Revista Colombiana de Reumatología

Telerheumatology: Previous, current, and future context, from the experience of an institution in Colombia

Description of a tele-rheumatology service in a Colombian institution

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ABSTRACT Introduction: Models in health care have been static for a long time, but recently there has been a change in recognising that technology in the area of information and communication could lead to a change in improving health services. Telemedicine has been increasing and its use now extends to the entire process of health care. It is beginning to be implemented in the rheumatology area, in Colombia. The characteristics of a tele-rheumatology service are described, as well as a more detailed observation of a cohort of patients with rheumatoid arthritis (RA), in order to identify strengths and improvements. Methods: A descriptive observational cross-sectional study was conducted on the total population of patients who were treated by the tele-rheumatology service in the synchronous modality for a period of 30 months. As regards the follow-up of patients with RA, all patients were included who were treated exclusively by means of synchronous telemedicine for a minimum period of 6 months with at least three follow-ups, in which it was possible to calculate the clinimetry by Das28 with the use of C reactive protein (CRP). Measures of frequency, central tendency and dispersion according to type of variable will be used for the descriptive analysis. Results: Data was collected from 1905 patients during the period between August 2017 and March 2020. A total of 4864 consultations were made. Non-attendance of 368 (7.85%) consultations was registered. There were 1784 (83%) patients with a definitive diagnosis by the rheumatologist. A total of 284 patients (14.9%) were discharged by the rheumatology service, and 85 (4.46%) were referred for an exclusively face-to-face evaluation. Auxiliary medical care at the place of origin was provided by a general practitioner in 1,749 (91%) cases. There was no security during the care process as regards the physical examination in 46 (2.4%) cases. Of the total number of patients, 184 (9.6%) cases came from rural areas or municipalities far from the place of care. Biological therapies were prescribed in 139 patients, 56 new prescription during the 30 months. Of 479 RA patients, 200 met the criteria for follow-up. Of these, according to the activity measured by DAS28 with the use of ultrasensitive CRP, 54 patients (27%) were found on admission to the program in remission, 23 (11.5%) patients had low activity, 81 (40.5%) patients had moderate activity, and high activity was found in 42 (21%) patients. Regarding the start of follow-up, there was a 47% increase in the number of patients in remission, and low activity to 19.5%, in contrast to a reduction of 25% in patients with moderate activity and in 9% increase high activity in their last measurement, possible during monitoring. In the group of 200 patients from long-term follow-up, biological therapies were used 61 times. Of the 166 patients during follow-up without biological therapies on admission, these were required in 16%. Discussion: A detailed follow-up of the patients was carried out in the telemedicine service in a synchronous way for a period of two and a half years. The low percentage of absences shows a good adherence to the program. Physical examination, the main reason for medical care at the remission site, was not without difficulties, in this minority it was necessary to carry out diagnostic images. It would be important to assess this group of patients where there are doubts regarding the physical examination, those who have a certain number of appointments without a definitive diagnosis, or in whom biological or high-cost therapies would be used should necessarily be referred to face-to-face consultation. In the group of patients with RA, the percentage of biological use is considered high in relation to the expected standards. This may be for several reasons, such as the high number of patients with prior use of biological agents, the majority of patients with long-term disease, and difficulties in accessing follow-up due to rheumatology, as well as the small number of sero-negative patients in the study population, and practices related to non-presential medical practice may overestimate the activity of the disease. In conclusion, telemedicine has great advantages in the care of rheumatology patients, although it requires modifications to improve these services in favour of patients.

