Angelica Vargas - Academia.edu (original) (raw)
Papers by Angelica Vargas
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 2014
Fibromyalgia often coexists and overlaps with other syndromes such as chronic fatigue, irritable ... more Fibromyalgia often coexists and overlaps with other syndromes such as chronic fatigue, irritable bowel syndrome, and interstitial cystitis. Chronic stress has been implicated in the pathogenesis of these illnesses. The sympathetic nervous system is a key element of the stress response system. Sympathetic dysfunction has been reported in these syndromes, raising the possibility that such dysautonomia could be their common clustering underlying pathogenesis. The objective of this study was to carry out a review of all published comparative case-control studies investigating sympathetic nervous system performance in fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and interstitial cystitis. Online databases PubMed and EMBASE were accessed using the following key words: autonomic (OR) sympathetic (AND) fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and interstitial cystitis. All entries up to December 10th 2012 were reviewed by 2 independent investiga...
![Research paper thumbnail of [Basic physical principles of ultrasonography, anatomy of the musculoskeletal system and ecographic artifacts]](https://attachments.academia-assets.com/101605576/thumbnails/1.jpg)
](Acta ortopédica mexicana
Ultrasound is a simple, non invasive and accessible imaging technique that allows the evaluation ... more Ultrasound is a simple, non invasive and accessible imaging technique that allows the evaluation of the musculoskeletal system in real time, with the advantage of examining the joints in a dynamic way and with the aid of Doppler power, local inflammatory phenomena can be evaluated, without submitting the patient to radiation. It has the disadvantage of being operator dependant, which has to have a wide knowledge of the physical principles of ultrasonography, has to be familiar with the sonographic anatomy and musculoskeletal anatomy, but even more it is important that he has the ability to recognize the sonographic phenomena that can present as decoys, nominated artifacts. This knowledge is desirable to the specialist in musculoskeletal conditions, so that ecographic studies can be interpreted and recognizing artifacts and avoiding wrong diagnosis and unnecessary procedures. In the present review, the basic principles of ecography are analyzed, the normal sonographic anatomy of the ...
Reumatología Clínica, 2007
Rheumatic Disease Clinics of North America, 2009
Prevailing linear-reductionist medical models seem unable to explain complex diseases like fibrom... more Prevailing linear-reductionist medical models seem unable to explain complex diseases like fibromyalgia (FM) and similar maladies fully. In contrast, paradigms derived from the new complexity theory seem to provide a more coherent explanation for the pathogenesis of these intangible illnesses. Different lines of investigation have shown that patients who have FM experience degradation of their main complex adaptive system, namely, the autonomic nervous system (ANS). It has been proposed that such autonomic dysfunction may cause the multiple symptoms of FM, including chronic widespread pain. 1 This article is divided into two parts. The first part intends to be evidence based and reviews basic concepts of the ANS related to pain generation. This first part also reviews all controlled studies listed in PubMed looking at ANS performance in FM. The second part of the article contains a holistic pathogenetic proposal for FM based on the new complexity science paradigms. In this second section, ''allostasis'' and ''allostatic load'' are proposed as pertinent concepts for FM. This holistic model intends to be hypothesis generating; therefore, it needs to be tested with appropriate scientific studies. PART ONE Autonomic Nervous System: Basic Concepts Related to Pain Generation The ANS is the portion of the nervous system that controls the function of the different organs and systems of the body. One striking characteristic of this system is the rapidity and intensity of the onset of its action and its dissipation. This unpredictable performance has chaotic features. The ANS is activated by centers located in the
Arthritis Research & Therapy, 2011
Introduction: At present, there is neither a laboratory test nor an imaging technique able to dif... more Introduction: At present, there is neither a laboratory test nor an imaging technique able to differentiate people with fibromyalgia (FM) from healthy controls. This lack of an objective biomarker has hampered FM recognition and research. Heart rate variability (HRV) analyses provide a quantitative marker of autonomic nervous system activity. Nighttime is a stable period in which most people are resting. Sleep is modulated by autonomic activity. Sleeping problems are prominent in FM. The objectives of this study are: 1) to explore different nocturnal HRV parameters as potential FM biomarkers and 2) to seek correlation between such HRV parameters and diverse FM symptoms. Methods: We studied 22 women suffering from FM and 22 age-matched controls. All participants filled out several questionnaires related to FM symptoms. All participants used a Holter monitor over 24 hours while undertaking their routine activities during the day and while sleeping at their homes at night. Time-domain HRV parameters analyzed from 0000 to 0600 hours included, among others: mean normal-normal interbeat intervals (mean NN), standard deviation of the NN intervals (SDNN), and standard deviation of the successive NN differences (SDSD). Results: Nocturnal SDNN of less than 114 ms had the greatest predictive value to set apart patients from controls with an odds ratio of 13.6 (95% confidence interval: 3.9 to 47.8). In patients, decreased nighttime HRV markers indicative of sympathetic predominance had significant correlations with several FM symptoms: SDSD was associated with pain intensity (r =-0.65, P = 0.001). SDNN correlated with constipation (r =-0.53, P = 0.001), and mean NN with depression (r =-0.53, P = 0.001). Controls displayed an opposite behavior. For them, increased nighttime SDNN correlated with Fibromyalgia Impact Questionnaire scores (r = 0.69, P = 0.001) and with other FM symptoms. Conclusions: Nocturnal HRV indices indicative of sympathetic predominance are significantly different in FM women when compared to healthy individuals. In FM patients, these HRV parameters correlated with several symptoms including pain severity. Opposite associations were seen in controls. FM may not be just one end of a continuous spectrum of common symptoms. Nocturnal HRV analyses are potential FM biomarkers.
