C Ramos-Remus

University of Guadalajara, Guadalajara, Jalisco, Mexico

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Publications (78)318.61 Total impact

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    ABSTRACT: OBJECTIVES: Although blood databank-based studies have shown that rheumatoid arthritis (RA)-related autoantibodies are present before the onset of RA, information on their positive predictive value (PPV) to develop RA in healthy individuals is scarce. This study aimed to assess the 5-year PPV of serum IgM-RF and anti-CCP2 in the development of RA in healthy relatives of patients with RA. METHODS: Healthy relatives of RA patients were invited to participate in a cohort study. At baseline, participants underwent a medical history, and determined serum IgM-RF (nephelometry) and anti-CCP2 antibodies (ELISA). The subjects were followed every four months using a structured interview (COPCORD questionnaire). When COPCORD was positive, subjects had an in-office rheumatology assessment including joint count. The outcome was defined as fulfillment of ARA criteria for RA. RESULTS: 819 initially healthy relatives of 252 patients with RA were included (69% female, 41% offspring, mean age 36 ± 12 years). Eleven (1.3%) were positive to both anti-CCP2 and RF, 12 (1.4%) only to anti-CCP2 and 16 (2%) only to RF. RA developed in 17 (2%) during the 5-year follow up (3312 persons-year for the seronegative group and 205 persons-year for the anti-CCP2 positive group). The PPV was 64% when both anti-CCP2 and RF were positive and 58% when only anti-CCP2 was positive. Offspring of patients with RA had an independent 3-fold risk of developing RA. CONCLUSION: It is possible to determine the magnitude of risk for developing RA using simple routine laboratory tests in healthy relatives of patients with RA. This article is protected by copyright. All rights reserved.
    Arthritis & Rheumatology 08/2015; DOI:10.1002/art.39297 · 7.87 Impact Factor
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    ABSTRACT: Deflazacort (DFZ) on the current evidence fails to maintain the charm as offered at the introduction. The higher cost and lack of evidence of superior safety from robust and larger studies remains big shortcomings. In fact, a careful evaluation of the immuno-suppressive potency of DFZ is needed to establish a safe posology for humans. Hence, the lack of true bio-equivalence compared to other glucocorticoids leaves enough doubt to make one think that with DFZ one may use more than what is necessary when facing a clinical situation
    Indian Journal of Rheumatology 12/2014; 9(4). DOI:10.1016/j.injr.2014.09.004
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    ABSTRACT: The aim of this study was to assess whether family members perceive health-related quality of life (HRQoL) of family members with rheumatic illnesses differently from the perceptions of these patients themselves. Cross-sectional study of consecutive patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and ankylosing spondylitis (AS) attending two outpatient rheumatic clinics. HRQoL was assessed using the Spanish version of the World Health Organization Disability Assessment Scale (WHODAS-II) questionnaire; the “proxy” version is available for relatives. All patients and one proxy per patient separately answered the questionnaire at the clinic. Differences were determined by coefficients of determination (r 2), Z scores, and meaningful differences of 30 %. Two hundred and ninety-one patients (111 SLE, 100 RA, and 80 AS) and their respective proxies were included. The mean age was 35 ± 13 years in SLE, 49.5 ± 14 years in RA, and 40 ± 14 years in AS patients. Divergent perceptions between patients and their proxies were found in 57 % of the SLE group, in 69 % of the RA group, and in 47 % of the AS group as per WHODAS-II global score. Stronger disagreement occurred for all the three groups in domains representing cognition and interaction with other people: around 60 % in the SLE group, 80 % in the RA group, and 40 % in the AS group. A substantial proportion of family members perceived the HRQoL of rheumatic family members differently from the perception of the patients themselves, most of the time biased toward underestimation, suggesting problems in the dynamics of efficient communication and social support.