Vitamin D deficiency in patients with spondylarthritis in a Spanish (Castilla-La Mancha) hospital

RESUMEN Introducción: Las espondiloartritis son un grupo de enfermedades inflamatorias crónicas con afectación principalmente del esqueleto axial y también de articulaciones periféricas. En cuanto al metabolismo óseo de estos pacientes, se ha observado en algunos estudios que existen niveles más bajos de vitamina D en pacientes con espondiloartritis. Objetivo: Estimar la prevalencia de déficit/insuficiencia de vitamina D, el metabolismo fosfocálcico y sus implicaciones en una cohorte de pacientes con espondiloartritis. Metodología: Estudio observacional, descriptivo y transversal. Se llevó a cabo una revisión retrospectiva de la base de datos de pacientes con espondiloartritis que fueron atendidos en las consultas externas del Servicio de Reumatología del Hospital General Universitario de Ciudad Real entre junio del 2018 y junio del 2019. Las variables se describieron usando medidas de frecuencia o medidas de tendencia central/dispersión según correspondiera. Resultados: Se analizaron 115 pacientes, de los cuales 64 fueron hombres y 51 mujeres, con una edad media de 45,97 años (± 13,41 DE). Del total de los pacientes, 59 presentaron espondilitis anquilosante, 24 artropatía psoriásica, 9 artritis asociada a enfermedad inflamatoria intestinal, 12 espondiloartritis axial no radiográfica y 11 artritis reactiva. Los niveles de vitamina D fueron de 23,81 ng/ml (±10,5 DE), con un 77,4% de los pacientes con cifras de déficit/insuficiencia de vitamina D. Agrupados por el subtipo de espondiloartritis y según las cifras de déficit/insuficiencia de vitamina D, 45 pacientes tenían espondilitis anquilosante, 19 artropatía psoriásica, 9 artritis asociada a enfermedad inflamatoria intestinal, 7 espondiloartritis axiales no radiográficas y 9 artritis reactivas. Además, el déficit de vitamina D (< 20 ng/ml) se presentaba la mayoría de las veces en las estaciones de primavera e invierno, con 31 y 26 pacientes respectivamente. Conclusiones: Una optimización de los niveles de vitamina D puede implicar una mejoría en la situación clínica del paciente, medida tanto por BASDAI y DAPSA como por PCR y VSG. En consecuencia, se recomienda la monitorización y suplementación de vitamina D en pacientes con hipovitaminosis D.

ABSTRACT Introduction: Spondyloarthritis is a group of chronic inflammatory diseases that mainly affect the axial skeleton, and also the peripheral joints. In bone metabolism studies on these patients, it has been observed that there are lower levels of vitamin D in patients with spondyloarthritis. Objective: To estimate the prevalence of vitamin D deficiency / insufficiency, as well as calcium/ phosphate metabolism and their implications in a cohort of patients with spondyloarthritis. Methodology: Observational, descriptive, and cross-sectional study. A retrospective review of the databases was carried out on patients with spondyloarthritis who were treated in the outpatient clinics of the Rheumatology Department of the General University Hospital of Ciudad Real between June 2018 and June 2019. Variables are described using frequency and central tendency / dispersion measurements as appropriate. Results: The study included 115 patients, of whom 64 were men and 51 women, with a mean age of 45.97 years (± 13.41 SD). They included 59 patients with ankylosing spondylitis, 24 with psoriatic arthropathy, 9 arthritis associated with inflammatory bowel disease, 12 non-radiographic axial spondylarthritis, and 11 reactive arthritis. Vitamin D levels were 23.81 ng/ml (± 10.5 SD), with 77.4% of patients with vitamin D deficiency / insufficiency levels. Grouped by the spondylarthritis subtype, and according to vitamin D deficiency / insufficiency, 45 patients had ankylosing spondylitis, 19 psoriatic arthropathy, 9 arthritis associated with inflammatory bowel disease, 7 non-radiographic axial spondyloarthritis, and 9 reactive arthritis. Furthermore, vitamin D deficiency (< 20 ng/ml) mainly occurred in the spring and winter seasons, with 31 and 26 patients, respectively. Conclusions: An optimization of vitamin D levels may lead to an improvement in the clinical situation of the patients, as measured by both BASDAI and DAPSA, as well as by PCR and ESR. Therefore, vitamin D monitoring and supplementation is recommended in patients with vitamin D deficiency.

