Tocilizumab for the treatment of adult-onset Still's disease

Adult-onset Still´s disease (AOSD) is a systemic inflammatory condition that affects mainly young people. The clinical course consists of two distinctive patterns: one with a predominance of systemic symptoms and another manifested by progressive chronic polyarthritis. Glucocorticoids remain the mainstay in the treatment of AOSD. However, biologic therapies are often required to achieve clinical remission and allow glucocorticoid discontinuation. Areas covered: The review summarizes the main retrospective and prospective studies, and case series on the use of the anti-interleukin (IL)-6 receptor tocilizumab in AOSD. Expert opinion: Since IL-6 serum levels are highly increased in both active systemic and polyarticular phenotypes, IL-6 blockade was considered to be a plausible therapeutic option for the management of AOSD. Tocilizumab, the only anti-IL-6-receptor antagonist currently available for AOSD, has proved to be effective for the management of refractory AOSD patients, including those with life-threatening complications. Nevertheless, there are some reports describing patients who are refractory to any therapy. Future research should focus on the identification of prognostic biomarkers that help us to tailor an individualized treatment for each type of patient and in the search of new disease activity indices that help us to monitor the response to the therapy more closely

Unmet needs in the management of cardiovascular risk in inflammatory joint diseases

Introduction: Increased cardiovascular (CV) morbidity and mortality is observed in inflammatory joint diseases (IJDs) such as rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. However, the management of CV disease in these conditions is far from being well established.Areas covered: This review summarizes the main epidemiologic, pathophysiological, and clinical risk factors of CV disease associated with IJDs. Less common aspects on early diagnosis and risk stratification of the CV disease in these conditions are also discussed. In Europe, the most commonly used risk algorithm in patients with IJDs is the modified SCORE index based on the revised recommendations proposed by the EULAR task force in 2017.Expert opinion: Early identification of IJD patients at high risk of CV disease is essential. It should include the use of complementary noninvasive imaging techniques. A multidisciplinary approach aimed to improve heart-healthy habits, including strict control of classic CV risk factors is crucial. Adequate management of the underlying IJD is also of main importance since the reduction of disease activity decreases the risk of CV events. Non-steroidal anti-inflammatory drugs may have a lesser harmful effect in IJD than in the general population, due to their anti-inflammatory effects along with other potential beneficial effects.MA González-Gay’s research has been supported by grants from “Fondo de Investigaciones Sanitarias” PI06/0024, PS09/00748, PI12/00060, PI15/00525,PI18/00043, and RD12/0009/0013 and RD16/0012 (RIER) from “Instituto de Salud Carlos III” (ISCIII) (Spain), co-funded by FEDER funds

Treatment of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is an inflammatory disease characterized by bilateral pain involving predominantly the shoulders and proximal aspects of the arms and less commonly the neck and the pelvic girdle. This review discusses briefly the main epidemiological data and clinical features of this condition. Especial attention is paid in the management of the disease. For this reason, both the classic management and the impact of new therapies are discussed in depth. In general, patients with PMR experience a rapid response to 12.5-25?mg/prednisone/day in less than a week. Patients with poor response to glucocorticoids or with relapsing disease require other therapies aimed mainly to spare glucocorticoids. Among them, methotrexate is the most commonly used. Nevertheless, different studies indicate that this agent yields only a modest effect. Biologic therapies against the main cytokines involved in the pathogenesis of the disease have been used in refractory patients. However, randomized controlled trials do not support the use of anti-tumor necrosis factor agents in PMR. In contrast, several case series and retrospective studies highlight the efficacy of the anti-interleukin-6 receptor tocilizumab in PMR. Nonetheless, controlled trials are needed to fully establish the beneficial effect of this agent. The potential favorable effect of the Janus-kinase inhibitors and new anti-interleukin-6 antagonists remains to be determined

A Review of the Dermatological Complications of Giant Cell Arteritis

Giant cell arteritis (GCA) is characterized by granulomatous inflammation of large and medium-sized vessels. It is the most common vasculitis among elderly people in Europe and North America. GCA usually presents with ischemic cranial manifestations such as headache, scalp tenderness, visual manifestations, and claudication of the tongue and jaw. Thickness and tenderness of temporal arteries are the most recognizable signs of GCA on physical examination. Laboratory tests usually show raised acute phase reactants. Skin manifestations are uncommon in GCA and are rarely found as a presenting symptom of GCA. Necrosis of the scalp and tongue is the most common ischemic cutaneous manifestation of GCA. Although infrequent, when present it reflects severe affection and poor prognosis of GCA. Panniculitis-like lesions have been reported in the setting of GCA, with nodules being the most common finding. Other entities, such as generalized granuloma annulare or basal cell carcinoma have been occasionally described in GCA patients. Prompt recognition and initiation of therapy are crucial to prevent serious complications of GCA. When high suspicion of GCA exists, immediate administration of glucocorticoids is recommended. It is advisable to refer the patient to a specialist GCA team for further multidisciplinary assessment.Funding: This line of research on vasculitis was partially supported by RETICS Programs, RD08/0075 (RIER), RD12/0009/ 0013 and RD16/0012 from “Instituto de Salud Carlos III” (ISCIII) (Spain)

Effects of disease activity on lipoprotein levels in patients with early arthritis: can oxidized LDL cholesterol explain the lipid paradox theory?