    Rheumatology International 05/2014; 34(12). DOI:10.1007/s00296-014-3044-9 · 1.63 Impact Factor
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    ABSTRACT: Background Beliefs and emotions drive behavior. Rheumatologists face a broad range of disorders, and delivering related information can be conflicting to patients’ believes and thus evoke offensive emotions; in addition, rheumatologists may have feelings associated with diagnoses and project them with consequences in doctor-patient relationship. Objectives A) To explore connotations and potential offensiveness of 10 different mechanistic labels for rheumatic symptoms in new referred patients with musculoskeletal complaints. B) To explore the potential offensiveness of 10 different mechanistic scenarios in Mexican and Canadian rheumatologists. Methods A) Consecutive patients attending for the first time at rheumatology outpatient clinic in México were interviewed (structured format) before they saw the rheumatologist. Patients were asked about feelings provoked (i.e. angry, hopeful, etc.) if the rheumatologist gave them one out of ten different mechanistic labels (i.e. stress, autoimmunity, etc.); the rheumatologist was asked then for a medical diagnosis. B) Canadian and Mexican rheumatologists were invited to answer an internet based structured questionnaire about the feelings they may have at the moment they identify each of the 10 different provided scenarios. The “offensive score” was calculated as the proportion of individuals who endorsed offensive feelings, as per protocol definitions; then, a “number needed to offend” (NNO) was calculated assuming an ideal world in which no one is ever offended and using standard estimates for number needed to harm. Results 150 patients were included, 78% were females, the mean age ± SD was 49±15 yr and formal education 9.5±4 yr. Overall, inheritance, degenerative and inflammatory labels had fewest negative connotations (NNO 16, 12 and 13, respectively), and psychological, functional, and “idiopathic” the most (NNO 3, 3 and 2). Recoding mechanistic labels into “organic” and “functional” the differences were significant (NNO 9 and 3). Stratification by rheumatic diagnosis, patients with inflammatory systemic diseases expressed more negative connotations with functional, “idiopathic” and “not sleeping well” labels (NNO 3 for each). Patients with diseases such as fibromyalgia accepted better autoimmune, inherited disease or inflammatory labels (NNO 17, 9 and 18, respectively) than psychological, functional and “idiopathic” labels (NNO 2, 3 and 1). By other hand, 186 Mexican rheumatologists (36% response rate) and 71 Canadian rheumatologists (23% response rate) answered the questionnaire. Overall, inflammatory and autoimmune labels had the fewest negative connotations (NNO 90 for both), and idiopathic and somatization the most (NNO 2 and 3). Recoding diagnosis labels into “organic” and “functional” the differences in the NNO were notable (51 and 4 for Mexicans and 47 and 5 for Canadians). No other significant differences were observed between Mexican and Canadian rheumatologist. Conclusions Receiving or giving mechanistic/explanatory labels clearly produce feelings and carries a risk to offend. In this study the NNO in patients and rheumatologists went from 1 to 90. Rheumatologists should seek better ways to deliver accurate information, avoiding idiopathic, functional and psychological labels. Disclosure of Interest None Declared
    Annals of the Rheumatic Diseases 01/2014; 71(Suppl 3):714-714. DOI:10.1136/annrheumdis-2012-eular.1339 · 10.38 Impact Factor
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    ABSTRACT: Background Although there is much discussion regarding when to initiate a biological agent in rheumatoid arthritis (RA) patients, data on when to stop these agents is scant. Disease activity outcomes after the ending of an industry sponsored clinical trials may provide useful information regarding the duration of drug-free remission for a given biological agent. Objectives To assess the length of remission and rate of relapse of disease activity after ending the open label, long-term extension study (5 yrs) using tocilizumab in RA patients enrolled in the OPTION trial. Methods Patients who no longer received tocilizumab because of the ending of the extension study (5 yrs) of the OPTION trial were analyzed. All patients were: a) in remission (DAS28 <2.6, 0 swollen joints) at the time of the last tocilizumab administration (week 260), b) followed thereafter every 8 weeks until relapse (1 or more swollen joints), c) on a stable methotrexate dose during the follow-up. Results Forty patients were analyzed, 85% females with a mean age of 53.5 yrs. During the first 12 months of follow-up, 21 (52.5%) patients continued in remission. Relapses occurred in 19 (47.5%) patients, 11 (58%) of them during the first three months after the last tocilizumab administration. No variables were identified to predict length of remission. Conclusions Long-term remission is possible in a substantial number of RA patients after suspension of tocilizumab. Additional data are required to support recommendations for discontinuing a biological agent after achieving remission. These recommendations would impact in patients’ safety and the economic burden imposed by these treatments. Disclosure of Interest None Declared