Arthritis & Rheumatism, 2009
OR 3.05). these associations existed even after gallstone and gender stratification. similarly, a... more OR 3.05). these associations existed even after gallstone and gender stratification. similarly, aDRβ3 t190C polymorphism was also associated with gsD risk, though limited only to female gsD patients. In contrary, aDRa2a C-1291g conferred a marginally increased risk only in gsD patients. aDRβ1 C1165g polymorphism was not associated with gBC and gsD susceptibility when compared to controls. Conclusion aDRβ3 t190C polymorphism is significantly associated with gBC and gsD susceptibility. the aDRβ3 t190C may be involved in the pathophysiology of gBC by both gallstone-dependent pathway and by some other independent mechanisms. Keywords adrenergic receptors (aDR) • gallbladder cancer (gBC) • gallstone disease (gsD) • singlenucleotide polymorphisms (snP) • Case-control study Abbreviations gBC gallbladder cancer aDR adrenergic receptors hC healthy controls gsD gallstone disease snP single-nucleotide polymorphism sPss statistical package for social sciences FDR False discovery rate OR Odds ratio CI Confidence interval hWe hardy-Weinberg equilibrium Introduction gallbladder carcinoma (gBC) is rare but highly aggressive tumor with poor prognosis (Misra et al. 2003).
Arthritis Research & Therapy, 2007
Autonomic dysfunction is frequent in patients with fibromyalgia (FM). Heart rate variability anal... more Autonomic dysfunction is frequent in patients with fibromyalgia (FM). Heart rate variability analyses have demonstrated signs of ongoing sympathetic hyperactivity. Catecholamines are sympathetic neurotransmitters. Catechol-O-methyltransferase (COMT), an enzyme, is the major catecholamine-clearing pathway. There are several single-nucleotide polymorphisms (SNPs) in the COMT gene associated with the different catecholamine-clearing abilities of the COMT enzyme. These SNPs are in linkage disequilibrium and segregate as 'haplotypes'. Healthy females with a particular COMT gene haplotype (ACCG) producing a defective enzyme are more sensitive to painful stimuli. The objective of our study was to define whether women with FM, from two different countries (Mexico and Spain), have the COMT gene haplotypes that have been previously associated with greater sensitivity to pain. All the individuals in the study were female. Fifty-seven Mexican patients and 78 Spanish patients were compared with their respective healthy control groups. All participants filled out the Fibromyalgia Impact Questionnaire (FIQ). Six COMT SNPs (rs2097903, rs6269, rs4633, rs4818, rs4680, and rs165599) were genotyped from peripheral blood DNA. In Spanish patients, there was a significant association between three SNPs (rs6269, rs4818, and rs4680) and the presence of FM when compared with healthy controls. Moreover, in Spanish patients with the 'high pain sensitivity' haplotype (ACCG), the disease, as assessed by the FIQ, was more severe. By contrast, Mexican patients displayed only a weak association between rs6269 and rs165599, and some FIQ subscales. In our group of Spanish patients, there was an association between FM and the COMT haplotype previously associated with high pain sensitivity. This association was not observed in Mexican patients. Studies with a larger sample size are needed in order to verify or amend these preliminary results. COMT = catechol-O-methyltransferase; FIQ = Fibromyalgia Impact Questionnaire; FM = fibromyalgia; HLA = human leukocyte antigen; LD = linkage disequilibrium; SNP = single-nucleotide polymorphism.
JCR: Journal of Clinical Rheumatology, 2020
BACKGROUND Spread of complex regional pain syndrome (CRPS) outside the affected limb is a well-re... more BACKGROUND Spread of complex regional pain syndrome (CRPS) outside the affected limb is a well-recognized phenomenon; nevertheless, the actual evolution from CRPS to fibromyalgia is poorly documented. Similar mechanisms have been recently put forward to explain the development of CRPS and fibromyalgia including dorsal root ganglia (DRG) hyperexcitability and small fiber neuropathy. OBJECTIVES The aims of this study were to describe 3 cases with typical CRPS evolving to full-blown fibromyalgia and to discuss the potential pathogenetic mechanisms linking these debilitating illnesses. METHODS This was a review of medical records and PubMed search on the relationship between CRPS-fibromyalgia with DRG and small nerve fiber neuropathy. RESULTS Our 3 cases displayed over time orderly evolution from CRPS to fibromyalgia. Dorsal root ganglion hyperexcitability and small fiber neuropathy have been recently demonstrated in CRPS and in fibromyalgia. Dorsal root ganglia contain the small nerve fiber cell bodies surrounded by glial cells. After trauma, DRG perineuronal glial cells produce diverse proinflammatory mediators. Macrophages, lymphocytes, and satellite glial cells may drive the immune response to more rostrally and caudally located DRG and other spinal cord sites. Dorsal root ganglion metabolic changes may lead to small nerve fiber degeneration. This mechanism may explain the development of widespread pain and autonomic dysfunction. CONCLUSIONS Clinicians should be aware that CRPS can evolve to full-blown fibromyalgia. Spreading of neuroinflammation through DRG glial cell activation could theoretically explain the transformation from regional to generalized complex pain syndrome.
Clinical Rheumatology, 2016
This is a repository copy of A survey of anatomical items relevant to the practice of rheumatolog... more This is a repository copy of A survey of anatomical items relevant to the practice of rheumatology: upper extremity, head, neck, spine, and general concepts..