Background An increased risk of cardiovascular (CV) complications has been described in patients with rheumatoid arthritis (RA). It is the result of the combined effect of classic CV risk factors and others that are specific to the disease. Methods We assessed data from 448 early arthritis (EA) patients: 79% women, age (median [p25-p75]) at onset: 55 [44?67] years and disease duration at study entry 5 [3?8] months; and 72% fulfilled the 1987 RA criteria at 2?years of follow-up. Rheumatoid factor was positive in 54% of patients and anti-citrullinated peptide antibodies in 50%. The follow-up of patients ranged from 2 to 5?years with more than 1400 visits with lipoprotein measurements available (mean 2.5 visits/patient). Demographic- and disease-related variables were systematically recorded. Total cholesterol (TC), high-density lipoprotein (HDL-C), and low-density lipoprotein (LDL-C) levels were obtained from routine laboratory tests. Oxidized-LDL (oxLDL-C) levels were assessed using a commercial ELISA kit. We fitted population-averaged models nested by patient and visit to determine the effect of independent variables on serum levels of TC, its fractions, and oxLDL-C. Results After adjustment for several confounders, high-disease activity was significantly associated with decreased TC, HDL-C, and LDL-C levels and increased oxLDL-C levels. Standardized coefficients showed that the effect of disease activity was greater on oxLDL-C and HDL-C. Interestingly, we observed that those patients with lower levels of LDL-C showed higher oxLDL-C/LDL-C ratios. Conclusions High-disease activity in EA patients results in changes in the HDL-C and oxLDL-C levels, which in turn may contribute to the increased risk of CV disease observed in these patients.Our manuscript was supported by grants RD16/0011/0012, RD16/0011/0009, RD16/0011/0004, PI05/2044, and PI18/0371 from the Ministerio de Economía y Competitividad (Instituto de Salud Carlos III) and co-funded by Fondo Europeo de Desarrollo Regional (FEDER)

Treatment of giant cell arteritis

Giant cell arteritis (GCA) is the most common form of vasculitis in adults. Cranial manifestations are typical clinical features of this vasculitis. Sometimes the presenting symptoms are nonspecific and, in some cases, large-vessel involvement may prevail. Polymyalgia rheumatica is a frequent manifestation that in some cases may be the presenting symptom of GCA. Visual complications, in particular the risk of blindness, constitute the most feared manifestations of GCA. Prompt recognition of this vasculitis is required to avoid irreversible complications. Prednisone/prednisolone at a dose of 40-60?mg/day is the cornerstone therapy in GCA. Glucocorticoids lead to rapid improvement of symptoms and may reduce the risk of irreversible visual loss. However, relapses are common when the prednisone dose is tapered. Therefore, additional therapies are required in relapsing GCA or when a rapid reduction of glucocorticoids is needed. The most widely used conventional immunosuppressive drug is methotrexate Adjunctive treatment with methotrexate may decrease the risk of relapses and reduce glucocorticoid exposure. However, comprehensive reviews indicate that the efficacy of methotrexate in GCA is modest. The experience with other conventional immunosuppressive drugs in GCA patients is scarce. In some cases, the new biologic agents are required. Among them, the most frequently used is the recombinant humanized anti-IL-6 receptor antibody tocilizumab. It improves clinical symptoms, reduce the cumulative prednisone dose and the frequency of relapses in GCA patients. However, anti-tumor necrosis factor-? therapy is not useful in GCA. Promising results on other biologic agents, such as abatacept, ustekinumab or anakinra, require further confirmatory studies