    Annals of the Rheumatic Diseases 01/2014; 71(Suppl 3):69-70. DOI:10.1136/annrheumdis-2012-eular.1732 · 10.38 Impact Factor
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    ABSTRACT: This study aims to explore the different connotations and potential offensiveness of ten mechanistic labels in newly referred Mexican patients with rheumatic symptoms as well as in Mexican and Canadian rheumatologists. Patients with musculoskeletal complaints newly referred for a rheumatology assessment were interviewed consecutively before they saw the rheumatologist. Patients were asked to choose one of nine feelings provoked by ten different illness mechanism labels. Rheumatologists gave a medical diagnosis after seeing the patients. Mexican and Canadian rheumatologists were invited to answer a structured questionnaire about their feelings at the moment they identified each of the ten different provided scenarios. Patients' and rheumatologists' feelings were classified as "offended" or "nonoffended." The "offensive score" was used to calculate a "number needed to offend" (NNO). One hundred and fifty patients were included. Inherited, immunological, and inflammatory labels had the fewest negative connotations (NNOs 17, 12, and 14, respectively), and psychological, functional, idiopathic, and sleep disturbance labels had the most (NNO 2 and 3, respectively). Functional labels were almost four times more offensive than organic labels. Stratified by rheumatologist diagnosis, patients with functional disorders were more accepting of organic-based mechanistic labels. A higher potential to offend was observed when patients with functional somatic conditions were given functional mechanistic labels (NNOs 1 to 4). The survey was completed by 186 Mexican rheumatologists and 71 Canadian rheumatologists. Primarily functional disorders such as somatization and anxiety had a high potential to evoke offensive feelings (NNOs 3 to 7). No significant differences in the NNO were found between Mexican and Canadian rheumatologists. Getting or giving mechanistic/explanatory labels is emotional. Both patients and rheumatologists experienced offended feelings with functional or idiopathic labels.
    Clinical Rheumatology 10/2013; 33(4). DOI:10.1007/s10067-013-2407-z · 1.77 Impact Factor
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    ABSTRACT: Temporomandibular disorder (TMD) is an inclusive term in which those conditions disturbing the masticatory function are embraced. It has been estimated that 33% of the population have signs of TMD, but less than 5% of the population will require treatment. The objective of this study was to measure the frequency of TMD in rheumatoid arthritis (RA), osteoarthrosis (OA), ankylosing spondylitis (AS) and systemic lupus erythematosus, and to define the limitations in everyday's life that patients perceive when present. A six-month survey of consecutive outpatients in a rheumatology clinic in a teaching hospital in Mexico was carried out. We defined TMD as: 1) the presence of pain; 2) difficulty on mouth opening, chewing or speaking; 3) the presence of non-harmonic movements of the temporomaxilar joints. All three characteristics had to be present. Z test was used to define differences between proportions. We present the results of 171 patients. Overall, 50 patients had TMD according to our operational definition (29.24%). Up to 76% of the sample had symptoms associated with the condition. TMD is more frequent in OA and in AS (29.24% vs 38% OA, P=0.009; 39% AS; P=0.005). We found no association between the severity of TMD and the request for specific attention for the discomfort produced by the condition. Only 8 of 50 (16%) patients with TMD had requested medical help for their symptoms, and they were not the most severe cases. TMD is more frequent in RA and OA. Although it may produce severe impairment, patients seem to adapt easily.
    Reumatismo 07/2013; 65(3):126-30. DOI:10.4081/reumatismo.2013.126
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    ABSTRACT: OBJECTIVE: Data on when to stop use of biological agents in rheumatoid arthritis (RA) are scant. We assessed the length of remission and the rate of clinical relapse in patients with RA who had to discontinue treatment with tocilizumab (TCZ) because of the ending of longterm (5 yrs) open-label clinical trials. METHODS: All patients at 2 participating centers in Mexico were in remission, defined as Disease Activity Score 28 ≤ 2.6, with no swollen joints at the time of the last TCZ infusion. Patients were followed thereafter every 8 weeks for 12 months or until relapse. Relapse was defined as the presence of ≥ 1 swollen joint. Doses of methotrexate and antiinflammatory drugs were not changed during the followup period. RESULTS: Forty-five patients were analyzed, 87% were women (mean age 52 yrs, mean disease duration 14 yrs). During the 12 months of followup, 44% of patients maintained remission. Relapses occurred in 56% of patients: 14 during the first 3 months after the last TCZ administration. Retreatment using other agents achieved low disease activity or remission. CONCLUSION: Longterm clinical remission is possible in a number of patients with RA after suspension of TCZ. This effect has also been reported with other biologic agents. Additional data are required to support recommendations for discontinuing a biological agent after achieving remission.