Reumatología Clínica
This paper emphasizes the anatomical substrate of several foot conditions that are seldom discuss... more This paper emphasizes the anatomical substrate of several foot conditions that are seldom discussed in this context. These include the insertional and non-insertional Achilles tendinopathies, plantar fas-ciopathy, inferior and posterior heel spurs, foot compartment syndromes, intermetatarsal bursitis and Morton's neuroma. It is a rather superficial anatomical review of an organ that remains largely neglected by rheumatologists. It is our hope that the cases discussed and the cross examination by instructors and participants will stimulate study of the foot and the attention it deserves.
Arthritis research & therapy, 2006
'Rhupus' is a rare condition sharing features of rheumatoid arthritis (RA) and systemic lupus ery... more 'Rhupus' is a rare condition sharing features of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). If rhupus is a distinctive entity, an overlap between RA and SLE or a subset of SLE is currently debated. This study was performed to explore the prevalence of antibodies against cyclic citrullinated peptides (anti-CCP antibodies) in rhupus. Patients meeting American College of Rheumatology criteria for RA, SLE, or both were included. Clinical and radiographic features were recorded and sera were searched for anti-CCP antibodies, rheumatoid factor, antinuclear antibodies, anti-extractable nuclear antigens, and antibodies against double-stranded DNA (anti-dsDNA antibodies). Seven patients for each group were included. Clinical and serological features for RA or SLE were similar between rhupus and RA patients, and between rhupus and SLE patients, respectively. Values for anti-CCP antibodies obtained were significantly (p < 0.05) higher in RA (6/7) and rhupus (4/ 7) than in SLE patients (0/7) and healthy subjects (0/7). Our data support the possibility that rhupus is an overlap between RA and SLE, because highly specific autoantibodies for RA (anti-CCP) and for SLE (anti-dsDNA and anti-Sm) are detected in coexistence.
The Journal of rheumatology, 2008
BioMed Research International, 2013
Objective. To characterize the ultrasound (US) pattern of joint involvement in primary Sjögren’s ... more Objective. To characterize the ultrasound (US) pattern of joint involvement in primary Sjögren’s syndrome (pSS).Methods. Seventeen patients with pSS, 18 with secondary Sjögren’s syndrome (sSS), and 17 healthy controls underwent US examinations of various articular regions. Synovitis (synovial hypertrophy/joint effusion), power Doppler (PD) signals, and erosions were assessed.Results. In patients with pSS, synovitis was found in the metacarpophalangeal joints (MCP, 76%), wrists (76%), and knees (76%), while the proximal interphalangeal joints, elbows, and ankles were mostly unscathed. Intra-articular PD signals were occasionally detected in wrists (12%), elbows (6%), and knees (6%). Erosions were evident in the wrists of three (18%) patients with pSS, one of these also having anti-cyclic citrullinated peptide (anti-CCP) antibodies. While US synovitis does not discriminate between sSS and pSS, demonstration of bone erosions in the 2nd MCP joints showed 28.8% sensitivity and 100% speci...
Annals of the Rheumatic Diseases, 2014
Background The presence of subclinical inflammation promotes the progression of morphostructural ... more Background The presence of subclinical inflammation promotes the progression of morphostructural joint damage in RA patients. Currently, clinical remission is based on the count of swollen and painful joints associated with acute phase reactants. Adding an image technique like grey scale (GS) US and power Doppler (PD) increases the capability to detect active synovitis. There are no studies on the association between active synovitis as defined by PD and more specific markers of inflammation like cytokines in patients with RA in clinical remission Objectives To identify subclinical synovitis in patients with RA in clinical remission using US and to characterize the biological profile of this group of patients by determining inflammatory cytokines Methods RA patients in clinical remission according to ACR/EULAR criteria were enrolled. Clinical evaluation was performed and DAS28 calculated. Cytokines (IL1b, 10, 6. 5, 2, 4, 8, GMCS, TNFa, IFNg,) were determined using ELISA kit (Human ultrasensitive cytokine 10 -plex panel [Invitrogen, CA, USA]). GS and PD ultrasound was assessed in 7 joints according to Backhaus et al (2). Esaote MyLab ® 25 ultrasound machine with 12-18 MHz linear probe was used. Results 21 patients were included. Clinical and demographic data are shown in the table. N=21 Age (years) 44.81 (25–69) Disease duration (months) 100.76 (28–353) Duration in clinical remission (months) 12.15 (1–43) DAS28 1.35 (0.99–2.42) Rheumatoid factor (positive) 95% (n=20) antiCCP (positive) 52% (n=11) GS synovitis was found in 95%, and tenosynovitis in 9.5%. PD was detected in 57%. There was no association between DAS28 and duration in clinical remission, disease duration and US-defined active synovitis (p=0.84, 0.309 and 0.762 respectively). Pro-inflammatory cytokines levels were elevated in patients with less than 6 months and in those with 13 to 24 months in clinical remission. Nevertheless, there was no correlation with US-defined synovitis (p=NS) Conclusions US detected a high percentage of subclinical synovitis in RA patients in clinical remission. Cytokine levels did not correlate with DAS 28 or ultrasound-defined active synovitis. References Brown AK, Conaghan P, Karim Z, et al. An explanation for the apparent dissociation between clinical remission and continues structural deterioration in rheumatoid arthritis. Arthritis Rheum 2008; 58(10): 2958-2967 Backhaus M, Ohrndorf S, Kellner H, et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum 2009; 61(9): 1194-1201 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4855
Reumatología Clínica, 2012
The clinical anatomy of several pain syndromes of the knee is herein discussed. These include the... more The clinical anatomy of several pain syndromes of the knee is herein discussed. These include the iliotibial tract syndrome, the anserine syndrome, bursitis of the medial collateral ligament, Baker's cyst, popliteus tendon tenosynovitis and bursitis of the deep infrapatellar bursa. These syndromes are reviewed in terms of the structures involved and their role in knee physiology. All of the discussed structures can be identified in their normal state and more so when they are affected by disease. The wealth of information gained by cross examination of the medial, lateral, posterior and anterior aspects of the knee brings to life knowledge acquired at the dissection table, from anatomical drawings and from virtual images.
