between these two groups. Our findings indicated that the -174G/C polymorphism of IL6 is associated with severe joint radiographic damage [maximum likelihood odds ratios (MLE_OR): 8.03; 95%CI 1.22-187.06; P = 0.03], whereas the -572G/C polymorphism of IL6 exhibited no such association (MLE_OR: 1.5; 95%CI 0.52-4.5; P = 0.44). Higher anti-cyclic citrullinated peptide antibody levels were associated with more severe joint radiographic damage (P = 0.04). We conclude that there is a relevant association between the -174G/C IL6 polymorphism and severe radiographic damage. Future studies in other populations are required to confirm our findings.

The -174G/C Interleukin-6 Gene Promoter Polymorphism as a Genetic Marker of Differences in Therapeutic Response to Methotrexate and Leflunomide in Rheumatoid Arthritis

Objective. To evaluate the association of -174G/C IL-6 polymorphism with failure in therapeutic response to methotrexate (MTX) or leflunomide (LEF). This prospective, observational cohort included 96 Mexican-Mestizo patients with moderate or severe rheumatoid arthritis (RA), initiating MTX or LEF, genotyped for IL-6 -174G/C polymorphism by PCR-RFLP. Therapeutic response was strictly defined: only if patients achieved remission or low disease activity (DAS-28 < 3.2). Results. Patients with MTX or LEF had significant decrement in DAS-28 (p < 0.001); nevertheless, only 14% and 12.5% achieved DAS-28 < 3.2 at 3 and 6 months. After 6 months with any of these drugs the -174G/G genotype carriers (56%) had higher risk of therapeutic failure compared with GC (RR: 1.19, 95% CI: 1.07-1.56). By analyzing each drug separately, after 6 months with LEF, GG genotype confers higher risk of therapeutic failure than GC (RR = 1.56; 95% CI = 1.05-2.3; p = 0.003), or CC (RR = 1.83; 95% CI = 1.07-3.14; p = 0.001). This risk was also observed in the dominant model (RR = 1.33; 95% CI = 1.03-1.72; p = 0.02). Instead, in patients receiving MTX no genotype was predictor of therapeutic failure. We concluded that IL-6 -174G/G genotype confers higher risk of failure in therapeutic response to LEF in Mexicans and if confirmed in other populations this can be used as promissory genetic marker to differentiate risk of therapeutic failure to LEF.

Therapy with intermittent pulse cyclophosphamide for pulmonary hypertension associated with systemic lupus erythematosus

The aim of this study was to compare the efficacy of intravenouscyclophosphamide(IVCYC) versus oral enalapril in mild or moderate pulmonary hypertension (PH) in systemic lupus erythematosus (SLE). Thirty-four patients with SLE who had systolic pulmonary artery pressure (SPAP) > 30mmHg by Doppler echocardiography were randomized to receive IVCYC (0.5g/mt2 body surface area, monthly), or oral enalapril (10mg/day) for six months. The primary outcome was the significant decrease in SPAP. An additional outcome measure included the improvement in the heart functional class (NYHA). Sixteen patients received cyclophosphamide and 18 enalapril. IVCYC decreased the median values of SPAP from 41 to 28mmHg (P < 0.001), and enalapril from 35 to 27mmHg (P 0.02). IVCYC reduced more than twice as much SPAP than enalapril (P 0.04). In those patients with SPAP ≥35mmHg, cyclophosphamidedecreased from 43 to 27mmHg (P 0.003), but enalapril was not effective (P 0.14). The NYHA functional class improved only in those with cyclophosphamide (P 0.021). Also IVCYC had a higher frequency of side effects including infections (RR 1.6; 95% CI, 1.001-2.47), and gastrointestinal side effects (RR 14.6; 95% CI,2.15-99.68). We concluded that IVCYC was effective in mild and moderate PH associated with SLE. Further research is needed to evaluate its long-term efficacy.

Association between bone turnover markers, clinical variables, spinal syndesmophytes and bone mineral density in Mexican patients with ankylosing spondylitis

OBJECTIVES

To compare bone turnover marker (BTM) levels and bone mineral density (BMD) between patients with ankylosing spondylitis (AS) and healthy controls (HC) and to evaluate, in AS, the association between BTM levels and clinical variables, spinal syndesmophytes, and BMD using multivariate analysis.