Prevalence of latent tuberculosis determined using the Purified Protein Derivative (PPD) test in adult patients with rheumatoid arthritis receiving biotechnological therapy

RESUMEN Introducción: Colombia es un país endémico para tuberculosis (TB), con una prevalencia de 26 casos por millón. Sin embargo, no se cuenta con datos recientes y claros respecto a la prevalencia de tuberculosis latente (TBL) en la población con artritis reumatoide (AR) candidata a terapia biotecnológica. Metodología: Estudio de corte transversal con componente analítico para determinar la pre-valencia de TBL en pacientes con AR candidatos a terapia biotecnológica. Resultados: La prevalencia de TBL en pacientes con AR candidatos a terapia biotecnológica es alta, del 18,3% (IC 95% 14,7-21,9), y en los cruces exploratorios se encontró una relación entre TBL y la variable género masculino (p ≤ 0,001), hallazgos anormales en la radiografía de tórax (p = 0,039) y el tabaquismo (p = 0,028). Conclusión: La prevalencia de TBL en pacientes con AR candidatos a terapia biotecnológica es alta. Se requieren estudios prospectivos para evaluar la incidencia de TB en este grupo de pacientes y así corroborar su asociación.

ABSTRACT Introduction: Although tuberculosis (TB) is endemic in Columbia, with a prevalence of 26 cases per million, there are no recent and clear data regarding the prevalence of latent tuberculosis (LBT) in the population with rheumatoid arthritis (RA), candidates for biotechnological therapy. Methodology: A cross-sectional study with an analytical component to determine the prevalence of LBT in patients with RA who are candidates for biotechnological therapy. Results: The prevalence of LTB in RA patients who are candidates for biotechnological therapy is high, 18.3% (95% CI: 14.7-21.9). In the exploratory analysis, a relationship between LBT and male gender was found (P ≤ .001), as well as abnormal findings on chest radiography (P = .039), and smoking (P = .028). Conclusion: The prevalence of LTB in patients with RA who are candidates for biotechnological therapy is high. Prospective studies are needed to evaluate the incidence of TB in this group of patients and corroborate this association.

Factors associated with the use of tumor necrosis factor alpha inhibitors in a population of Colombian patients with spondyloarthritis

RESUMEN Introducción: El uso de TNFi es cada vez más frecuente en los pacientes con espondiloartritis. Identificar tempranamente aquellos que los requerirán o poder predecir su uso puede ayudar a hacer un tratamiento más efectivo y oportuno racionalizando su uso. Objetivo: Determinar los factores qué mejor explican la indicación de TNFi en la población en estudio. Material y métodos: La asociación entre el uso de medicamentos anti-TNFα y las variables categóricas demográficas, clínicas, de laboratorio, radiológicas y de tratamiento se exploró por prueba exacta de Fisher. La asociación con las variables cuantitativas fue evaluada con t de Student o U de Mann Withney, de acuerdo con su distribución. Aquellas variables con p < 0,25 fueron ingresadas a modelos univariante de regresión logística explicativa para construir los OR crudos; aquellas con p < 0,25 se incluyeron en el modelo multivariante para construir OR ajustados. Resultados y discusión: La población está constituida por 181 pacientes. Modelo univariante: la artritis reactiva, uretritis y compromiso periférico fueron factores protectores para el uso de TNFi. Espondiloartritis axial, lumbalgia inflamatoria, dolor glúteo alternante, rigidez matinal sacroilitis demostrada por cualquier método, tratamiento con inhibidores COX-2, tiempo de evolución de tres arios o más y los puntajes de BASDAI y BASFI se asociaron con el uso de TNFi. Modelo multivariante: artritis reactiva (OR 0,1, IC 95% 0,012-0,86, p = 0,036), lumbalgia inflamatoria (OR 13,63, IC 95% 1,36-136, p = 0,026), sacroilitis (OR 7,71, IC 95% 1,04-57, p = 0,045, uso de coxib (OR 10,1, IC 95% 2,71-37,62, p = 0,001) y el puntaje máximo de BASDAI (4-6: OR 6,1, IC 95% 1,3-28,7, p = 0,022, mayor de 6: OR 15,8, IC 95% 2,2-113, p = 0,006) se asociaron independientemente con el uso de TNFi. El uso de coxib se asoció con la indicación de usar TNFi tanto en los pacientes con espondiloartritis axial (OR 4,2, IC 95% 1,74-10,11, p = 0,001) como periférica (OR 4, IC 95% 1,85-8,62, p < 0,001). Conclusiones: El inicio de la enfermedad en la forma de artritis reactiva se comportó como un factor protector para la necesidad posterior de usar TNFi, mientras que presentar lumbalgia inflamatoria, sacroilitis demostrada por cualquier método, el tratamiento con coxib y el puntaje máximo de BASDAI mayor de 4 se asociaron con el uso de estos medicamentos.