Reumatología Clínica, 2012
The contents of this review may appear odd. After a brief description of the coxofemoral joint, t... more The contents of this review may appear odd. After a brief description of the coxofemoral joint, the entities discussed include ilioinguinal neuropathy within the context of the nerves that may be damaged during lower abdominal surgery, meralgia paresthetica, piriformis syndrome with the appropriate caveats, trochanteric syndrome, "ischial bursitis" and trochanteric syndrome caused by ischemia. These cases were chosen to stress our belief that rheumatologists are first and foremost internists. We further believe that being current in other pathologies such as peripheral neuropathies and certain vascular syndromes sooner or later benefits our patients.
Reumatología Clínica, 2012
This article reviews the underlying anatomy of trigger finger and thumb (fibrous digital pulleys,... more This article reviews the underlying anatomy of trigger finger and thumb (fibrous digital pulleys, sesamoid bones), flexor tenosynovitis, de Quervain's syndrome, Dupuytren's contracture, some hand deformities in rheumatoid arthritis, the carpal tunnel syndrome and the ulnar nerve compression at Guyon's canal. Some important syndromes and structures have not been included but such are the nature of these seminars. Rather than being complete, we aim at creating a system in which clinical cases are used to highlight the pertinent anatomy and, in the most important part of the seminar, these pertinent items are demonstrated by cross examination of participants and teachers. Self learning is critical for generating interest and expanding knowledge of clinical anatomy. Just look at your own hand in various positions, move it, feel it, feel also your forearms while you move the fingers, do this repeatedly and inquisitively and after a few tries you will have developed not only a taste, but also a lifelong interest in clinical anatomy.
Reumatología Clínica, 2012
The elbow patients herein discussed feature common soft tissue conditions such as tennis elbow, g... more The elbow patients herein discussed feature common soft tissue conditions such as tennis elbow, golfers' elbow and olecranon bursitis. Relevant anatomical structures for these conditions can easily be identified and demonstrated by cross examination by instructors and participants. Patients usually present rotator cuff tendinopathy, frozen shoulder, axillary neuropathy and suprascapular neuropathy. The structures involved in tendinopathy and frozen shoulder can be easily identified and demonstrated under normal conditions. The axillary and the suprascapular nerves have surface landmarks but cannot be palpated. In neuropathy however, physical findings in both neuropathies are pathognomonic and will be discussed.
Rheumatology, 2008
Objective. Evaluate the presence and severity of myocardial ischaemia in a population of asymptom... more Objective. Evaluate the presence and severity of myocardial ischaemia in a population of asymptomatic patients with primary APS (PAPS) using 13 N-ammonia PET. Methods. We studied 36 patients, 18 with a diagnosis of PAPS and 18 healthy volunteers. All patients underwent a two-phase (rest-stress) 13 N-ammonia PET. Myocardial perfusion images were acquired and then analysed by two experts in the field. Results. We found ischaemia in 7/18 asymptomatic PAPS patients (38.8%). The anterolateral wall was the most commonly affected cardiac territory [5/7 PAPS patients (71.4%)]. In a severity analysis, we found that five patients (71.4%) had mild ischaemia, one patient (14.2%) had moderate ischaemia and another one (14.2%) had severe defects. All the healthy volunteers studied showed normal myocardial perfusion images. Conclusion. An important proportion of PAPS patients, even when asymptomatic, showed myocardial perfusion defects assessed with PET. Most of the ischaemic patients had mild defects and the anterolateral wall was the territory mainly affected.
Journal of Nuclear Cardiology, 2005
This study was designed to assess the prognostic value of left ventricular (LV) functional parame... more This study was designed to assess the prognostic value of left ventricular (LV) functional parameters as measured by quantitative gated-SPECT (QGS) and their contribution to a follow-up study in patients with coronary artery disease (CAD. BACKGROUND: The prognostic value of QGS in a follow-up study has not been fully evaluated yet, although the high reproducibility of QGS has been well validated. METHODS: After coronary intervention, 89 patients underwent two times of myocardial SPECT, and were followed up for a mean period of 393 Ϯ 169 days. The segmental perfusion was analyzed visually, while the ejection fraction (EF) and end-diastolic volume (EDV) were calculated using an automatic QGS algorithm. The differences between the second and first time of the LV fuctional values were calculated as dEF (%) and dEDV (ml), respectively. RESULTS: The 89 patients were classified into 3 groups according to their second time of myocardial perfusion imaging as follows: 65 patients with unchanged perfusion were classified into group A, 6 patients with improved perfusion into group B, and 18 patients with worsening perfusion into group C. There were no significant differences in the LV parameters in group A (dEF: 2.7 Ϯ 8.4, dEDV:Ϫ1.1 Ϯ 11.9%) and group B (dEF: 1.2 Ϯ 6.7, dEDV: Ϫ10.8 Ϯ 14.0). In group C, significantly increased LV volume was observed at the second time SPECT (dEDV: 20.9 Ϯ 15.4, pϭ0.03) although there was no difference in EF (dEF: Ϫ1.5 Ϯ 6.6). CONCLUSION: The QGS measurements of LV functional parameters were highly reproducible over a long period of time. Furthermore, an increased LV volume was observed in patients in whom myocardial perfusion had deteriorated at the follow-up SPECT. We concluded that QGS is a clinically useful tool for follow-up of the patients with CAD.