METHOD

Seventy-eight AS patients were compared with 58 HC matched by gender. Spinal syndesmophytes in AS and other characteristics were assessed. C-terminal telopeptide fragments of type I collagen (CTX), bone-specific alkaline phosphatase (BAP), osteocalcin (OC) serum levels, and BMD of the lumbar spine, femoral neck, and forearm were evaluated.

RESULTS

AS males and females had lower BAP levels than their respective HC (p < 0.001 and p = 0.001). AS patients with bridging syndesmophytes had higher OC levels than AS patients either with non-bridging syndesmophytes (p = 0.001) or without spinal syndesmophytes (p < 0.001). OC and CTX levels correlated significantly with the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). In the multivariate linear regression adjusted by age, gender, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), BMD in the lumbar spine, and C-reactive protein (CRP), we observed an association between BAP levels and anti-tumour necrosis factor (anti-TNF) use (p = 0.05) whereas OC levels were associated with mSASSS (p < 0.001) and anti-TNF use (p = 0.05), and CTX levels were exclusively associated with mSASSS (p = 0.03). In the logistic regression analysis, only OC levels were associated with the presence of syndesmophytes in AS [odds ratio (OR) 2.42, 95% confidence interval (CI) 1.19-5.75].

CONCLUSIONS

We observed an increase in OC levels in AS patients with syndesmophytes. BTM levels were associated with the severity of spinal damage. Future longitudinal studies should evaluate whether these BTMs should be included as tools to determine the prognosis and progression of spinal damage.

Pulmonary function in ankylosing spondylitis: association with clinical variables

To evaluate the association between pulmonary function and clinical variables in ankylosing spondylitis (AS) and to compare the pulmonary function of patients with AS with that of healthy controls, 61 AS patients and 74 healthy controls were included. In AS, we assessed clinical disease indices (BASDAI, BASFI, BASG), morning stiffness, number of hypersensitive entheses, metrology measures, 6-min walking test, acute phase reactants, radiological presence of "bamboo spine," and severity of radiological involvement in sacroiliac and vertebral joints. AS and healthy controls had similar age and gender. All the parameters of pulmonary function were significantly diminished in AS than in healthy controls (p < 0.001), with a higher proportion of restrictive pattern (57.4 vs. 5.4 %). In AS, pulmonary function correlated negatively with BASDAI, BASFI, BASG, morning stiffness, number of hypersensitive entheses, occiput-wall distance, and ESR, and positively with 6-min walking test. There was no association between pulmonary function with radiological stage of vertebral joints and sacroiliac joints, "bamboo spine," disease duration, or chest expansion. A higher frequency of AS patients had a decreased pulmonary function and results of the 6-min walking test. These abnormalities in AS were more related with disease activity than with mobility limitation.

Cervical human papillomavirus infection in Mexican women with systemic lupus erythematosus or rheumatoid arthritis

Cervical human papillomavirus (HPV+) infection is associated with an increased risk of cervical dysplasia. Although the frequency of HPV+ in systemic lupus erythematosus (SLE) has been investigated in some races its prevalence in Hispanic women is still unknown. This cross-sectional study evaluated the prevalence of cervical HPV+ in Mexican women with SLE ( n = 34) or rheumatoid arthritis (RA) ( n = 43) and in healthy controls ( n = 146). These women were interviewed about risk factors for sexually transmitted infections and cervical cytology analysis was performed. HPV+ viral types were identified using PCR: HPV+ was observed in 14.7% of SLE, 27.9% of RA and 30.8% of controls. High-risk HPV types were observed in 11.7% of women with SLE, 27.9% of women with RA, and in 26% of the controls. High-risk viral types 58, 35 and 18 were the most frequently identified in SLE. Two women with SLE had a high-grade squamous intraepithelial lesion and one had cervical cancer. An association was observed between methotrexate utilization, longer duration of therapy with prednisone, and HPV+ in RA or SLE. Thus, there is a high prevalence of cervical HPV infection in Mexican women with SLE or RA, and physicians must be vigilant in preventing the development of cervical dysplasia.

Factors associated with hyperhomocysteinaemia in Mexican patients with rheumatoid arthritis

BACKGROUND

Hyperhomocysteinaemia is a factor related to the development of atherosclerosis in rheumatoid arthritis (RA). However, Hispanics with RA develop high rates of coronary disease; there are no studies about the frequency and factors related to high levels of homocysteine in Mexican patients.