ABSTRACT Introduction: The use of tumor necrosis factor (TNF) alpha inhibitors is increasing in patients with spondyloarthritis. Early identification of those that would require them, or the ability to predict their use, could lead to a more effective and timely treatment by rationalizing their use. Objective: To determine factors that better explain the indication of TNFi in the study population. Material and methods: The association between anti-TNFα use and categorical demographic, clinical, laboratory, radiological and treatment variables was explored using Pearson's Chi2 or Fisher's exact test. The association with the quantitative variables was evaluated using Student's t test or Mann Whitney U test, depending on their distribution. Those variables with P < 0.25 were entered into univariate models of explanatory logistic regression to construct crude ORs, and those with P < 0.25 were included in the multivariate model to construct adjusted ORs. Results and discussion: The study population includes 181 patients. In the univariate model: reactive arthritis, urethritis, and peripheral involvement were protective factors for the use of TNFi. Axial spondyloarthritis, inflammatory lumbalgia, alternating gluteal pain, morning stiffness, sacroiliitis demonstrated by any method, treatment with COX-2 inhibitors, evolution time of three years or more, and BASDAI and BASFI scores were associated with the use of TNFi. Multivariate model: reactive arthritis (P = 0.036), inflammatory back pain (P = 0.026), sacroiliitis (P = 0.045), use of coxibs (P = 0.001) and the maximum score of BASDAI (P = 0.022, P = 0.006) were independently associated with the use of TNFi. The use of coxibs was associated with the indication of using TNFi in both patients with axial spondyloarthritis (P = 0.001) and peripheral (P < 0.001). Conclusions: The onset of the disease in the form of reactive arthritis behaved as a protective factor for the subsequent need to use TNFi, while presenting with inflammatory back pain, sacroiliitis, demonstrated by any method, treatment with coxibs, and the maximum score of BASDAI greater than 4 associated with the use of these medications.

Antiphospholipid syndrome (APS): Clinical and immunoserological differences between primary and secondary APS in a Colombian cohort

