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

This article provides a thorough review of erosive osteoarthritis of the hands, including the small changes observed over time in the epidemiology of the disease and the literature on genetic, etiopathogenic and clinical features. We also review the most useful complementary tests, the key points of the differential diagnosis, and end with an update on the treatment of this entity. Better understanding of this disease will help to achieve en earlier diagnosis of its signs and symptoms, a better therapeutic approach, and closer monitoring of disease progression to avoid future disability.

Sporadic inclusion body myositis (IBM) is a major subgroup among idiopathic inflammatory myopathies. The clinical and pathologic findings of this disease are well defined but are not always easy to identify. IBM mainly affects men aged more than 50 years old who usually present with chronic and sometimes asymmetrical weakness and atrophy, thus requiring a wide differential diagnosis. Some well-characterized autoimmune diseases are associated with IBM. However, unlike dermatomyositis, there is no association with neoplastic disease. Clinical and histopathological data are mandatory in the diagnosis of IBM, while laboratory and electromyographic studies are usually non-diagnostic. In contrast, magnetic resonance imaging may help in diagnosis and should possibly be included in the diagnostic criteria. The pathogenesis of IBM is still not well-defined, as it involves interrelations among inflammatory, degenerative and mitochondrial phenomena. Diagnostic delay is the rule, and the response to available treatments is poor except when an autoimmune disease is associated with IBM.

Femoroacetabular impingement (FAI) is a clinical and radiological syndrome resulting from repetitive abutment between the acetabular rim and the femur. This syndrome should be included in the differential diagnosis of hip pain, especially in the young. The most important imaging technique for suspected FAI is standard radiology, but the gold-standard for diagnosis is arthro-magnetic resonance imaging (MRI). The cornerstone of treatment is surgery but outcome depends on several factors such as physical activity, FAI type, disease duration, surgical technique and, especially, whether the cartilage is damaged. For non-prosthetic surgical treatment to be effective, early diagnosis of FAI is essential. Late diagnosis, when hip osteoarthritis is already present, limits surgery to hip replacement.

Complex regional pain syndrome (CRPS) is a painful disorder, classified in two types depending on whether no nerve lesion has been detected (type I) or whether a nerve lesion is present (type II). CRPS usually develops after a noxious event (trauma injury or surgery), but can sometimes appear spontaneously, and genetic factors may predispose to CRPS. Several etiopathogenic concepts have been proposed, such as neurogenic inflammation, pathological sympathetic activation and neuroplastic changes in the central nervous system. Diagnosis is mainly based on clinical symptoms and signs, such as autonomic, motor and sensory disturbances. The most common and early symptom is pain, as well as distal edema, sweating, disturbances of skin temperature and color, hyperalgesia, motor weakness and, in chronic phases, skin and muscle atrophy. Therapy should be based on a multidisciplinary approach, including non-pharmacological therapies (physiotherapy, occupational therapy, psychological therapy), pharmacological treatments (analgesics, steroids, free radical scavengers, calcitonin, bisphosphonates), and invasive interventions (sympathetic nerve blockade, spinal cord stimulators).

Silent lupus nephritis (SLN) is an unusual clinical presentation of lupus nephritis (LN) and may be an underdiagnosed entity. Renal biopsy is the only diagnostic method but is invasive and is not indicated in asymptomatic patients. Consequently, the prevalence of this disease is difficult to determine. Data from more than 250 SLN cases published in the literature were analyzed from isolated cases, case studies and prospective studies. Of the 226 well-described cases, we selected 197 reported after the 1970s. Patients with class I lesions (n = 29, 15%) were excluded as they fell outside the definition of SLN. Among included patients, there were 107 with class II (54.3), 45 with class III (22.8%), 50 with class IV (25.4%), 9 with class V (4.6%) and one with class VI. Forty percent had proliferative forms (classes III and IV), the most severe forms of LN.

Of the 197 patients, 65 patients (33%) from six publications were followed-up. The data did not allow conclusions to be drawn on the epidemiology or prognosis of this entity. Future studies are required to clarify these issues.

In the international literature, rheumatoid arthritis (RA) of the elderly is considered to be that affecting persons aged over 65 years. Currently, this population comprises most series of patients with RA and includes both persons with disease onset after this age and those with chronic RA developing years previously. RA with onset after the age of 65 is called elderly onset rheumatoid arthritis (EORA) and shows slightly different clinical manifestations from RA developing in younger individuals. However, both the therapeutic arsenal used and the objectives proposed for the treatment of RA of the elderly differ little from those employed in younger patients. The same therapies are employed but are adapted to the particular characteristics of this population, such as pharmacokinetic changes, comorbidities, and an increased susceptibility to infection. The aim of treatment —disease remission— is the same as in younger patients. Excessive caution in the use of drugs may lead to suboptimal treatment, especially in the initial stages when the disease is more active, and leave irreversible sequelae. Treatment should be individually tailored to the patient's characteristics, with adequate monitoring. Traditionally, elderly patients more frequently received glucocorticoids and were rarely treated with disease-modifying antirheumatic drugs (DMARDs) or biological agents. People over 65 years are underrepresented in clinical trials but there seem to be no particular contraindications to the use of methotrexate or anti-tumor-necrosis factor (anti-TNF) agents in this population. Data from national registries in several countries have confirmed the similar safety and efficacy of DMARDs and anti-TNF agents in elderly patients. Data on the administration of other biological agents in the elderly are limited. Rheumatologists should be aware of the higher risk of adverse events in this population, especially when using non-steroidal anti-inflammatory drugs, and should recognize the need to adjust treatment to the individual characteristics and comorbidities of each patient.

Acupuncture is a medical procedure and therefore requires a diagnosis, a therapeutic indication and a prognosis. These tasks form part of medical expertise and must be carried out by suitably qualified and accredited health professionals. Recent investigations have started to establish the scientific basis of acupuncture and consequently the mechanisms of action and the local and systemic mediators involved in this modality are beginning to be understood. Published systematic reviews indicate that the main rheumatic diseases the benefit from acupuncture are osteoarthritis, myofascial pain syndrome, epicondylitis, and neck, shoulder and low back pain. From the perspective of evidence-based medicine, the use of acupuncture in the treatment of osteoarthritis and chronic cervical and lumbar pain is efficient in terms of quality-adjusted life years. Accordingly, acupuncture is a strategy that should be considered in excellent healthcare management.

Wartenberg's syndrome is a rare compression neuropathy of the sensory branch of the radial nerve and is characterized by pain and paresthesia in the radial dorsal forearm radiating to the back of the thumb and second and third fingers. The etiology of this syndrome can be varied. Diagnosis is based on clinical history, physical examination and electromyography. The most common treatment is nonsurgical with splints and steroid injections. The prognosis of Wartenberg's syndrome is usually good. The present article reviews this entity.