    The Journal of Rheumatology 06/2013; 40(7). DOI:10.3899/jrheum.121427 · 3.17 Impact Factor
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    Clinical and experimental rheumatology 04/2013; 31. · 2.97 Impact Factor
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    ABSTRACT: The cost of certain diseases may lead to catastrophic expenses and impoverishment of households without full financial support by the state and other organizations. To determine the socioeconomic impact of the rheumatoid arthritis (RA) cost in the context of catastrophic expenses and impoverishment. This is a cohort-nested cross-sectional multicenter study on the cost of RA in Mexican households with partial, full, or private health care coverage. Catastrophic expenses referred to health expenses totaling >30% of the total household income. Impoverishment defined those households that could not afford the Mexican basic food basket (BFB). We included 262 patients with a mean monthly household income (US dollars) of $376 (0–18,890.63). In all, 50.8%, 35.5%, and 13.7% of the patients had partial, full, or private health care coverage, respectively. RA annual cost was $ 5534.8 per patient (65% direct cost, 35% indirect). RA cost caused catastrophic expenses in 46.9% of households, which in the logistic regression analysis were significantly associated with the type of health care coverage (OR 2.7, 95%CI 1.6–4.7) and disease duration (OR 1.024, 95%CI 1.002–1.046). Impoverishment occurred in 66.8% of households and was associated with catastrophic expenses (OR 3.6, 95%CI 1.04–14.1), high health assessment questionnaire scores (OR 4.84 95%CI 1.01–23.3), and low socioeconomic level (OR 4.66, 95%CI 1.37–15.87). The cost of RA in Mexican households, particularly those lacking full health coverage leads to catastrophic expenses and impoverishment. These findings could be the same in countries with fragmented health care systems.
    06/2012; 8(4):168-73. DOI:10.1016/j.reuma.2012.05.002
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    ABSTRACT: Etanercept, a fully human tumor necrosis factor soluble receptor, is effective in treatment of ankylosing spondylitis (AS). Current guidelines suggest sulfasalazine (SSZ) treatment as initial therapy for the management of patients with AS with peripheral arthritis versus therapy with biologics. We compared the efficacy of etanercept with SSZ in patients with AS with peripheral joint involvement. The efficacy of etanercept 50 mg once weekly was compared with that of SSZ up to 3 g daily in subjects with ≥ 1 swollen peripheral joint at baseline, using data from a 16-week randomized double-blind study in subjects with AS. Efficacy was assessed by the Assessment in AS criteria and the Bath AS Disease Activity, Functional, and Metrology indices. The last observation carried forward method was used for imputation of missing values. Of 566 subjects included in original study, 181 (etanercept 121; SSZ 60) had ≥ 1 swollen peripheral joint and 364 (etanercept 250; SSZ 124) had none at baseline. AS patients treated with etanercept showed significantly greater improvement than those treated with SSZ in all joint assessments regardless of swollen joint involvement. In this analysis, etanercept was significantly more effective than SSZ for management of patients with AS and peripheral joint involvement.
    The Journal of Rheumatology 02/2012; 39(4):836-40. DOI:10.3899/jrheum.110885 · 3.17 Impact Factor
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    ABSTRACT: This study aims to measure the frequency of medication error (ME) in rheumatology outpatients of the Social Security System (SS) in Mexico and to measure the costs by comparing the days lost at work as direct consequence of the medication error against the theoretical cost of no error in the process. A prospective 6-month survey was conducted in a reference hospital in Guadalajara, Mexico. ME was defined as any discrepancy between the prescription and medicine taken by patients. The origin of the discrepancy was identified and registered. We present 381 patients: 292 with rheumatoid arthritis, 57 with ankylosing spondylitis, and 32 with systemic lupus erythematosus. One hundred twenty seven (33%) had medication errors. Ninety eight (77%) got worse in their condition due to ME. Forty percent of MEs were due to patients' decisions, 41% to a lack of availability of medication which should have been provided by SS, and 18% to a non-justified medical decision by primary-care providers. Patients lost in average 3 working days each month because of the ME. The cost of ME is high. In the case analyzed, opportune access to treatment represents a lower cost for the system, but it represents a significant loss of days at work each month. ME is a signal of a system failure. Inter-professional teamwork is needed to perfect the system.