RESUMEN Introducción: El síndrome antifosfolípido (SAF) es una enfermedad autoinmune sistémica, caracterizada por trombosis recurrente, que puede afectar la circulación arterial y venosa. Objetivo: Analizar las diferencias inmunológicas y farmacológicas, así como los desenlaces clínicos de una cohorte de pacientes con SAF primario y secundario. Materiales y métodos: Estudio de corte transversal que incluyó 352 pacientes con diagnóstico de SAF atendidos entre los arios 2014 y 2018. Se analizaron variables sociodemográficas, clínicas e inmunológicas y se realizó un análisis univariado y un análisis bivariado mediante la prueba chi-cuadrado para determinar diferencias entre los pacientes con SAF primario y SAF secundario. Finalmente, se hizo un análisis multivariado para buscar asociaciones con los desenlaces clínicos trombóticos en los pacientes con SAF. Resultados: La edad promedio de la población fue de 42,4 ± 14 años; el 84,6% correspondió a sexo femenino. El 67,6% de los pacientes tenía diagnóstico de SAF primario y un 32,4% de SAF secundario, siendo el lupus eritematoso sistémico (LES) la enfermedad asociada en un 84%. Dentro de los eventos trombóticos, el más frecuente fue la trombosis venosa profunda (17,3%), seguida por el ataque cerebrovascular (9,9%). En los eventos obstétricos existió una prevalencia del 39,4% para abortos. No se encontraron diferencias en el perfil sociodemográfico ni en el perfil inmunoserológico entre los pacientes con diagnóstico de SAF primario y aquellos con SAF secundario. Los eventos trombóticos tuvieron mayor frecuencia en el grupo de SAF primario, pero solo la tromboembolia pulmonar alcanzó significación estadística. Eventos obstétricos como los abortos no fueron diferentes entre ambos grupos. Dentro de los factores asociados a los eventos trombóticos, se encontró que el sexo femenino tiene una probabilidad 5 veces mayor de accidente cerebrovascular y 3 veces mayor de trombosis venosa profunda. Los anti- β2GPI tipo IgM aumentaron alrededor de 3 veces la probabilidad de presentar abortos en mujeres con SAF. Conclusión: Se presenta una de las cohortes colombianas más grandes de pacientes con SAF reportadas hasta el momento en la literatura. La población es comparable clínica y sociodemográficamente con lo encontrado en otros estudios, aunque la prevalencia de SAF primario fue mayor y las complicaciones trombóticas fueron menores. La tromboembolia pulmonar fue significativamente mayor en el grupo de SAF primario.

ABSTRACT Introduction: Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by recurrent thrombosis that can affect the arterial and venous circulation. Objective: To analyze the immunological and pharmacological differences, as well as the clinical outcomes of a cohort of patients with primary APS and secondary APS. Materials and methods: A retrospective cohort study was conducted that included 352 records of patients diagnosed with APS and treated between 2014 and 2018. A description is presented of the sociodemographic, clinical, and immunological profile of the population. A bivariate analysis performed using the chi-squared test to determine differences between groups with primary APS and secondary APS, and finally a multivariate analysis to search for associations with thrombotic clinical outcomes in patients with APS. Results: The mean age was 42.4 ± 14 years, and 84.6% were females. Two-thirds (67.6%) of the patients had a diagnosis of primary APS, and 32.4% of secondary APS, of which 84% were associated with systemic lupus erythematosus (SLE). Among the thrombotic events, the most frequent were deep vein thrombosis (17.3%) and stroke (9.9%). Obstetric events were frequent, with a prevalence of 39.4% for miscarriages. No differences were found in the sociodemographic or immunoserological profile when comparing the group of primary vs. secondary APS. Thrombotic events were more frequent in the primary APS group, although only pulmonary embolism reached statistical significance. There were no differences between the two groups as regards obstetric events, such as miscarriages. Women were found to be 5 times more likely to have a stroke and 3 times more to have deep vein thrombosis. The anti-β2GPI type IgM increased the probability of presenting miscarriages about 3 times in women with APS. Conclusion: The study contains one of the largest Colombian cohorts with APS reported so far, and although it is both clinically and sociodemographically similar to other cohorts, there is a higher prevalence of primary APS. There was a lower frequency of thrombotic complications compared to other cohorts. Patients with primary APS had a tendency to develop thrombosis, as has already been reported in the literature.

Use of benzodiazepines and antidepressants in patients who attend a Rheumatology clinic

ABSTRACT Introduction: During the last decades, benzodiazepines (BZD) and antidepressants (ADP) have been among the most prescribed therapies in all developed countries. They have side effects, and BZD carry a risk of abuse and dependence disorders. The purpose of this study was to evaluate the prevalence of BZD and ADP among patients who attend a Rheumatology clinic, as well as the indication for these drugs. Methods: The study included patients who were referred for the first time to the Rheumatology clinic. Demographical data, reason for referral, and final diagnosis were recorded. The indication for ADP and/or BZD was recorded, as well as the duration of treatment. Sample size was estimated for a 0.05% alpha risk. Univariate and multivariate analyses were performed in order to study the relationships with the demographical or clinical characteristics. Results: A total of 350 patients were included (women 77.1%, men 22.9%). Most of them (73.4%) had been referred for musculoskeletal pain. More than a third (36.6%) of patients were on BZD and/or ADP. The most frequent reasons for their prescription were anxiety, depression, and insomnia. The final diagnosis in the clinic was a non-inflammatory condition in 82%, and an inflammatory one in 18%. In the univariate analyses, the use of BZD/ADP was associated with female gender (p<.001), unemployment (p<.001) and non-inflammatory final diagnosis (p < .001). In the multivariate analyses, the use of BZD and/or ADP was associated with female sex (p = .002 [OR 3.4, 95% CI; 1.6-7.4]), and a non-inflammatory final diagnosis, specifically fibromyalgia (p = .007 [OR 16.1, 95% CI; 2.2-120.7]). Conclusion: Use of BZD and ADP is high and associated with non-inflammatory disease.