OBJECTIVE

To evaluate the prevalence and characteristics associated with hyperhomocysteinaemia in Mexican patients with RA.

METHODS

One hundred and fifty-two patients with RA were compared with 153 controls. The assessment in RA included clinical characteristics, disease activity (RADAR), functioning (HAQ-Di and global functional status), comorbidity, and radiological damage. Laboratory determinations included total serum homocysteine (tHcy), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), and lipid profile.

RESULTS

Median levels of homocysteine were higher in RA compared with controls (11.3 vs. 9.3, p<0.001). Twenty per cent of the patients with RA had hyperhomocysteinaemia (>15 micromol/L) compared with 6% in controls (p<0.001). There was statistical association between hyperhomocysteinaemia in RA with male gender (p<0.001), impairment in the global functional status (p = 0.004), higher radiological damage (p = 0.001), and CRP (p = 0.04). There was no association with RADAR, HAQ-Di, or RF, methotrexate dose or duration of use. In the adjusted multivariate model, the two variables associated with higher risk for hyperhomocysteinaemia were male gender (OR = 4.2, 95% CI 2 to 12, p = 0.006) and higher radiological damage (III-IV) (OR = 3.4, 95% CI 1.3 to 9, p = 0.01).

CONCLUSIONS

Our data show a high prevalence of hyperhomocysteinaemia in Mexican patients with RA. More effort is required to evaluate and treat earlier this coronary risk factor.

Subacute renal failure in diabetic nephropathy due to endocapillary glomerulonephritis and cholesterol embolization

Patients with established diabetic nephropathy could have other glomerular diseases superimposed on diabetic glomerulosclerosis. Cholesterol embolization syndrome (CES) is a systemic disorder caused by cholesterol crystal embolization from ulcerated atherosclerosis plaques in the aorta and its major branches. Curiously, there are few papers describing the association between diabetic nephropathy and CES. On the other hand, the clinical picture of CES resembles systemic vasculitis, and there is a controversy regarding the association between CES and glomerular or vascular inflammation. We report a case of atypical CES that developed after cardiac catheterization in a diabetic man; it presented as subacute renal failure with proliferative and exudative endocapillary glomerulonephritis.

Serum concentrations of aminoterminal propeptide of type III procollagen and propeptide of human type I procollagen in systemic lupus erythematosus

The purpose of this study was to assess the association between the serum levels of aminoterminal propeptide of type III procollagen (PIIINP) and carboxyterminal propeptide of type I procollagen (PICP) with disease activity and damage in systemic lupus erythematosus (SLE). Thirty-three patients with SLE were compared with 31 controls. The assessment in SLE included disease activity indices (SLEDAI, MEX-SLEDAI) and damage index (SLICC/ACR). PIIINP and PICP were measured by radioimmunoassay. Compared with controls, mean levels of PIIINP were higher in SLE (2.9+/-1.8 vs. 1.8+/-1.2, P=0.006). PICP was also increased in SLE versus controls (163+/-94 vs. 102+/-62, P=0.007). PIIINP was correlated with SLICC/ACR (r=0.33, P=0.048). No correlation was observed between PICP and PIIINP with other clinical or therapeutic variables. These preliminary data suggests a role of PIIINP as a marker for chronic damage. Follow-up studies are required to evaluate its utility in predicting future damage.

Decreased progression to rheumatoid arthritis or other connective tissue diseases in patients with palindromic rheumatism treated with antimalarials

OBJECTIVE

To determine whether the use of antimalarials is associated with a reduction in the risk of developing rheumatoid arthritis (RA) or other connective tissue diseases in patients with palindromic rheumatism.

METHODS

We conducted a retrospective cohort study based on a review of medical records to evaluate the outcome of patients with palindromic rheumatism referred to an academic center from 1986 to 1996: 113 patients complied with the selection criteria, including diagnostic criteria for palindromic rheumatism and onset of disease since 1980. After adjusting for potential confounders, Kaplan-Meier methods and Cox regression models were used to estimate the risk of developing RA or other connective tissue disease in patients who had received antimalarials compared to those who had not.