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 2014
Fibromyalgia often coexists and overlaps with other syndromes such as chronic fatigue, irritable ... more Fibromyalgia often coexists and overlaps with other syndromes such as chronic fatigue, irritable bowel syndrome, and interstitial cystitis. Chronic stress has been implicated in the pathogenesis of these illnesses. The sympathetic nervous system is a key element of the stress response system. Sympathetic dysfunction has been reported in these syndromes, raising the possibility that such dysautonomia could be their common clustering underlying pathogenesis. The objective of this study was to carry out a review of all published comparative case-control studies investigating sympathetic nervous system performance in fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and interstitial cystitis. Online databases PubMed and EMBASE were accessed using the following key words: autonomic (OR) sympathetic (AND) fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and interstitial cystitis. All entries up to December 10th 2012 were reviewed by 2 independent investiga...
Acta ortopédica mexicana
Ultrasound is a simple, non invasive and accessible imaging technique that allows the evaluation ... more Ultrasound is a simple, non invasive and accessible imaging technique that allows the evaluation of the musculoskeletal system in real time, with the advantage of examining the joints in a dynamic way and with the aid of Doppler power, local inflammatory phenomena can be evaluated, without submitting the patient to radiation. It has the disadvantage of being operator dependant, which has to have a wide knowledge of the physical principles of ultrasonography, has to be familiar with the sonographic anatomy and musculoskeletal anatomy, but even more it is important that he has the ability to recognize the sonographic phenomena that can present as decoys, nominated artifacts. This knowledge is desirable to the specialist in musculoskeletal conditions, so that ecographic studies can be interpreted and recognizing artifacts and avoiding wrong diagnosis and unnecessary procedures. In the present review, the basic principles of ecography are analyzed, the normal sonographic anatomy of the ...
Reumatología Clínica, 2007
Rheumatic Disease Clinics of North America, 2009
Prevailing linear-reductionist medical models seem unable to explain complex diseases like fibrom... more Prevailing linear-reductionist medical models seem unable to explain complex diseases like fibromyalgia (FM) and similar maladies fully. In contrast, paradigms derived from the new complexity theory seem to provide a more coherent explanation for the pathogenesis of these intangible illnesses. Different lines of investigation have shown that patients who have FM experience degradation of their main complex adaptive system, namely, the autonomic nervous system (ANS). It has been proposed that such autonomic dysfunction may cause the multiple symptoms of FM, including chronic widespread pain. 1 This article is divided into two parts. The first part intends to be evidence based and reviews basic concepts of the ANS related to pain generation. This first part also reviews all controlled studies listed in PubMed looking at ANS performance in FM. The second part of the article contains a holistic pathogenetic proposal for FM based on the new complexity science paradigms. In this second section, ''allostasis'' and ''allostatic load'' are proposed as pertinent concepts for FM. This holistic model intends to be hypothesis generating; therefore, it needs to be tested with appropriate scientific studies. PART ONE Autonomic Nervous System: Basic Concepts Related to Pain Generation The ANS is the portion of the nervous system that controls the function of the different organs and systems of the body. One striking characteristic of this system is the rapidity and intensity of the onset of its action and its dissipation. This unpredictable performance has chaotic features. The ANS is activated by centers located in the
Arthritis Research & Therapy, 2011
Introduction: At present, there is neither a laboratory test nor an imaging technique able to dif... more Introduction: At present, there is neither a laboratory test nor an imaging technique able to differentiate people with fibromyalgia (FM) from healthy controls. This lack of an objective biomarker has hampered FM recognition and research. Heart rate variability (HRV) analyses provide a quantitative marker of autonomic nervous system activity. Nighttime is a stable period in which most people are resting. Sleep is modulated by autonomic activity. Sleeping problems are prominent in FM. The objectives of this study are: 1) to explore different nocturnal HRV parameters as potential FM biomarkers and 2) to seek correlation between such HRV parameters and diverse FM symptoms. Methods: We studied 22 women suffering from FM and 22 age-matched controls. All participants filled out several questionnaires related to FM symptoms. All participants used a Holter monitor over 24 hours while undertaking their routine activities during the day and while sleeping at their homes at night. Time-domain HRV parameters analyzed from 0000 to 0600 hours included, among others: mean normal-normal interbeat intervals (mean NN), standard deviation of the NN intervals (SDNN), and standard deviation of the successive NN differences (SDSD). Results: Nocturnal SDNN of less than 114 ms had the greatest predictive value to set apart patients from controls with an odds ratio of 13.6 (95% confidence interval: 3.9 to 47.8). In patients, decreased nighttime HRV markers indicative of sympathetic predominance had significant correlations with several FM symptoms: SDSD was associated with pain intensity (r =-0.65, P = 0.001). SDNN correlated with constipation (r =-0.53, P = 0.001), and mean NN with depression (r =-0.53, P = 0.001). Controls displayed an opposite behavior. For them, increased nighttime SDNN correlated with Fibromyalgia Impact Questionnaire scores (r = 0.69, P = 0.001) and with other FM symptoms. Conclusions: Nocturnal HRV indices indicative of sympathetic predominance are significantly different in FM women when compared to healthy individuals. In FM patients, these HRV parameters correlated with several symptoms including pain severity. Opposite associations were seen in controls. FM may not be just one end of a continuous spectrum of common symptoms. Nocturnal HRV analyses are potential FM biomarkers.