RESUMEN Introducción: Durante las últimas décadas, las benzodiacepinas (BZD) y los antidepresivos (ADP) han estado entre las terapias más prescritas en todos los países desarrollados. Estos fármacos tienen efectos secundarios y las BZD pueden ocasionar abuso y problemas de dependencia. El objetivo de este estudio fue evaluar la prevalencia de consumo de BZD y ADP entre los pacientes que acuden a una consulta de reumatología por primera vez, así como la indicación para ellos. Métodos: Se incluyeron pacientes remitidos por primera vez a la consulta de reumatología. Se registraron los datos demográficos, el motivo de la derivación y el diagnóstico final. Con respecto al tratamiento con ADP y/o BZD, se registraron su duración y la indicación de la prescripción. El tamaño de la muestra se estimó para un riesgo alfa de 0,05%. Se realizaron análisis univariantes y multivariantes para estudiar las asociaciones con características demográficas o clínicas. Resultados: Se incluyeron 350 pacientes (mujeres 77,1%, hombres 22,9%). La mayoría de ellos habían sido remitidos por dolor musculoesquelético (73,4%). Más de un tercio (36,6%) de los pacientes estaban en tratamiento con BZD y/o ADP. Las causas más frecuentes para su prescripción fueron ansiedad, depresión e insomnio. El diagnóstico final fue patología no inflamatoria en el 82% de los casos e inflamatoria en el 18% de estos. En el análisis univariante, el uso de BZD y/o ADP se asoció con el sexo femenino (p< 0,001), el desempleo (p< 0,001) y el diagnóstico de patología no inflamatoria (p< 0,001). En el análisis multivariante, el uso de BZD y/o ADP se asoció con el sexo femenino (p=0,002 [OR 3,4; IC 95% 1,6-7,4]) y el diagnóstico de patología no inflamatoria, específicamente con la fibromyalgia (p = 0,007 [OR 16,1; IC 95% 2,2-120,7]). Conclusión: El consumo de BZD y ADP es frecuente y está asociado con patología no inflamatoria.

Temporal artery Doppler ultrasound in patients with giant cell arteritis: State of the art and systematic review of the literature

RESUMEN La arteritis de células gigantes es una vasculitis que afecta de manera predominante a vasos de gran calibre y aparece en personas mayores de 50 arios. Su presentación clínica incluye cefalea, alteraciones auditivas o síntomas similares a polimialgia reumática. En su forma más grave puede causar pérdida de visión uni- o bilateral, secundaria a neuropatía óptica isquémica de tipo arterítico. En la actualidad, el estándar de referencia para su diagnóstico es la biopsia de arterias temporales, procedimiento que no es inocuo y que puede tener como complicaciones infección, lesión nerviosa o sangrado, entre otras. Entre las técnicas no invasivas de diagnóstico, el ultrasonido y el Doppler de arterias temporales han tomado un rol cada vez más importante en el diagnóstico de esta entidad, dado que son pruebas benignas, con nulos efectos adversos y, a través de estrategias como las clínicas fast-track apoyadas en este método diagnóstico, se ha logrado reducir las complicaciones isquémicas de la enfermedad.