RESULTS

Age of disease onset was 40+/-12 yrs, and mean disease duration 4.8+/-4 yrs; two-thirds of the patients were female. Sixty-two (55%) patients received antimalarials, for a mean duration of therapy of 28 mo. Thirty-three (29%) patients developed RA, 3 developed systemic lupus, and 4 developed other connective tissue diseases. Twenty (32%) patients in the antimalarial group developed a secondary disease, compared to 20 (39%) who did not receive therapy. Statistically significant differences were observed comparing time to event in both groups. The estimated median time to development of a chronic disease was 162 months in treated and 56 months in untreated patients. After adjusting for other variables in the Cox regression models, significant risk reduction in the development of a secondary disease was observed for antimalarial use (hazard ratio = 0.24; 95% CI 0.09-0.61). For RA, the risk reduction was 0.19 (95% CI 0.07-0.57). We conducted a sensitivity analysis around our censoring estimates. The risk reduction remained statistically significant, with 0.36 for RA and 0.41 for RA or other connective tissue disease.

CONCLUSION

Use of antimalarials in patients with palindromic rheumatism is associated with a reduction in the risk of developing subsequent RA or other connective tissue disease.

Prognostic factors for the development of rheumatoid arthritis and other connective tissue diseases in patients with palindromic rheumatism

OBJECTIVE

Palindromic rheumatism is characterized by attacks of acute arthritis of short duration. In the long term, a substantial proportion of patients will develop rheumatoid arthritis (RA) or other connective tissue diseases, but the determinants of subsequent chronic disease have not been adequately established. We identify clinical prognostic factors for the development of RA and other connective tissue diseases in patients with palindromic rheumatism in a retrospective cohort study.

METHODS

The medical records of 4900 patients with arthritis referred from 1986 to 1996 to 3 rheumatologists at an academic center were reviewed. One hundred sixty patients were diagnosed as having palindromic rheumatism. After review, 127 complied with diagnostic criteria for palindromic rheumatism. Disease duration was estimated as time of first attack until the last consultation, or the development of RA or other connective tissue disease. Survival analysis including Cox regression was used to identify clinical variables associated with the risk of developing RA or other connective tissue disease, adjusting for varying disease duration.

RESULTS

Sixty-five percent of the patients were female. Age at onset was 40+/-12 years. Mean disease duration was 6+/-6 years, and mean followup by the rheumatologists was 40+/-45 months. Joints more frequently affected were wrist, knee, and metacarpophalangeal. Forty-three patients (34%) subsequently developed a connective tissue disease including 36 (28%) RA, 3 (2%) systemic lupus erythematosus, and 4 (3%) other connective tissue diseases. In the final Cox regression model the hazard ratio for development of a connective tissue disease in the presence of a positive rheumatoid factor (RF) was 2.9 (p = 0.002), for proximal interphalangeal (PIP) joint involvement 2.4 (p = 0.02), for wrist involvement 2.5 (p = 0.05), for female sex 2.2 (p = 0.05), and for age at onset 1.03 (per year) (p = 0.001). Female patients with positive RF and involvement of the hands had an 8-fold risk of developing disease, compared with patients with one or fewer of these features.

CONCLUSION

Positive RF and early involvement of the wrist and PIP joints predict the subsequent development of RA or other connective tissue disease in patients with palindromic rheumatism, and identify a group of patients at increased risk.

Referral and diagnosis of common rheumatic diseases by primary care physicians

OBJECTIVE

To describe primary care patterns of referral and diagnoses of patients with rheumatic diseases referred to rheumatologists.

METHODS

The medical records of all consecutive patients referred in 1994 by >300 primary care physicians to two rheumatologists at an academic centre were reviewed. The referring physician diagnosis was compared with the rheumatologist's diagnosis. Sensitivity, specificity and predictive values of primary care diagnoses were estimated using the rheumatologist diagnosis as the 'gold standard'.

SETTING

University-based rheumatology out-patient clinic.

RESULTS

Over half of the patients referred had a rheumatologist diagnosis of soft-tissue rheumatism or a spinal pain syndrome. Three hundred and forty-seven patients (49%) had a primary care diagnosis of a defined rheumatic disease. Of these, 142 (41%) of the primary care diagnoses were subsequently modified by the rheumatologist. The highest agreement between primary care physician and rheumatologist was observed for crystal-induced arthritis (kappa = 0.86), and the lowest agreement for polymyalgia rheumatica (kappa = 0.39) and systemic lupus (kappa = 0.46). Sensitivity was lowest for a primary care diagnosis of fibromyalgia (48%) and highest for ankylosing spondylitis (94%). Positive predictive values were generally low, in particular for systemic lupus erythematosus (33%) and polymyalgia rheumatica (30%).