Arthritis & Rheumatism, 2009
OR 3.05). these associations existed even after gallstone and gender stratification. similarly, a... more OR 3.05). these associations existed even after gallstone and gender stratification. similarly, aDRβ3 t190C polymorphism was also associated with gsD risk, though limited only to female gsD patients. In contrary, aDRa2a C-1291g conferred a marginally increased risk only in gsD patients. aDRβ1 C1165g polymorphism was not associated with gBC and gsD susceptibility when compared to controls. Conclusion aDRβ3 t190C polymorphism is significantly associated with gBC and gsD susceptibility. the aDRβ3 t190C may be involved in the pathophysiology of gBC by both gallstone-dependent pathway and by some other independent mechanisms. Keywords adrenergic receptors (aDR) • gallbladder cancer (gBC) • gallstone disease (gsD) • singlenucleotide polymorphisms (snP) • Case-control study Abbreviations gBC gallbladder cancer aDR adrenergic receptors hC healthy controls gsD gallstone disease snP single-nucleotide polymorphism sPss statistical package for social sciences FDR False discovery rate OR Odds ratio CI Confidence interval hWe hardy-Weinberg equilibrium Introduction gallbladder carcinoma (gBC) is rare but highly aggressive tumor with poor prognosis (Misra et al. 2003).
Arthritis Research & Therapy, 2007
Autonomic dysfunction is frequent in patients with fibromyalgia (FM). Heart rate variability anal... more Autonomic dysfunction is frequent in patients with fibromyalgia (FM). Heart rate variability analyses have demonstrated signs of ongoing sympathetic hyperactivity. Catecholamines are sympathetic neurotransmitters. Catechol-O-methyltransferase (COMT), an enzyme, is the major catecholamine-clearing pathway. There are several single-nucleotide polymorphisms (SNPs) in the COMT gene associated with the different catecholamine-clearing abilities of the COMT enzyme. These SNPs are in linkage disequilibrium and segregate as 'haplotypes'. Healthy females with a particular COMT gene haplotype (ACCG) producing a defective enzyme are more sensitive to painful stimuli. The objective of our study was to define whether women with FM, from two different countries (Mexico and Spain), have the COMT gene haplotypes that have been previously associated with greater sensitivity to pain. All the individuals in the study were female. Fifty-seven Mexican patients and 78 Spanish patients were compared with their respective healthy control groups. All participants filled out the Fibromyalgia Impact Questionnaire (FIQ). Six COMT SNPs (rs2097903, rs6269, rs4633, rs4818, rs4680, and rs165599) were genotyped from peripheral blood DNA. In Spanish patients, there was a significant association between three SNPs (rs6269, rs4818, and rs4680) and the presence of FM when compared with healthy controls. Moreover, in Spanish patients with the 'high pain sensitivity' haplotype (ACCG), the disease, as assessed by the FIQ, was more severe. By contrast, Mexican patients displayed only a weak association between rs6269 and rs165599, and some FIQ subscales. In our group of Spanish patients, there was an association between FM and the COMT haplotype previously associated with high pain sensitivity. This association was not observed in Mexican patients. Studies with a larger sample size are needed in order to verify or amend these preliminary results. COMT = catechol-O-methyltransferase; FIQ = Fibromyalgia Impact Questionnaire; FM = fibromyalgia; HLA = human leukocyte antigen; LD = linkage disequilibrium; SNP = single-nucleotide polymorphism.
JCR: Journal of Clinical Rheumatology, 2020
BACKGROUND Spread of complex regional pain syndrome (CRPS) outside the affected limb is a well-re... more BACKGROUND Spread of complex regional pain syndrome (CRPS) outside the affected limb is a well-recognized phenomenon; nevertheless, the actual evolution from CRPS to fibromyalgia is poorly documented. Similar mechanisms have been recently put forward to explain the development of CRPS and fibromyalgia including dorsal root ganglia (DRG) hyperexcitability and small fiber neuropathy. OBJECTIVES The aims of this study were to describe 3 cases with typical CRPS evolving to full-blown fibromyalgia and to discuss the potential pathogenetic mechanisms linking these debilitating illnesses. METHODS This was a review of medical records and PubMed search on the relationship between CRPS-fibromyalgia with DRG and small nerve fiber neuropathy. RESULTS Our 3 cases displayed over time orderly evolution from CRPS to fibromyalgia. Dorsal root ganglion hyperexcitability and small fiber neuropathy have been recently demonstrated in CRPS and in fibromyalgia. Dorsal root ganglia contain the small nerve fiber cell bodies surrounded by glial cells. After trauma, DRG perineuronal glial cells produce diverse proinflammatory mediators. Macrophages, lymphocytes, and satellite glial cells may drive the immune response to more rostrally and caudally located DRG and other spinal cord sites. Dorsal root ganglion metabolic changes may lead to small nerve fiber degeneration. This mechanism may explain the development of widespread pain and autonomic dysfunction. CONCLUSIONS Clinicians should be aware that CRPS can evolve to full-blown fibromyalgia. Spreading of neuroinflammation through DRG glial cell activation could theoretically explain the transformation from regional to generalized complex pain syndrome.
Clinical Rheumatology, 2016
This is a repository copy of A survey of anatomical items relevant to the practice of rheumatolog... more This is a repository copy of A survey of anatomical items relevant to the practice of rheumatology: upper extremity, head, neck, spine, and general concepts..
Reumatología Clínica
This paper emphasizes the anatomical substrate of several foot conditions that are seldom discuss... more This paper emphasizes the anatomical substrate of several foot conditions that are seldom discussed in this context. These include the insertional and non-insertional Achilles tendinopathies, plantar fas-ciopathy, inferior and posterior heel spurs, foot compartment syndromes, intermetatarsal bursitis and Morton's neuroma. It is a rather superficial anatomical review of an organ that remains largely neglected by rheumatologists. It is our hope that the cases discussed and the cross examination by instructors and participants will stimulate study of the foot and the attention it deserves.
