Seminarios de la Fundación Espa?ola de Reumatología最新文献

In the medical literature dactylitis is defined as a “inflammation of a finger or toe”. It is a typical manifestation of spondyloarthritides, especially of psoriatic arthritis, although this peculiar inflammation can be produced by other entities, such as inflammatory dactylitis (spondyloarthritis, gout or sarcoidosis), infectious dactylitis (tuberculosis, syphilis or blistering distal dactylitis) or non-inflammatory dactylitis (sickle-cell disease). In spondyloarthritis, dactylitis is the result of a flexor tenosynovitis and secondarily of small joint synovitis. Some clinical trials with tumor necrosis factor (TNF)-blockers have evaluated secondary dactylitis and have generally shown efficiency in the control of this peculiar sign. Gout can produce dactylitis due to urate crystal deposits, while other radiological features are similar to those of spondyloarthritides. Chronic sarcoidosis is another cause of dactylitis secondary to granulomatous invasion of the bone and soft tissues. Infectious forms of dactylitis are typical in pediatric ages and can be due to osteomyelitis, as in the case of tuberculosis and syphilis, or to infection of the soft tissues, as in blistering distal dactylitis. Finally, in sickle cell anemia, inflammation is a result of bone marrow infarction.

Juvenile-onset spondyloarthritis is a special group within the entities included in the concept of spondyloarthritis, and is characterized by a predominantly peripheral involvement (arthritis and enthesitis), and more frequent presentation as undifferentiated forms. However, like its adult-onset equivalent, it has the potential to develop structural damage and progress to juvenile ankylosing spondylitis, with consequent irreversible functional impairment. Many important advances have been made in the understanding of the genetics and pathophysiology of juvenile-onset spondyloarthritis, as well as in the diagnosis and treatment of this entity. These advances are summarized in this article.

The biological therapies based in the anti-tumor necrosis factor-α (TNF) are an effective alternative for the treatment of chronic inflammatory diseases. However, given that anti-TNF-α therapy has been associated with reactivation of latent tuberculosis infection, a previous evaluation of the patients is required in order to avoid their progression to active TB in case of being infected. Tuberculin skin testing (TST) is used to diagnose tuberculosis infection but it has low specificity in patients who have received the BCG vaccine and low sensitivity in patients with altered cell-mediated immunity. In vitro assays based on the detection of interferon-γ (IFN) released by T cells stimulated by specific Mycobacterium tuberculosis antigens have emerged as an option for the diagnosis of tuberculosis infection. The results to date show, that they are a viable alternative to TST thanks to their higher specificity and sensitivity. Although there are some preliminary results indicating that the IFN-γ tests could be used alone, at the moment it seems more prudent to use them in combination with the TST, considering infection when either of them is positive.

This article reviews the papers published on the factors related to the development of adverse effects in rheumatoid arthritis patients treated with anti-tumor necrosis factor-α drugs.

The adverse effects studied were: infectious disease, cardiovascular complications, tumor development and mortality risk.

Psoriatic arthritis (PA) is defined as an inflammatory form of arthritis associated with psoriasis. This condition is mainly characterized by the presence of arthritis, enthesitis, typical radiographic findings, and the absence of rheumatoid factor. The increase in immune and inflammatory cells of the synovitis produces cytokines and other molecules that may influence bone remodelling, increasing the frequency of osteoporosis and fragility fractures. Osteoporosis has been better documented in rheumatoid arthritis than in PA and there is less information on the bone mass of PA patients. Osteoporosis in PA has been studied less extensively and in heterogeneous groups of patients, and the results are contradictory since not all studies have shown a higher incidence of osteoporosis. The present review summarizes the suggested etiopathogenic mechanisms and possible strategies in the clinical management and treatment of this entity and provides a review of the studies published on the topic. The main mechanisms involved in osteoporosis in PA would seem to be the activation of osteoclastogenesis by the inflammatory disease itself and corticosteroid therapy. PA is a common condition in clinical practice and it more data on osteoporosis in these patients would help to improve decision making in the management of the PA.