LA TOMA DE DECISIONES EN SALUD PÚBLICA: UNA REVISIÓN DEL PROCEDIMIENTO DESDE EL ENFOQUE RACIONAL

Se presenta una revisión que contextualiza y define el uso de las habilidades cognoscitivas para la toma de decisiones dentro del campo de la salud pública, y analiza cómo éstas se pueden desarrollar en el ámbito de la formación de recursos humanos en salud.  Se llevó a cabo una investigación documental de la literatura sobre el tema, teniendo como directriz el seguimiento a los principales autores y sus referencias hasta el año 2005. Los documentos encontrados fueron sujetos a un proceso de selección por pertinencia del tema y fueron sujetos a análisis de contenido. A partir de la propuesta de Herbert Simon en 1956 la teoría de la toma de decisiones es definida y posteriormente se encuentra a una serie de autores que analizan el proceso e identifican y operacionalizan las habilidades cognoscitivas que lo generan. El proceso de toma de decisiones coincide más con un proceso de orden racional que de orden heurístico o casual. Los autores coinciden en que la toma de decisiones es un proceso intelectual que debe ejercitarse y evaluarse en el personal que trabaja en el ámbito de la salud pública, debe formar parte de las competencias del personal de salud. Abstract A review that contextualizes and defines the use of cognitive skills for decision-making within the field of public health, and discusses how they can be developed in the field of training of human resources in health. Was conducted documentary research literature on the subject, taking as a guideline to follow the lead authors and references to 2005. The documents found were subject to a selection process by relevance of the topic and were subjected to content analysis. Since the proposal of Herbert Simon in 1956 the theory of decision making is defined and is subsequently a number of authors who analyze the process and identify and operationalize cognitive skills that generate it. The decision making process coincides with a rational order processing heuristic or random order. The authors agree that decision making is an intellectual process that must be exercised and evaluated in the staff working in the field of public health, should be part of the skills of health workers. Palabras Clave: Toma de decisiones, habilidades, competencias, salud públic

Antioksidativna aktivnost ferementiranih i nefermentiranih esktrakata iz otpada nastalog pri proizvodnji kave

Coffee pulp contains natural antioxidants like hydroxycinnamic acids, most of which are covalently linked to the cell wall. These compounds can be released by fermentation or enzymatic processes. In this study, the antioxidant properties of fermented and nonfermented coffee pulp have been evaluated. Coffee pulp was fermented by solid-state fermentation using the fungus Aspergillus tamarii. Fermented and nonfermented samples of coffee pulp were extracted with aqueous methanol followed by alkaline hydrolysis. In both cases, the total polyphenol concentration was quantified by Folin-Ciocalteu method, then hydroxycinnamic acids were concentrated using ethyl acetate and quantified by HPLC. The antioxidant properties of samples were determined by radical monocation of 2,2’-azinobis-( 3-ethylbenzothiazoline-6-sulphonic acid) [ABTS]·+: the antioxidant activity was determined by kinetic parameters known as ED50, tED50 and antiradical efficiency (AE). Fermented extracts containing free hydroxycinnamic acids showed better antiradical activity against [ABTS]·+ than the other nonfermented ones. There were no significant differences in the total content of polyphenols in fermented and nonfermented coffee pulp, but the content of total hydroxycinnamic acids was higher in the nonfermented coffee pulp extracts (47.1 g/kg) than in the fermented coffee pulp (30.9 g/kg). Nevertheless, the fermentation process increased the fraction of free hydroxycinnamic acids (47 %) and consequently decreased those covalently linked to the cell wall. The results of the antioxidant activity assays could be explained by the presence of free hydroxycinnamic acids. Fermented coffee pulp assays showed that free hydroxycinnamic acids were metabolised by A. tamarii. This study shows the potential of using coffee pulp as a natural source of antioxidants.Otpad nastao pri proizvodnji kave sadržava prirodne antioksidanse, kao što su hidroksicinamične kiseline, od kojih je većina kovalentno vezana za staničnu stijenku. Takvi se spojevi mogu osloboditi fermentacijom ili pomoću enzima. U ovom su radu istražena antioksidativna svojstva fermentiranih i nefermentiranih esktrakata, pri čemu je fermentacija provedena s pomoću plijesni Aspergillus tamarii na čvrstoj podlozi od otpada nastalog pri proizvodnji kave. Fermentirani i nefermentirani spojevi esktrahirani su vodenom otopinom metanola, nakon čega je provedena njihova alkalna hidroliza. U oba je slučaja koncentracija ukupnih polifenola određena Folin-Ciocalteu metodom, a zatim su hidroksicinamične kiseline koncentrirane pomoću etil acetata i analizirane HPLC-om. Antioksidativna su svojstva uzoraka, tj. vrijednosti ED50 i tED50 te antiradikalni učinak, određena pomoću radikala 2,2\u27-azinobis(3-etilbenzotiazolin-6-sulfonske kiseline) [ABTS].+. Fermentirani su ekstrakti sadržavali slobodne hidroksicinamične kiseline i imali su bolju antioksidativnu aktivnost s obzirom na [ABTS].+ od nefermentiranih ekstrakata. Nije bilo bitne razlike u koncentracijama ukupnih polifenola u fermentiranim i nefermentiranim ekstraktima, ali je udio hidroksicinamičnih kiselina bio veći u nefermentiranim (47,1 g/kg) nego u fermentiranim ekstraktima (30,9 g/kg). Fermentacija je povećala udjel slobodnih (na 47 %), a smanjila udjel vezanih hidroksicinamičnih kiselina. Zaključeno je da je antioksidativna aktivnost ekstrakata ovisila o udjelu slobodnih hidroksicinamičnih kiselina, koji se povećao nakon fermentacije otpada nastalog pri proizvodnji kave s pomoću A. tamarii. Time je potvrđeno da se postupak može primijeniti za ekstrakciju prirodnih antioksidanasa