    Clinical Rheumatology 09/2011; 30(11):1421-4. DOI:10.1007/s10067-011-1837-8 · 1.77 Impact Factor
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    ABSTRACT: Although arthritis is the most notable component, rheumatoid arthritis (RA) is a systemic inflammatory disorder where extra-articular manifestations are common; among them, central and peripheral nervous system involvement is frequent and associated with significant morbidity and, in some cases, reduced life span. It may produce a myriad of symptoms and signs ranging from subtle numbness in a hand, to quadriparesis and sudden death. Central and peripheral neurologic manifestations may arise from structural damage produced by RA in diarthroidal joints, by the systemic inflammatory process of the disease itself or by the drugs used to treat it. Neurologic syndromes may appear suddenly or developed slowly through months, and emerge early or after years of having RA. Neurologic manifestations may be easily overlooked or incorrectly assigned to peripheral arthritis unless the attending physician is aware of these complications. In this article, we review neurologic involvement in RA patients with emphasis on clinical approach for early detection.
    Clinical Rheumatology 09/2011; 31(1):1-12. DOI:10.1007/s10067-011-1841-z · 1.77 Impact Factor
  • 2nd Mexican-Canadian Congress of Rheumatology/39th Mexican Congress of; 06/2011
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    ABSTRACT: The aim of this study is to assess the trends in work disability and sick leave in ankylosing spondylitis (AS). In 1993 and 2007, patients diagnosed with AS that attended to a secondary- or a tertiary-care outpatient rheumatology clinics were evaluated for demographics, disease characteristics, axial mobility, working status, and work days missed due to sick leave or permanent disability. Factors that impacted labor status were identified by multiple regression analysis. In 1993, 91 study individuals (mean age 35 years, mean disease duration 10 ± 8 years) included 28 (31%) on permanent disability and 63 currently working; of these 63, 42 (67%) had missed at least 1 work day in the previous 12 months (mean 69 ± 63 days). In the next 5 years, the annual permanent disability was 3%. In 2007, 185 study individuals (mean age 42, mean disease duration 12 ± 10 years) included 53 (39%) on permanent disability and 132 active workers; 35 (66%) out of the 53 began permanent disability between 1999 and 2007 (2.1% annual disability rate), and 53 (40%) out of 132 active workers missed at least 1 work day in the previous 12 months (mean 52 ± 63 days). Only age predicted disability, with 10% and 11% increases in risk per year in 1993 and 2007, respectively (hazard ratios 1.09 and 1.11, respectively; p = 0.03 for both). Although the impact of AS on work seems to decrease slightly during the last 15 years, the actual impact is still substantial. An important proportion of patients went on permanent disability in the three decades before retirement. Extrapolating these results to official data for the year 2005, we may infer that between 1.3 million and nearly 15 million working days were missed that year due to AS.
    Clinical Rheumatology 03/2011; 30(3):361-7. DOI:10.1007/s10067-010-1669-y · 1.77 Impact Factor
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    ABSTRACT: Celiac disease (CD) is an enteric disease caused by dietary gluten in individuals with genetic predisposition. One of the clinical manifestations of CD is the peripheral arthritis that may simulate RA. To determine the frequency of anti-gliadin (aGL), anti-tissue transglutaminase (aTGT) and ultra purified anti-gliadin (AGLU) antibodies in patients with RA. Cross-sectional study. We included consecutive patients diagnosed as RA (ACR). Demographic and clinical data was registered by direct interview and serum levels of aGL, aTGT y aGLU were determined using ELISA. Eighty-five RA patients were included; 87% were women. Mean age was 44±12 years, mean disease duration 12 ±9 years. aGL IgG antibodies were positive in 16 patients, IgA aGL antibodies in 29 patients, aGLU in 14 patients and only one patient had aTGT. It is possible that CD may be the correct diagnosis in a patient with polyarthritis, even if the patient meets the ACR criteria for RA. In other words, CD should be considered among the differential diagnoses in a patient with poly-arthritis.