Garrod's pads, also known as knuckle pads, are asymptomatic papules located in the skin over the dorsal aspects of the metacarpophalangeal or interphalangeal joints. They may be idiopathic or associated with repetitive trauma, autosomal dominant diseases, and fibrosing disorders such as Dupuytren's contracture.

Primary Sjögren syndrome (PSS) is an autoimmune disease characterized by lymphocytic infiltration in exocrine glands, mainly the salivary and lachrymal glands, resulting in xerophthalmia and xerostomia. Occasionally, PSS has extra-glandular manifestations, including central (CNS) and peripheral nervous system (PNS) involvement. The reported prevalence varies in the literature, mainly because of heterogeneity in the diagnostic and classification criteria. Involvement of the PNS is more frequent than that of the CNS, presenting as axonal, sensory, autonomic or small fiber neuropathies and mononeuritis multiplex. CNS manifestations may be focal or diffuse and are associated with increased extra-glandular involvement and the presence of autoantibodies. Treatment is based on corticosteroids. In severe, refractory- or corticosteroid-dependant cases, immunosuppressant agents such as azathioprine or cyclophosphamide may be useful. Observational studies have suggested that rituximab is useful in some PSS extra-glandular manifestations. Currently, clinical trials with new biological agents such as belimumab and epratuzumab are being conducted in PSS.

Imaging techniques are routinely used to evaluate patients with suspected musculoskeletal infection. Although radiographs will not establish the diagnosis, they should always be performed when infection is suspected because of their utility in differential diagnosis and follow-up. Radiographs provide an overview of the anatomical region of interest and of previous alterations that can influence the selection and interpretation of subsequently used techniques. Magnetic resonance imaging is the most sensitive examination, does not irradiate, and provides excellent anatomic detail and rapid results. This technique is especially valuable in spondylodiscitis, osteomyelitis, and diabetic foot infections. Its main limitations are the false-positives caused by nonspecific bone edema and poor reliability in the assessment of short-term therapeutic response. Among nuclear medicine procedures, the 3-phase bone scan is widely available and highly accurate in previously healthy bone. Labeled leukocyte scintigraphy should be used in complicated osteomyelitis, such as prosthetic infection, although it is also useful to exclude infection in diabetic foot and neuropathic joints. Ga-67 scintigraphy is useful in spinal infections. In these infections, positron emission tomography can also be a useful alternative. Finally, it is important to remember atypical radiological presentations in distinct locations and particular clinical situations, as well as certain conditions that can mimic infection.

In the last few years there has been has been an explosion in information and communication technologies (ICT) both worldwide and in the health sector, mainly due to access to personal computers and internet expansion, which has facilitated access among health professionals and the public (whether patients, users, or citizens) to increasing information and communication on health. The spectrum of ICT is extremely wide and, in the last few years, has included electronic health (e-Health), defined as the set of techniques and devices used for treatment and the transmission of health information. Within e-Health, new fields are expanding, such as the electronic medical record and telemedicine.

Digital medicine has transformed the traditional medical record into the electronic medical record and has shifted ways of gaining medical knowledge to searches of literature databases and new knowledge management tools, such as clinical practice guidelines or systematic reviews. Moreover, health organizations require computerization of their support processes, which has transformed these organizations. Telemedicine represents another revolutionary change by allowing off-site diagnosis and treatment, as well as education and continuing medical training (e-learning).

Health professionals currently play an essential role in educating patients in the appropriate use of internet health resources. The doctor-patient relationship has become a «triadic» one, in which the computer plays an increasingly important role. ICT tend to improve patient safety but paradoxically also pose certain risks. In the next decade, there will be an unprecedented increase in health information, which will require enhanced measures to reduce the possible risks. These measures include the adoption of common standards, the development of better information systems, and greater training of users of the new ICT. Health professionals should be able to meet the challenge posed by this transformation.