CONCLUSION

Most patients referred to an academic rheumatology centre had soft-tissue rheumatism or other pain syndromes. In general, diagnostic agreement between rheumatologists and primary care physicians was low. Increased emphasis on musculoskeletal disorders should be encouraged in medical education to increase the efficiency of rheumatology referrals.

Use of alternative therapies by patients with rheumatic disease in Guadalajara, Mexico: prevalence, beliefs, and expectations

OBJECTIVE

To assess the prevalence, practices, beliefs, and expectations of patients with rheumatic diseases in relation to the use of alternative therapies.

METHODS

We conducted a cross-sectional survey of 300 consecutive patients with rheumatic diseases at 3 outpatient rheumatic disease clinics in Guadalajara, Mexico to evaluate the use of alternative therapies. A face-to-face structured interview was administered by a trained assistant to evaluate the prevalence of use and patient beliefs, perceptions, and expectations in relation to alternative therapies.

RESULTS

Two hundred fifty patients (83%) had used a total of 1,386 alternative therapies (range 1-19); 203 (68%) patients had used alternative therapy in the previous 12 months. Sixty-one percent received at least one alternative treatment before the first rheumatology consultation, but an additional 18% initiated these therapies after their initial contact with a rheumatologist at our clinics. Only 66 (26%) of the patients using alternative therapy notified their rheumatologist about their use. Thirty-six patients (14%) discontinued formal treatment at least on one occasion in order to receive alternative therapies, and only 8 (22%) notified their rheumatologist. Alternative therapy practitioners recommended discontinuation of conventional therapy on 57% of the occasions when formal treatments were discontinued. Mean expenditures per patient for fees to alternative therapy providers were equivalent to 28 days of the official minimum daily wage, and per patient costs for the remedies themselves were equivalent to 13 days of the official minimum daily wage. Patients who used alternative therapy in the past 12 months had lower education (7 versus 10 years, P < 0.001) and were slightly more disabled (1.7 versus 1.5, modified Health Assessment Questionnaire, P < 0.01).

CONCLUSIONS

In this survey most patients used alternative therapies for the treatment of their rheumatic disease. Alternative therapies were costly and appeared to decrease adherence to conventional therapy. Health care providers should openly discuss the use of alternative therapy in patients with rheumatic diseases.

Utilization and predictive value of laboratory tests in patients referred to rheumatologists by primary care physicians

OBJECTIVE

Antinuclear antibodies (ANA), rheumatoid factors (RF), and erythrocyte sedimentation rate (ESR) are among the most frequently requested tests in the diagnosis and investigation of connective tissue diseases (CTD). We evaluate the utilization patterns and predictive value of these tests in patients referred to rheumatologists by primary care physicians.

METHODS

We reviewed the records of all new patients referred by primary care physicians in 1994 to 2 rheumatologists practicing at the University of Alberta. Data extracted from the records included diagnostic tests requested by referring primary care physicians, signs and symptoms at the initial rheumatology consult, and followup diagnoses.

RESULTS

Seven hundred eleven new patients had been referred by over 300 primary care physicians: RF had been requested in 25%, ANA in 21%, and ESR in 29%. One hundred nine (15%) of the 711 patients had a CTD, 45 (6%) had rheumatoid arthritis (RA), and 8 (1%) systemic lupus erythematosus (SLE). The predictive values of positive tests for the diagnosis of CTD were low: 49% for RF, 29% for ANA, and 35% for ESR. For RA, the positive predictive values were 44% for RF, 8% for ANA, 17% for ESR; for SLE, 2, 12, and 3%, respectively. Diffuse musculoskeletal pain and fatigue were significantly associated with test utilization, although most patients with these symptoms had fibromyalgia or localized soft tissue rheumatism.