    01/2011; 7(1):27-9. DOI:10.1016/S2173-5743(11)70005-3
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    ABSTRACT: Celiac disease (CD) is an enteric disease caused by dietary gluten in individuals with genetic predisposition. One of the clinical manifestations of CD is the peripheral arthritis that may simulate RA.
    Reumatología Clínica 01/2011; 7(1). DOI:10.1016/j.reuma.2010.03.006
  • Cesar Ramos-Remus · Sergio Duran-Barragan
    Current Immunology Reviews 08/2010; 6(3):174-184. DOI:10.2174/157339510791823754
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    ABSTRACT: It has been suggested that autonomic nervous system dysfunction may explain all of fibromyalgia (FM) multisystem features. Such proposal is based mostly on the results of diverse heart rate variability analyses. The Composite Autonomic Symptom Scale (COMPASS) is a different validated method to recognize dysautonomia. The main objective of our study was to investigate symptoms of autonomic dysfunction in FM patients by means of COMPASS. A secondary objective was to define whether there is a correlation between COMPASS and Fibromyalgia Impact Questionnaire (FIQ) scores in FM patients. Design, analytical cross-sectional study. Our study population included 3 different groups of women: 30 patients with FM, 30 patients with rheumatoid arthritis, and 30 women who considered themselves healthy. All participants filled out COMPASS and FIQ questionnaires. FM patients had significantly higher values in all COMPASS domains. COMPASS total score (54.6 +/- 20.9; mean +/- standard deviation) clearly differentiated FM patients from the other 2 groups (21.6 +/- 16.5 and 9.5 +/- 10.2, respectively). P < 0.0001. The majority of FM patients gave affirmative answers to questions related to orthostatic, digestive, sleep, sudomotor, or mucosal dysfunction. There was a significant correlation between COMPASS and FIQ scores (Spearman r = 0.5, P < 0.005). Patients with FM have multiple nonpain symptoms related to different expressions of autonomic dysfunction. There is a correlation between a questionnaire that measures FM severity (FIQ) and an autonomic dysfunction questionnaire (COMPASS). Such correlation suggests that autonomic dysfunction is inherent to FM.
    Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases 03/2009; 15(4):172-6. DOI:10.1097/RHU.0b013e3181a1083d · 1.25 Impact Factor
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    ABSTRACT: We assessed the prevalence of selected clinical and radiological features of tendinous and ligamentous derangements in a consecutive sample of patients with systemic lupus erythematosus (SLE). Consecutive patients with SLE with no comorbidities attending a tertiary care center were prospectively assessed and underwent plain radiographic evaluation of the pelvis. Radiographs were analyzed by 2 blinded observers; radiographic sacroiliitis was graded 0 to IV. To better assess sacroiliac (SI) involvement, a computed tomography (CT) scan of the SI joints was performed in patients with grade III sacroiliitis. Hip joints and pubis were also assessed as described. Of the 192 included patients, 89% were female, mean age was 36 years, and mean disease duration was 10 years. Inflammatory low back pain was reported by 10% of patients. Sacroiliitis of any grade was observed in 31 patients (16%), and grade III (confirmed on CT scan) sacroiliitis was observed in 6% (95% CI 3% to 9%). Osteitis pubis was diagnosed in 6% (95% CI 3% to 10%) and coxofemoral migration in 8% (95% CI 2% to 9%). Jaccoud's arthropathy was found in 23%. Demographic and clinical variables were not statistically associated with radiographic sacroiliitis. Sacroiliitis and other tendinous and ligamentous derangements are not uncommon in patients with SLE. Based on these features and on previous reports, the term "SLE-related tendinous and ligamentous derangements" may be used to establish a common framework for further research and reporting.
    The Journal of Rheumatology 10/2008; 35(11):2187-91. DOI:10.3899/jrheum.080255 · 3.17 Impact Factor

Publication Stats

2k Citations
318.61 Total Impact Points


  • 1999–2013
    • University of Guadalajara
      Guadalajara, Jalisco, Mexico
  • 1993–2013
    • Mexican Institute of Social Security
      • Departamento de Reumatología
      Ciudad de México, The Federal District, Mexico
  • 2008–2011
    • Hospital General de Mexico
      Ciudad de México, Mexico City, Mexico
  • 1992–2000
    • University of Alberta
      • Department of Medicine
      Edmonton, Alberta, Canada