Arthritis research & therapy, 2006
'Rhupus' is a rare condition sharing features of rheumatoid arthritis (RA) and systemic lupus ery... more 'Rhupus' is a rare condition sharing features of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). If rhupus is a distinctive entity, an overlap between RA and SLE or a subset of SLE is currently debated. This study was performed to explore the prevalence of antibodies against cyclic citrullinated peptides (anti-CCP antibodies) in rhupus. Patients meeting American College of Rheumatology criteria for RA, SLE, or both were included. Clinical and radiographic features were recorded and sera were searched for anti-CCP antibodies, rheumatoid factor, antinuclear antibodies, anti-extractable nuclear antigens, and antibodies against double-stranded DNA (anti-dsDNA antibodies). Seven patients for each group were included. Clinical and serological features for RA or SLE were similar between rhupus and RA patients, and between rhupus and SLE patients, respectively. Values for anti-CCP antibodies obtained were significantly (p < 0.05) higher in RA (6/7) and rhupus (4/ 7) than in SLE patients (0/7) and healthy subjects (0/7). Our data support the possibility that rhupus is an overlap between RA and SLE, because highly specific autoantibodies for RA (anti-CCP) and for SLE (anti-dsDNA and anti-Sm) are detected in coexistence.
The Journal of rheumatology, 2008
BioMed Research International, 2013
Objective. To characterize the ultrasound (US) pattern of joint involvement in primary Sjögren’s ... more Objective. To characterize the ultrasound (US) pattern of joint involvement in primary Sjögren’s syndrome (pSS).Methods. Seventeen patients with pSS, 18 with secondary Sjögren’s syndrome (sSS), and 17 healthy controls underwent US examinations of various articular regions. Synovitis (synovial hypertrophy/joint effusion), power Doppler (PD) signals, and erosions were assessed.Results. In patients with pSS, synovitis was found in the metacarpophalangeal joints (MCP, 76%), wrists (76%), and knees (76%), while the proximal interphalangeal joints, elbows, and ankles were mostly unscathed. Intra-articular PD signals were occasionally detected in wrists (12%), elbows (6%), and knees (6%). Erosions were evident in the wrists of three (18%) patients with pSS, one of these also having anti-cyclic citrullinated peptide (anti-CCP) antibodies. While US synovitis does not discriminate between sSS and pSS, demonstration of bone erosions in the 2nd MCP joints showed 28.8% sensitivity and 100% speci...
Annals of the Rheumatic Diseases, 2014
Background The presence of subclinical inflammation promotes the progression of morphostructural ... more Background The presence of subclinical inflammation promotes the progression of morphostructural joint damage in RA patients. Currently, clinical remission is based on the count of swollen and painful joints associated with acute phase reactants. Adding an image technique like grey scale (GS) US and power Doppler (PD) increases the capability to detect active synovitis. There are no studies on the association between active synovitis as defined by PD and more specific markers of inflammation like cytokines in patients with RA in clinical remission Objectives To identify subclinical synovitis in patients with RA in clinical remission using US and to characterize the biological profile of this group of patients by determining inflammatory cytokines Methods RA patients in clinical remission according to ACR/EULAR criteria were enrolled. Clinical evaluation was performed and DAS28 calculated. Cytokines (IL1b, 10, 6. 5, 2, 4, 8, GMCS, TNFa, IFNg,) were determined using ELISA kit (Human ultrasensitive cytokine 10 -plex panel [Invitrogen, CA, USA]). GS and PD ultrasound was assessed in 7 joints according to Backhaus et al (2). Esaote MyLab ® 25 ultrasound machine with 12-18 MHz linear probe was used. Results 21 patients were included. Clinical and demographic data are shown in the table. N=21 Age (years) 44.81 (25–69) Disease duration (months) 100.76 (28–353) Duration in clinical remission (months) 12.15 (1–43) DAS28 1.35 (0.99–2.42) Rheumatoid factor (positive) 95% (n=20) antiCCP (positive) 52% (n=11) GS synovitis was found in 95%, and tenosynovitis in 9.5%. PD was detected in 57%. There was no association between DAS28 and duration in clinical remission, disease duration and US-defined active synovitis (p=0.84, 0.309 and 0.762 respectively). Pro-inflammatory cytokines levels were elevated in patients with less than 6 months and in those with 13 to 24 months in clinical remission. Nevertheless, there was no correlation with US-defined synovitis (p=NS) Conclusions US detected a high percentage of subclinical synovitis in RA patients in clinical remission. Cytokine levels did not correlate with DAS 28 or ultrasound-defined active synovitis. References Brown AK, Conaghan P, Karim Z, et al. An explanation for the apparent dissociation between clinical remission and continues structural deterioration in rheumatoid arthritis. Arthritis Rheum 2008; 58(10): 2958-2967 Backhaus M, Ohrndorf S, Kellner H, et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum 2009; 61(9): 1194-1201 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4855
Reumatología Clínica, 2012
The clinical anatomy of several pain syndromes of the knee is herein discussed. These include the... more The clinical anatomy of several pain syndromes of the knee is herein discussed. These include the iliotibial tract syndrome, the anserine syndrome, bursitis of the medial collateral ligament, Baker's cyst, popliteus tendon tenosynovitis and bursitis of the deep infrapatellar bursa. These syndromes are reviewed in terms of the structures involved and their role in knee physiology. All of the discussed structures can be identified in their normal state and more so when they are affected by disease. The wealth of information gained by cross examination of the medial, lateral, posterior and anterior aspects of the knee brings to life knowledge acquired at the dissection table, from anatomical drawings and from virtual images.