CONCLUSION

Primary care physicians frequently requested autoantibodies in patients referred to rheumatologists. Most tests were negative, and were often requested in patients without CTD, resulting in low positive predictive values and questionable clinical utility. These findings suggest inappropriate overuse and lack of understanding of the use of autoantibody tests in diagnosing rheumatic diseases. A decrease in inappropriate use could be achieved by emphasizing that fatigue and diffuse musculoskeletal pain are not indicative of CTD in the absence of other features such as joint swelling, typical rash, or organ involvement.

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.

Autonomic dysfunction in patients with systemic lupus erythematosus

OBJECTIVE

To assess the prevalence and severity of autonomic dysfunction (AD) in patients with systemic lupus erythematosus (SLE).

METHODS

Fifty-nine consecutive patients with SLE and 97 healthy controls were assessed for AD using 4 noninvasive tests: heart rate responses to the Valsalva maneuver (Val), maximum-minimum heart rate (MM) response to deep breathing, heart response to standing up (30:15 ratio), and changes in blood pressure to sustained handgrip (Hand). AD was categorized as incipient, definite, severe, or atypical according to criteria proposed by Ewing. Disease characteristics, comorbid conditions, disease activity index [Mexican Systemic Lupus Erythematosus Disease Activity Index (Mex-SLEDAI)], cardiac complaints, and drug history were also documented. Laboratory analysis included rheumatoid factor, antinuclear antibodies, anti-dsDNA antibodies, and anticardiolipin antibodies (aCL).

RESULTS

Forty-eight percent of the patients with SLE had one or more abnormal tests compared with 33% of the controls (p=0.05); differences were greater when the severity of the neuropathy was considered: 12 (21%) patients with SLE had definite or severe AD using Ewing's criteria, compared with only 2 (2%) controls (p < 0.001). No statistical associations were observed between AD and age, disease duration, hypertension, Mex-SLEDAI, anti-dsDNA, aCL antibodies, or other drugs.

CONCLUSION

The prevalence of AD in SLE using noninvasive tests is high. One-fifth of our patients had definite or severe AD. No significant associations were observed between AD and clinical or serological variables of disease activity. Prospective studies are needed to determine the potential effect of AD in the morbidity of patients with SLE.

Intravenous cyclophosphamide pulses in pyoderma gangrenosum: an open trial

OBJECTIVE

To evaluate the potential efficacy of intravenous bolus cyclophosphamide (IVCY) in patients with pyoderma gangrenosum.

METHODS

Consecutive patients with a diagnosis of pyoderma gangrenosum seen in a period of 3 years in tertiary care referral center were included. Patients received IVCY 500 mg/m2 of body surface area, every month until reaching a maximum of 6 doses, or healing of their ulcers or a lack of response after 3 doses. Patients were assessed every month during the time they received IVCY and every 3 months thereafter. The assessments included number and size of ulcers, and a safety profile of the study drug. Complete remission was defined as 100% ulcer healing, partial remission as a decrease > or = 50% but less than 100%, and therapeutical failure if the size of the ulcer increased or decreased < 50%.

RESULTS

Nine patients were included, 6 were men, the mean age was 46 yrs (range 24-76). The mean disease duration was 3.3 yrs (range 1 week to 9 yrs). Four patients had idiopathic pyoderma gangrenosum, 3 had associated rheumatoid arthritis, and 2 had associated systemic lupus erythematosus. Complete remission was observed in 7 patients, partial in one, and failure in one. Relapses were observed, 3 months after the last IVCY (2 cases) and 12 months after the last IVCY (one case). Transitory thrombocytopenia and leukopenia developed in one patient and nausea and vomiting in another.

CONCLUSION

IVCY appears effective in controlling the lesions of pyoderma gangrenosum and inducing remission for a substantial period in many individuals.

Two year followup of anterior and vertical atlantoaxial subluxation in ankylosing spondylitis

OBJECTIVE

To describe the clinical and radiological 2-yr followup of 22 patients with anterior atlantoaxial subluxation (AAS) from a prospective cohort of patients with ankylosing spondylitis.

METHODS

The 2-yr assessment included a structured questionnaire for rheumatologic and neurologic complaints and lateral cervical radiographs in maximal flexion view. Initial and 2-yr radiographs were assessed blind to patient data. The course of anterior AAS was classified as unchanged (< 1 mm), progression (> or = 1 mm) or regression (> or = 1 mm) at 2 yrs compared with baseline. Vertical AAS was classified using the Sakaguchi-Kauppi method. Magnification factor was corrected using the ratio of C3 width.