ABSTRACT Giant cell arteritis is a vasculitis that predominantly affects large calibre vessels, and usually appears in people over 50 years-old. Its clinical presentation includes headache, hearing impairment, or polymyalgia rheumatica-like symptoms. In its most severe form, it can cause uni- or bilateral vision loss secondary to arteritic ischaemic optic neuropathy. Currently, the gold standard for its diagnosis is the temporal artery biopsy, a procedure that is not harmless and may have complications such as infection, nerve injury, bleeding, among others. Among non-invasive diagnostic methods, the ultrasound and temporal artery Doppler have gained a predominant role in the diagnosis of giant cell arteritis, as it is a benign test with no adverse effects. Through strategies such as «fast-track» clinics, supported by this diagnostic method, a reduction has been achieved in ischaemic complications of the disease.

Pregnancy outcomes in patients with Takayasu's arteritis: Case series

RESUMEN Objetivo: La actividad y el riesgo de recaída de la arteritis de Takayasu son bajos durante la gestación. Hasta el 40% de las pacientes puede tener desenlaces obstétricos desfavorables, por lo que es importante conocer su comportamiento clínico. Describimos las características clínicas y el desenlace obstétrico de gestantes con arteritis de Takayasu atendidas en un hospital de alta complejidad. Materiales y métodos: Evaluación retrospectiva de historias clínicas de gestantes con arteritis de Takayasu atendidas en el Hospital Universitario San Vicente Fundación de Medellín, Colombia, entre 2011 y 2018. Resultados: Se incluyó en el estudio a 6 pacientes con mediana de edad al diagnóstico de 17,5 arios (RI 9,25), al parto de 24 arios (RI 8,25) y con una duración de la enfermedad de 5,5 arios (RI 10,5). Del total, 3 pacientes tenían compromiso aórtico extenso; al parto, 3 pacientes estaban activas y requirieron inmunosupresores, 5 tenían hipertensión arterial, una desarrolló preeclampsia en el segundo trimestre, una tenía insuficiencia mitral y tricuspídea grave con disminución de la fracción de eyección del ventrículo izquierdo; 2 tenían aneurismas (arteria subclavia izquierda y aorta ascendente). Ningún embarazo resultó en aborto ni parto pretérmino; hubo 2 óbitos fetales, uno por restricción del crecimiento intrauterino e insuficiencia placentaria, y otro de etiología desconocida; ambas pacientes con actividad de la enfermedad, afección aórtica extensa e hipertensión arterial. Fueron por cesárea 5 partos por indicación materna; no hubo disección aórtica, rotura aneurismática ni hemorragia cerebral. Conclusión: Las pacientes con enfermedad activa y afección aórtica extensa presentaron resultados obstétricos desfavorables, lo que indica que el inadecuado control de la vasculitis genera mayores complicaciones materno-fetales.

ABSTRACT Objective: The activity and risk of relapse of Takayasu's arteritis are low during pregnancy. Up to 40% of patients may have unfavorable obstetric outcomes therefore it is important to know their clinical behavior. We describe the clinical characteristics and obstetric outcome of pregnant women with Takayasu arteritis treated in a hospital of high complexity. Materials and methods: A retrospective evaluation of medical records of pregnant patients with Takayasu's arteritis treated at Hospital Universitario San Vicente Fundación in Medellin, Colombia between 2011 and 2018. Results: Six patients with a median age at diagnosis 17.5 (RI 9.25) years, at delivery 24 (RI 8.25) years, disease duration 5.5 (RI 10.5) years. Three patients had extensive aortic involvement; at delivery, 3 patients were active and required immunosuppressants, 5 had high blood pressure, one developed preeclampsia in the second trimester, one had severe mitral and tricuspid insufficiency with a decreased ejection fraction of the left ventricle; 2 had aneurysms (left subclavian artery and ascending aorta). No pregnancy resulted in abortion or preterm birth; there were 2 fetal deaths, one due to intrauterine growth restriction and placental insufficiency and another of unknown etiology; both patients with disease activity, extensive aortic condition, and arterial hypertension. Five deliveries were by cesarean section by maternal indication; there was no aortic dissection, aneurysmal rupture or cerebral hemorrhage. Conclusion: Patients with active disease and extensive aortic compromise presented unfavorable obstetric results, suggesting that inadequate control of vasculitis leads to greater maternal-fetal complications.