Reumatología Clínica, 2012
The contents of this review may appear odd. After a brief description of the coxofemoral joint, t... more The contents of this review may appear odd. After a brief description of the coxofemoral joint, the entities discussed include ilioinguinal neuropathy within the context of the nerves that may be damaged during lower abdominal surgery, meralgia paresthetica, piriformis syndrome with the appropriate caveats, trochanteric syndrome, "ischial bursitis" and trochanteric syndrome caused by ischemia. These cases were chosen to stress our belief that rheumatologists are first and foremost internists. We further believe that being current in other pathologies such as peripheral neuropathies and certain vascular syndromes sooner or later benefits our patients.
Reumatología Clínica, 2012
This article reviews the underlying anatomy of trigger finger and thumb (fibrous digital pulleys,... more This article reviews the underlying anatomy of trigger finger and thumb (fibrous digital pulleys, sesamoid bones), flexor tenosynovitis, de Quervain's syndrome, Dupuytren's contracture, some hand deformities in rheumatoid arthritis, the carpal tunnel syndrome and the ulnar nerve compression at Guyon's canal. Some important syndromes and structures have not been included but such are the nature of these seminars. Rather than being complete, we aim at creating a system in which clinical cases are used to highlight the pertinent anatomy and, in the most important part of the seminar, these pertinent items are demonstrated by cross examination of participants and teachers. Self learning is critical for generating interest and expanding knowledge of clinical anatomy. Just look at your own hand in various positions, move it, feel it, feel also your forearms while you move the fingers, do this repeatedly and inquisitively and after a few tries you will have developed not only a taste, but also a lifelong interest in clinical anatomy.
Reumatología Clínica, 2012
The elbow patients herein discussed feature common soft tissue conditions such as tennis elbow, g... more The elbow patients herein discussed feature common soft tissue conditions such as tennis elbow, golfers' elbow and olecranon bursitis. Relevant anatomical structures for these conditions can easily be identified and demonstrated by cross examination by instructors and participants. Patients usually present rotator cuff tendinopathy, frozen shoulder, axillary neuropathy and suprascapular neuropathy. The structures involved in tendinopathy and frozen shoulder can be easily identified and demonstrated under normal conditions. The axillary and the suprascapular nerves have surface landmarks but cannot be palpated. In neuropathy however, physical findings in both neuropathies are pathognomonic and will be discussed.
Rheumatology, 2008
Objective. Evaluate the presence and severity of myocardial ischaemia in a population of asymptom... more Objective. Evaluate the presence and severity of myocardial ischaemia in a population of asymptomatic patients with primary APS (PAPS) using 13 N-ammonia PET. Methods. We studied 36 patients, 18 with a diagnosis of PAPS and 18 healthy volunteers. All patients underwent a two-phase (rest-stress) 13 N-ammonia PET. Myocardial perfusion images were acquired and then analysed by two experts in the field. Results. We found ischaemia in 7/18 asymptomatic PAPS patients (38.8%). The anterolateral wall was the most commonly affected cardiac territory [5/7 PAPS patients (71.4%)]. In a severity analysis, we found that five patients (71.4%) had mild ischaemia, one patient (14.2%) had moderate ischaemia and another one (14.2%) had severe defects. All the healthy volunteers studied showed normal myocardial perfusion images. Conclusion. An important proportion of PAPS patients, even when asymptomatic, showed myocardial perfusion defects assessed with PET. Most of the ischaemic patients had mild defects and the anterolateral wall was the territory mainly affected.
Journal of Nuclear Cardiology, 2005
This study was designed to assess the prognostic value of left ventricular (LV) functional parame... more This study was designed to assess the prognostic value of left ventricular (LV) functional parameters as measured by quantitative gated-SPECT (QGS) and their contribution to a follow-up study in patients with coronary artery disease (CAD. BACKGROUND: The prognostic value of QGS in a follow-up study has not been fully evaluated yet, although the high reproducibility of QGS has been well validated. METHODS: After coronary intervention, 89 patients underwent two times of myocardial SPECT, and were followed up for a mean period of 393 Ϯ 169 days. The segmental perfusion was analyzed visually, while the ejection fraction (EF) and end-diastolic volume (EDV) were calculated using an automatic QGS algorithm. The differences between the second and first time of the LV fuctional values were calculated as dEF (%) and dEDV (ml), respectively. RESULTS: The 89 patients were classified into 3 groups according to their second time of myocardial perfusion imaging as follows: 65 patients with unchanged perfusion were classified into group A, 6 patients with improved perfusion into group B, and 18 patients with worsening perfusion into group C. There were no significant differences in the LV parameters in group A (dEF: 2.7 Ϯ 8.4, dEDV:Ϫ1.1 Ϯ 11.9%) and group B (dEF: 1.2 Ϯ 6.7, dEDV: Ϫ10.8 Ϯ 14.0). In group C, significantly increased LV volume was observed at the second time SPECT (dEDV: 20.9 Ϯ 15.4, pϭ0.03) although there was no difference in EF (dEF: Ϫ1.5 Ϯ 6.6). CONCLUSION: The QGS measurements of LV functional parameters were highly reproducible over a long period of time. Furthermore, an increased LV volume was observed in patients in whom myocardial perfusion had deteriorated at the follow-up SPECT. We concluded that QGS is a clinically useful tool for follow-up of the patients with CAD.