RESULTS

Anterior AAS was detected in 22 patients at baseline examination. Two patients also had vertical AAS; 86% were male. Mean age was 33 +/- 9 yrs and mean disease duration was 12 +/- 7 yrs. At followup, one patient had died of acquired immunodeficiency syndrome, 3 could not be reached, and 2 had undergone surgical fusion due to severe myelopathy and now showed complete neurological recovery. Of the remaining 16 patients, 7 (32%) showed progression and 9 (41%) showed no change in the C1-odontoid distance. Vertical AAS developed in one patient. After the 2-yr assessment, 3 additional patients had surgical fusion because of notable progression of AAS, despite absence of neurological signs.

CONCLUSION

Anterior AAS progressed in a number of these patients in the 2 yrs following its detection, and with or without neurological signs, surgical management was thought appropriate in a considerable number of them.

Cardiac manifestations in dermato-polymyositis

OBJECTIVE

To describe the functional and anatomic heart abnormalities of patients with dermato-polymyositis.

METHODS

Thirty-two consecutive patients with dermato-polymyositis (DM/PM) were studied. Patient assessments included a questionnaire for cardiac symptoms, physical examination, muscular enzymes, standard electrocardiogram (EKG), chest radiographs, spirometry, Holter monitoring and color Doppler flow (CDF) studies. Features evaluated with CDF included left ventricular diastolic dysfunction (LVDD), hyperdynamic heart, mitral valve prolapse, and endomyocardial fibrosis.

RESULTS

Twenty-five patients (78%) were female. The mean age was 43 years and the mean disease duration 6 years. Twenty-six (81%) patients had dermatomyositis. Only 2 (6%) had cardiac symptoms. Spirometry was performed in 20 patients, Holter monitoring in 23 and CDF in 26 patients. Electrical disturbances detected by either EKG or Holter were present in more than half of the patients studied. LVDD was identified in 11 patients (42%) and hyperdynamic heart in 4 (15%). None of the 26 patients studied by CDF had mitral valve prolapse. No significant differences in the frequency of cardiac abnormalities, including LVDD, were observed in relation to the diagnosis of DM or PM, the presence of Raynaud's phenomenon or calcinosis, or the disease activity status at the moment of the study.

CONCLUSIONS

Subclinical heart abnormalities are frequent in patients with DM/PM. LVDD appears to be common. Our findings suggest that cardial assessment of patients should be performed in order to detect abnormalities requiring specific therapy.

Frequency of atlantoaxial subluxation and neurologic involvement in patients with ankylosing spondylitis

OBJECTIVE

To determine the prevalence of anterior and vertical atlantoaxial subluxation (AAS) and its neurological effect in a consecutive sample of Mexican patients with ankylosing spondylitis (AS).

METHODS

Consecutive patients with a diagnosis of AS who attended 2 secondary care outpatient rheumatology clinic in the city of Guadalajara within a period of 6 mo were included in the study. Patients had prospective rheumatologic and neurologic assessments using structured questionnaires and examinations. Recorded variables included demographic data, disease characteristics, neurologic symptoms and signs, and axial mobility measurements. Somatosensory evoked potentials (SSEP) were performed in all patients. Patients also underwent standard cervical spine radiography with anteroposterior open mouth, and neutral, full flexion and extension lateral views.

RESULTS

We studied 103 patients. Mean age was 35 yrs, 74% were male, and mean disease duration was 10 yrs (S/- SD 7.9). Anterior AAS was observed in 22 patients (21%, 95% CI 13-29%) and vertical AAS in 2 cases (2%, 95% CI 0-7%). Ossification of the posterior longitudinal ligament (OPLL) was present in 16 patients. Statistically significant associations were observed between anterior AAS and SSEP (p < 0.0001) and OPLL (p = 0.04). The degree of radiologic sacroiliitis was also associated with anterior AAS. After completion of the study, 2 patients required surgical fusion due to severe cervical cord compression.

CONCLUSION

The prevalence of AAS and OPLL in this population was higher than previously reported in other settings. The association of anterior AAS with OPLL and radiological sacroiliitis could identify a subgroup of patients with more severe axial enthesopathy. Although clinically significant neurologic complications are not frequent in these patients, AAS may cause severe spinal cord compression requiring surgical fusion.