Subscapularis myositis: An uncommon complication in calcific tendinopathy. A case study

RESUMEN La tendinopatía calcificada del hombro se caracteriza por el depósito de cristales de hidroxiapatita en uno o varios tendones del hombro. Dentro de los procesos que ocurren en esta entidad está la fase de reabsorción, en la que los depósitos podrían migrar hacia estructuras adyacentes. Una muy rara complicación es la migración hacia la unión miotendinosa del tendón correspondiente, la cual provoca una importante reacción inflamatoria muscular que puede objetivarse en pruebas complementarias específicas. Presentamos un caso clínico de una tendinopatía calcificante del subescapular, con pos terior migración hacia la unión miotendinosa causando una miositis del mismo.

ABSTRACT Calcific tendinopathy of the shoulder is characterised by the deposit of hydroxy apatite crys tals in one or more tendons of the shoulder. Within the processes that occur within this disorder, there is the resorption phase, in which the deposits could migrate towards adjacent structures. A very rare complication is the migration towards the myotendinous junction of the corresponding tendon, which causes a significant muscular inflammatory reaction that can be seen in specific complementary tests. A clinical case is presented of a subscapular calcific tendinopathy, with subsequent migra tion to the myotendinous junction, causing myositis of the same.

Macrophage activation syndrome as a result of rheumatological diseases: Report of 4 cases

RESUMEN El síndrome de activación macrofágica (SAM) es una grave complicación de varias entidades reumáticas entre las que se encuentran la artritis idiopática juvenil sistémica, enfermedad de Still y lupus eritematoso sistémico. Este síndrome forma parte de las linfohistiocitosis hemofagocíticas adquiridas y constituye una enfermedad potencialmente mortal, con dificultad en su identificación y carencia de consensos en cuanto a su manejo. Describimos una serie de casos de pacientes con SAM, exponiendo su proceso diagnóstico, su relación con las enfermedades reumáticas de base, su seguimiento y tratamiento, así como los resultados de diferentes esquemas de manejo.

ABSTRACT Macrophage activation syndrome (MAS) is a serious complication of several rheumatic disorders, among which are the systemic juvenile idiopathic arthritis, Still's disease and systemic lupus erythematosus. This syndrome is part of the Acquired Haemophagocytic Lymphohistiocytoses, and is a potentially fatal disease, with difficulty in its identification and a lack of consensus regarding its management. A series of cases are describe of patients with macrophage activation syndrome, explaining their diagnostic process, their relationship with rheumatic diseases, their monitoring, and treatment, as well as the results of different management schemes.

Acropachy: From sign to disease

RESUMEN Las acropaquias, también llamadas dedos en palillo de tambor, se presentan como un aumento de la convexidad ungueal sobre una falange distal engrosada. Su origen es multifactorial, siendo la causa más frecuente las neoplasias, aunque también puede ser idiopático. Pueden encontrarse de forma aislada o formando parte de la osteoartropatía hipertrófica. La importancia de su diagnóstico radica en la alta frecuencia de enfermedad maligna subyacente, por lo que debe ser rápido y exhaustivo. Presentamos 2 casos de pacientes con acropaquias asociados a neoplasia subyacente.

ABSTRACT Acropachy, also called clubbed fingers, presents as increased nail convexity over a thickened distal phalanx. Its origin is multifactorial, with the most frequent cause being neoplasms, although it can also be idiopathic. They can be found in isolation, or as part of hypertrophic osteoarthropathy. The importance of its diagnosis lies in the high frequency of underlying malignant pathology, so it must be rapid and comprehensive. Two cases are presented of patients with acropachy associated with underlying neoplasia.

Benefits of the Bayes factor in rheumatology research

Reply letter: Benefits of the Bayes factor in rheumatology research